Targeted Therapies and Skin Rashes

It's important to be aware of this possible side effect

In This Article

If you've experienced an acne-like rash, dry skin, itching, or nail changes while taking medication to treat lung cancer, you're not alone. For certain people with cancer, targeted therapy medications have made a great difference, lengthening survival with fewer side effects than many chemotherapy drugs. However, these drugs can cause irritating skin problems.

Since the medications are often taken for an extended period of time, learning how to prevent or manage rash symptoms can result in a better quality of life.

Why Targeted Therapies Effect Skin

Using genetic testing, doctors can now identify specific mutations in cancer cells which make those cells grow rapidly or damage other cells. Medications have been approved that target these mutations in lung cancer cells, preventing the cancer from spreading or better enabling the immune system to kill the cancer cells.

Targeted therapy drugs offer the chance for good outcomes without the severe side effects associated with chemotherapy such as neutropenia (low white blood cell count), nausea, or anemia.

But they have drawbacks, and skin rashes are among the most common ones associated with targeted therapy drugs that work on three specific genetic mutations:

Although researchers are still working to fully understand why these drugs cause skin irritation, it seems to be connected to the job they do to halt the growth of cancer cells.

In addition to blocking mutated cells, the drugs seem to block the proper growth of epidermal (skin) cells that form a protective barrier and promote skin's flexibility. This results in the outer layer of the skin thinning, an increased sensitivity to bacteria and UV damage, and related symptoms.

Acne Rash

Medications that target EGFR mutations, known as EGFR inhibitors or tyrosine kinase inhibitors, frequently cause an acne-like rash that can be very uncomfortable and difficult to deal with. Some find it distressing and that it makes them feel self-conscious around others.

Symptoms may include:

  • Itching
  • Burning
  • Stinging
  • Pain associated with the irritation

The rash most often appears on the scalp, face, upper body, and other sun-exposed areas. 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.

Up to 90% of patients on EGFR inhibitors develop inflammation and bumps within two weeks of starting treatment. The rash often gets worse over the first month, starting out mild and progressing from there:

  1. The rash starts with redness of the skin and a burning sensation.
  2. The skin then begins to crust and becomes dry.
  3. Round, flat or raised red spots (papules) and pimples with pus (pustules) appear.
  4. Eventually, skin infections may develop.

In the majority of cases, symptoms can be well controlled. The most common complaint is mild pain, burning, and sensitivity. However, emotional and social anxiety can also be common while the rash persists.

Symptoms should begin to ease around six to eight weeks after therapy is started.

Acne-like rashes that result from specific EFGR inhibitors are sometimes known by the drugs that cause them—for example, Tarceva rash.

Severity and Grading

These rashes may be generally classified as mild, moderate, or severe:

  • Mild: The most common type of EGFR inhibitor-related rash, it occurs with no ulceration (open areas), weeping (drainage), or infection.
  • Moderate: Mild to moderate symptoms of itching and tenderness may be present, but there's only minimal disruption to everyday activities.
  • Severe: This type of rash covers larger areas (the face, upper chest, and upper back), is usually associated with severe itching and tenderness, and includes open sores, drainage, and secondary skin infection. It often impairs quality of life.

They may be more specifically graded as follows:

Grade Papules/Pustules Redness/Tenderness Other
1 Affect less than 10% of the body None Rash may be covered with appropriate make-up
2 Cover 10% to 30% of the body Possible •Social and emotional impact possible
•Everyday activities limited in some way
3 Cover more than 30% of the body Possible •Local secondary infections possible
Social and emotional impact possible
•Significant limitations to everyday activities
4 Any percentage of the body Possible Severe life-threatening superinfections occur with the need for hospitalization
5 Fatal Fatal Extremely rare degree of infection that results in death
 

Other Skin Problems

With EGFR inhibitors or other targeted therapy changes, you may not experience the acne-like skin issues, but other problems may occur, such as: 

  • A feeling of being sunburned even if your skin isn’t red and hasn't been exposed to the sun
  • Increased sensitivity (burning or blistering) when exposed to UV rays
  • Dry, brittle, itchy, scaly and cracked skin—especially on the hands and feet
  • Sores around the fingernails and toenails
  • Hand-foot syndrome, which can cause tingling and numbness, redness, and blisters

Treatment Options

While there are rare incidents of skin rashes related to targeted therapies causing critical infections, approximately 80% of the rashes can be controlled with simple measures.

The treatment options for skin rashes with EGFR inhibitors depend on the severity of the rash as well as whether or not there's evidence of a secondary infection. Discuss the best course of treatment with your doctor before applying any topical creams or taking any medications.

Doctor recommendations may include using simple over-the-counter treatments or prescription medications.

Mild rashes may resolve on their own without any treatment. If you do need to treat a small area, alcohol-free, perfume-free, and dye-free skin creams or ointments may relieve some discomfort. You may be prescribed a mild corticosteroid cream or antibiotic.

For rashes over larger areas of the body that cause itching and soreness, you might be prescribed a prescription cream or gel and/or oral antibiotics.

