14.4 skin problems in oncology

Question 1

What are the three layers of the skin? Which layer contains the skin’s blood supply

Answer 1

epidermis
dermis
Subcutaneous fat

dermis contains blood supply

Question 2

List two types of cells found in the epidermis

Answer 2

keratinocytes (main)
melanocytes
Langerhans cells
Merkel cells

Question 3

List two specialized units located within epidermis

Answer 3

hair follicle
sebaceous gland
eccrine and apocrine sweat glands

Question 4

List three cancers that most commonly cause hematogenous spread of cancer to the skin

Answer 4

breast
lung
melanoma
colon

Question 5

List three causes of brown discoloration in people with advanced cancer

Answer 5

generalized melanosis - a shower of single melanoma cell dissemination

adrenal insufficiency

ACTH producing tumors

Chemo side effect

hemosideran deposition due to widespread inflammation

Question 6

List two causes of generalized xerosis, list the most commoon cause of erythoderma; what is the best management for these conditions?

Answer 6

xerosis - general dryness - chemotherapy side effect, decreased food intake, hypoproteinaemia, renal failure
Management - daily use of emollient

erythoderma - general redness of the skin - most common leukemia/lymphoma
management - emollients, steroids

Question 7

List three mechanisms for radiation induced skin damage

Answer 7

radiation destroys section of basal keratinocytes stimulating non-cycling basal cells into a cycling phase; continued destruction from xrt overwhelms process and causes severe destruction

damage to dermal vasculature - capillary disruption, extravasation, inflammation -> release of histamine

hair growth interrupted

damage to sweat and sebbaceous glands

Question 8

List the four stages of acute radiodermatis

Answer 8

erythema and edema (appear 1-2w, peak 3-4)
dry desquamation
moist desquamation
ulceration

Question 9

List four factors that influence the risk of acute radiodermatis

Answer 9

radiation energy
total dose and fractionation
use of bolus material that reduces skin sparing effect of megavoltage units
individual sensitivity
older age
previous sun damage

Question 10

What is radiation recall? How is it treated

Answer 10

inflammatory reactions triggered by cytotoxic chemotherapy that develop in previously irradiated areas

treatment withdrawal and steroids if needed

Question 11

What is the most common paraneoplastic skin disorder? What are its two pathognomonic findings? How is it treated?

Answer 11

dermatomyositis

heliotrope rash (violaceous periorbital rash) and gottron’s papules (slightly elevated, violaceous papules found over joints - digits, elbows, knees)

corticosteroids are mainstay of tx

Question 12

List four common skin associated adverse events from traditional cytotoxic chemotherapeutic agents

Answer 12

alopecia
mucositis
nail changes and paronychia
hand foot syndrome
chronic graft vs host

Question 13

List two common oral infections that can complicate mucositis

Answer 13

HSV1

mucosal candidiasis

Question 14

What is the most common skin reaction from each of the following classes of medication?
EGFR inhibitors (erlotinib)
Non-specific TKIs (sunitinib)
BRAF inhibitors (dabrafinib)

Answer 14

EGFR inhibitors - acneiform pustules on background sebborheic dermatitis-like erythematous plaques

Non-specific TKIs - hand-foot skin reaction (different from hand foot syndrome) - causes hyperkeratotic lesions and blistering on flexural surfaces of digits

BRAF inhibitors - follicular accentuation similar to keratosis pilaris

Question 15

List four skin problems that can occur in bedridden patients

Answer 15

tinea corpis and cruris
mucocutaneous candidiasis
vaginal candidiasis
diaper dermatitis
pressure ulcers

Question 16

A patient has a painful diaper related dermatitis. What two types of creams should be used in the area of the rash

Answer 16

5% dexpanthenol and zinc oxide ointments (barrier cream)

topical corticosteroid

Question 17

List four RF for the development of pressure ulcers

Answer 17

immobilization
older age
Malnutrition 
dehydration
immune suppresion
cancer related coagulopathy
hypoperfusion of the skin
increased susceptibility to skin infections

Question 18

What can you do to prevent radiodermatitis

Answer 18

nothing

Question 19

List 4 ways to treat acute radiodermatitis

Answer 19

washing with mild soap
avoid razors/deodorant
ointment/lotion/cream to moisten skin
Gels
steroid cream
oil-in-water emulsion 
calendula oil
sulcrafate
barrier films

Question 20

What is chronic radiodermatitis and why does it occur?

Answer 20

A second phase of dermal thinning that develops after 52 weeks

Thinning, tightening hyperpigmentation of skin

due to impact of XRT on vasculature