Targeted Therapy and Skin Rashes

Acne-like rashes with targeted therapies for EGFR, BRAF, and MEK

If you've experienced an acne-like rash, dry skin, itching, and nail changes while taking an epidermal growth factor (EGFR) inhibitor such as Tarceva (erlotinib) you're not alone. For certain people with cancer, these targeted therapies have made a great difference, lengthening survival with fewer side effects than many chemotherapy drugs. Skin problems, such as a rash that resembles acne (but isn't), dry skin, and fingernail changes, however, can be annoying at best, and since these medications are often taken for an extended period of time, learning how to manage these symptoms is important. Recent research suggests that preventive treatment may also be effective, resulting in better quality of life.

EGRF Inhibitors

Epidermal growth factor receptor inhibitors (EGFR inhibitors) work by targeting EGFR, and important protein that is involved in the growth of many cancerous tumors. EGFR is also found in skin cells, leading to the common skin symptoms associated with treatment. EGFR inhibitors are a type of tyrosine kinase inhibitor.

EGFR inhibitors that have been linked with skin rashes include:

  • Tarceva (erlotinib):
  • Gilotrif (afatinib)
  • Iressa (gefitinib):
  • Erbitux (cetuximab):
  • Tagrisso (osimirtinib)
  • Tykerb (lapatinib)
  • Portrazza (necitumumab)
  • Perjeta (pertuzumab)
  • Vectibix (panitumumab)
  • Caprelsa (vandetinib)

BRAF and MEK Inhibitors

BRAF and MEK inhibitors are also associated with similar rashes and include drugs such as:

  • Tafinlar (dabrafenib)
  • Mekinist (trametinib)
  • Zelboraf (vemurafenib)
  • Braftori (encorafenib)
  • Cotellic (cobimetinib)
  • Mektovi (binimetinib)

Skin Problems

Common skin problems noted in people treated with EGFR inhibitors include:

  • An acne type rash
  • Dry, scaly skin
  • Itching
  • Fingernail and toenail tenderness (paronychia), swelling,
  • Hair changes (change in texture, change in hair growth, or hair loss)

Many of these symptoms can be managed with moisturizing lotions as well as protecting the skin to prevent infections, but further treatment or preventive treatment may be considered.

EGFR Inhibitors and Acne-Like Skin Rashes

The acne appearing rash is the most disturbing skin symptoms for the majority of people who use these medications.


Acne-like sores (lesions that look like whiteheads) closely resemble the acne often seen in teenagers. It frequently involves the face, the area behind the ears, the neck, the upper trunk in a V-shaped pattern, and the scalp. Less commonly it affects the lower back, abdomen, buttocks, and upper and lower extremities. The rash does not occur on the palms of the hands or the feet.

Dermatology terminology can be confusing if you read information about this rash, but a few simple definitions can help. A papule simply means a bump on the skin. A pustule means a bump that looks pus-filled or is draining. The term follicular simply means the skin sores are near or in a hair follicle.


The number of people who experience an acne-type rash can vary with the different types of EGFR inhibitors. With Tarceva (erlotinib), most people will have this rash to some degree.

Impact of Skin Problems

Skin problems on epidermal growth factor receptor inhibitors can significantly impact both physical and emotional quality of life for people taking these medications. One survey found that these side effects affected the physical, functional, emotional, and social well-being of people taking these drugs. The most common complaints were about the physical symptoms, including pain, a burning sensation, and sensitivity.

When Does the Rash Occur and How Long Does It Last?

Skin rashes on EGFR inhibitors usually begin 1 week to 2 weeks after treatment is started, are at their worst 2 weeks to 3 weeks after treatment has begun, and may gradually resolve or disappear completely over the next 2 months to 3 months. Knowing that the rash tends to improve over time has helped some people cope with the symptoms.

A Rash May Mean Greater Effectiveness

Studies do suggest that people who develop a rash on the drug have a better response rate and better overall survival. Because of this, and because the drug is often taken for an extended period of time, it is very important to be proactive in treating symptoms of the rash.

Skin problems related to other cancer treatments such as chemotherapy and radiation therapy may be present along with those from EGFR inhibitors and should be addressed carefully by your oncologist.