Serious rashes that disrupt sleep and impact your quality of life are also likely to put you at risk for infections. In addition to prescription creams or gels and oral antibiotics, you may be given corticosteroid pills.

Medication Changes

If your skin problems are severe, the dose of targeted therapy medication will also need to be reduced. Expect to see your doctor often during this time.

If the rash doesn’t get better within about two weeks, the targeted drug is often stopped until the skin changes improve. It may then be re-started with continued skincare.

Roughly 10% of people on targeted therapies develop a rash that requires a medication change. As an example, the usual dosage of Tarceva (erlotinib) is 150 milligrams (mg) daily. An oncologist may consider lowering this dose to 100 mg or even 50 mg daily if skin issues arise. Research shows that Tarceva can effectively treat some cases of lung cancer at doses as low as 25 mg.

Interestingly, studies suggest that patients who develop a significant rash while using these targeted therapies are more likely to have a positive response to the treatment compared to those who don't develop a rash (42% vs. 7%). Knowing this may lead you to decide that the benefits of the drug you are on are worth withstanding associated discomfort.

If you are undergoing combined therapy treatment, you may experience skin problems related to chemotherapy and radiation therapy in addition to an EGFR rash or rashes from other targeted therapy treatments.

Your oncologist will need to assess your side effects to see if treatments may need to be adjusted to address the problems.

Future Treatments

A promising new treatment is also being studied. The drug Emend (aprepitant), a medication usually used for chemotherapy-induced nausea and vomiting, has been given to lung cancer patients suffering from severe rashes caused by targeted therapy drugs.

In studies, the medication completely controlled the skin rash and itching associated with Tarceva.

Prevention

Knowing the risk for rashes while taking targeted therapy drugs, it helps to have a strategy in place when you begin treatment so you can avoid serious complications.

Consider the following:

  • Keeping skin clean to avoid bacteria build-up and infections
  • Using heavy moisturizing lotions
  • Protecting your skin from the sun using UV blocking clothes or staying out of the sun; avoid sunscreens that make the rash worse
  • Avoiding skin irritants such as petroleum-based products

Researchers have found that using moisturizers with a substance known as polydatin (a glycosylated polyphenol that protects the body's tissue) reduces the incidents of rash in people who take certain EGFR inhibitors. Studies continue to look at how it works and what other substances might be effective prophylactics.

A Word From Verywell

Rashes from targeted therapy drugs can be uncomfortable and aesthetically undesirable. Fortunately, there are treatments that can help with such rashes. Simply knowing that the rash could be a positive sign that your medication is working may also help reduce some of the stress of dealing with these skin changes.

Some people hesitate to "complain" to their doctor as a rash is rarely severe. If your rash is bothersome in any way, make sure to talk to your oncologist.

Was this page helpful?
Article Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Cancer Institute. Targeted therapy.

  2. Arrieta O, Carmona A, De jesus vega MT, Lopez-mejia M, Cardona AF. Skin communicates what we deeply feel: antibiotic prophylactic treatment to reduce epidermal growth factor receptor inhibitors induced rash in lung cancer (the Pan Canadian rash trial). Ann Transl Med. 2016;4(16):313. doi:doi.org/10.21037%2Fatm.2016.08.19

  3. American Cancer Society. Targeted therapy side effects. Updated December 27, 2019.

  4. Barton-burke M, Ciccolini K, Mekas M, Burke S. Dermatologic Reactions to Targeted Therapy: A Focus on Epidermal Growth Factor Receptor Inhibitors and Nursing Care. Nurs Clin North Am. 2017;52(1):83-113. doi:10.1016%2Fj.cnur.2016.11.005

  5. Fabbrocini G, Panariello L, Caro G, Cacciapuoti S. Acneiform Rash Induced by EGFR Inhibitors: Review of the Literature and New Insights. Skin Appendage Disord. 2015;1(1):31-7. doi:10.1159%2F000371821

  6. Szejniuk WM, Mcculloch T, Røe OD. Effective ultra-low doses of erlotinib in patients with EGFR sensitising mutation. BMJ Case Rep. 2014;2014. doi:10.1136/bcr-2014-204809

  7. Petrelli F, Borgonovo K, Cabiddu M, Lonati V, Barni S. Relationship between skin rash and outcome in non-small-cell lung cancer patients treated with anti-EGFR tyrosine kinase inhibitors: a literature-based meta-analysis of 24 trials. Lung Cancer. 2012;78(1):8-15. doi:10.1016/j.lungcan.2012.06.009

  8. Seki N, Ochiai R, Haruyama T, et al. Need for Flexible Adjustment of the Treatment Schedule for Aprepitant Administration against Erlotinib-Induced Refractory Pruritus and Skin Rush. Case Rep Oncol. 2019;12(1):84-90. doi:10.1159/000493256

  9. Fuggetta MP, Migliorino MR, Ricciardi S, et al. Prophylactic Dermatologic Treatment of Afatinib-Induced Skin Toxicities in Patients with Metastatic Lung Cancer: A Pilot Study. Scientifica (Cairo). 2019;2019:9136249. doi:10.1155/2019/9136249

Additional Reading