Reguiai, Z., Bachet, J.B., Bachmeyer, C., Peuvrel, L., Beylot-Barry, M., Bezier, M., . . . Bouche, O. (2012). Management of cutaneous adverse events induced by anti-EGFR (epidermal growth factor receptor): A French interdisciplinary therapeutic algorithm. Supportive Care in Cancer, 20, 1395–1404.

To draft an algorithm for optimal management of cutaneous adverse events with epidermal growth factor receptor (EGFR)-inhibitors in patients receiving EGFR treatment.

The quality of publications was analyzed using the Oxford scale for methodology. Information about practices was collected through a questionnaire developed by a steering committee. The questionnaire was completed by 67 individuals including oncologists, gastroenterologists, and radiotherapists via regional meetings in seven towns in France, chaired by three to five local experts. A national meeting was held to build an algorithm. Participants comprised 20 members who were on the steering committee, were regional meeting chairs, and were in a bibliographic study group.

Databases searched were PubMed, Embase, and the Cochrane Collaboration. Reference lists of articles retrieved were manually searched.

Search keywords were EGFR inhibitor (and each specific drug name), skin toxicity, rash, acne, aceneiform, nail, paronychia, hair, alopecia, hirsutism, hypertrichosis, trichomegaly, xerosis, pruritus, and itch.

Inclusion and exclusion criteria were not stated.

• Recommendations regarding the use of preventive doxycycline on initiation of EGFR are level II. All other recommendations are level IV, expert opinion only.
• Preventive measures on introduction of EGFR inhibitors include the following.
  • Systemic cyclines (doxycycline 100–200 mg per day, lymecycline 300 mg, or minocycline 100 mg) for at least six weeks
  • Moisturizing skin cream
  • Perfume-free cleanser with pH close to skin pH
  • Conventional photoprotection with clothing or an anti-ultraviolet with a sun protector factor (SPF) of 15 or higher
  • Cut nails straight, but not too short.
  • Nonaggressive shaving, with caution
  • Avoid harsh manicure or pedicure, ordinary soap, alcohol-based products, and physical irritation.
• Provide care for folliculitis according to grade and paronychia according to the level of symptoms. Use the same types of interventions as outlined for prevention, with the addition of topical steroids in paronychia.
• Additional recommendations with xerosis by grade are provided, including use of emollients (e.g., bath oil), occlusive dressing, and skin adhesive with fissures.
• Topical steroids are not indicated for xerosis, and the efficacy of antihistamines has not been demonstrated.

• Most recommendations had expert opinion–level evidence only, and comprised general skin and nail care recommendations.
• The investigators noted that few data exist regarding dose reduction with EGFRs to evaluate the impact on skin lesions.

This algorithm recommended prophylactic use of systemic cyclines with EGFR treatment across the board. Additional skin and nail care recommendations provided generally are seen elsewhere and are in agreement with expert consensus. A lack of clarity exists regarding dose reduction or treatment delays and the impact on skin symptoms. In addition, a lack of research evidence exists for interventions other than cyclines.