Severity of the Rash

Acne type rashes due to EGFR inhibitors are usually broken down into three categories:

  • Mild: A mild Tarceva is defined as one that has no ulceration (open areas), weeping (drainage), or infection. People usually have only mild symptoms and it does not interfere with normal life activities.
  • Moderate: A moderate Tarceva rash may be localized or generalized. There is usually no ulceration, weeping, or infection. Mild to moderate symptoms of itching and tenderness may be present, but there is only minimal interference with life activities.
  • Severe: A severe rash is often generalized (covering the face, upper chest, and upper back) and is usually associated with severe symptoms of itching and tenderness. It significantly impacts the quality of life. There can be ulceration (open sores), weeping (drainage), and signs of a secondary skin infection such as redness, yellow or green discharge, and fever.

Rashes can also be separated by grades (see below).


How your rash will be treated will depend upon the severity of the rash, as well as your personal preferences. Even though the rash resembles acne, it is not an acne rash, and will not respond to most acne treatments.

Daily Care

Preventive strategies include keeping the skin clean, avoiding sunburns, and using moisturizers to keep your skin hydrated. The best bet for avoiding sunburns is to avoid direct sunlight during midday, and to use protective clothing.

Sunscreens, especially sunblocks can make EGFR inhibitor rashes worse.

Occluding the rash with vaseline products can likewise exacerbate hair follicle inflammation and worsen the rash.

It's important to note that treatments for one symptom related to EGFR inhibitors may worsen another symptom and vice versa. For example, moisturizers may help with dryness and itching but worsen the acne type rash.

Prophylactic Polydatin

A 2019 study found that prophylactic (preventive) treatment with Polydatin could reduce the risk of severe skin rashes in people treated with Gilotrif (afatinib), and it's thought that this could work with other EGFR inhibitor-induced rashes as well. Polydatin is a glycosylated polyphenol that has anti-inflammatory activity in skin cells.

Treatment Options

The treatment options for skin rashes with EGFR inhibitors depend on the severity of the rash as well as whether or not there is evidence of a secondary infection. Treatments may include topical antibiotics, oral antibiotics, oral corticosteroids, reducing the dose, or discontinuing the drug.

Roughly 10 percent of people develop a rash which requires a medication change. As an example, with Tarceva, the "usual" dosage is 150 mg daily. An oncologist may consider lowering this dose to 100 mg or even 50 mg daily. This can be frightening, especially if the medication is working well for you. It may help to be aware that a 2014 study found that even very low doses of Tarceva, as low as 25 mg daily, have been effective in treating some people with lung cancer.

Common Terminology Criteria for Adverse Events

The grade of acne-like rashes and corresponding treatment recommendations are included in the common terminology criteria for adverse events put out by the National Cancer Institute.

Grade 1

  • The rash affects less than 10% of the body area and is associated with only mild discomfort or itching
  • Topical drugs are usually recommended, such as topical erthyromycin, clindamycin, or metronidazole. Topical corticosteroids may also be used.
  • Non-occlusive make-up or sunscreen may be used to improve appearance when going out in public.

Grade 2

  • The rash covers 10 percent to 30% of the body area, and causes distress emotionally and/or socially such that it impacts daily activities.
  • Oral tetracycline derivatives are recommended due to their anti-inflammatory activity. Choices include tetracyclines, oxytetracyclines, doxycycline, and lymecycline. Full dose treatment is used for four weeks to eight weeks, followed by low-dose maintenance treatment.

Grade 3

  • The rash covers 30 percent of body area with either a significant impact on daily activities and psychosocial function or evidence of local secondary infection.
  • Treatment with oral tetracycline derivatives plus oral corticosteroid (such as prednisone) for three to five days. Antihistamines may be needed for itching. A change in dose or EGFR-interval should be considered.

Grade 4

  • Any amount of body area with extensive secondary infection (symptoms of blistering or ulceration).
  • EGFR inhibitor should be temporarily stopped. Hospitalization may be needed with intravenous antibiotics and corticosteroids.

Future Treatments

For severe symptoms that prompt consideration of reducing the dose or stopping treatment, a promising new treatment option was noted in a 2019 case report. In this report, the drug Emend (aprepitant), a medication usually used for chemotherapy-induced nausea and vomiting, resulted in complete control of the skin rash and itching associated with Tarceva (erlotinib).

A Word From Verywell

Rashes from EGFR inhibitors can be uncomfortable and unsightly (who wants to feel like a teenager with acne again?) Fortunately, there are treatments that can help with the rash, and sometimes just knowing that the rash could be a positive sign that the medication is working can reduce some of the stress of the rash. If your rash is bothersome, make sure to talk to your oncologist. Some people hesitate to "complain" as a rash is not as life-threatening as many potential side effects of treatment. Yet, quality of life is extremely important as you cope with cancer.

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