Acneiform lesions secondary to ZD1839, an inhibitor of the epidermal growth factor receptor

Characterisation of the cutaneous pathology in non-small cell lung cancer (NSCLC) patients treated with the EGFR tyrosine kinase inhibitor erlotinib

INTRODUCTION

EGFR inhibitors (EGFRIs) have been shown to be clinically effective in various cancers. Unique skin toxicity is commonly observed with EGFRIs and a correlation between the clinical benefit of EGFRIs and this characteristic rash has been reported. Erlotinib is a potent EGFRI approved for treatment of non-small cell lung cancer (NSCLC) and pancreatic cancer.

METHODS

This is the first time in which patients were given increasing doses of an EGFRI to induce a mechanistic rash and study its associated pathology in skin. Biopsies were collected during treatment from both rash-affected and unaffected skin of 23 NSCLC patients and compared with pre-treatment biopsies.

RESULTS

Altered differentiation of appendegeal epithelium (hair follicles and sebaceous glands) was remarkable in both affected and unaffected skin, although epidermal growth was not significantly reduced. A predominantly mononuclear leucocyte infiltrate was detected in the interfollicular dermis or around skin appendages. This infiltrate included TRAIL-positive cells with a dendritic cell (DC) morphology, although T-cells, antigen-presenting DCs and macrophages were also evident. This is the first report showing the involvement of a dendritic cell subtype with EGFRI skin toxicity.

CONCLUSIONS

Altered differentiation of pilosebaceous epithelium is evident in both rash-affected and unaffected skin and constitutes the primary process of EGFRI in human skin. We propose that this eventually triggers inflammation and the EGFRI rash. TRAIL-positive inflammatory cells could link rash development and immune-triggered apoptosis of epithelial cells, including those of underlying carcinomas.

Investigation of papulopustular eruptions caused by cetuximab treatment shows altered differentiation markers and increases in inflammatory cytokines

BACKGROUND

Epidermal growth factor receptor (EGFR) critically regulates tumour cell division, survival and metastasis. Agents that inhibit EGFR have been used in the treatment of advanced-stage malignancies, but cause variable cutaneous side-effects, most often papulopustular eruptions and xerosis.

OBJECTIVES

We assayed expression of inflammatory cytokines [interleukin (IL)-1alpha, tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, human leucocyte antigen (HLA)-DR and intercellular adhesion molecule (ICAM)-1], differentiation markers (filaggrin, involucrin and loricrin) and phosphorylated EGFRs (pEGFRs) in papulopustular eruptions to determine the association between these markers and the eruptions caused by cetuximab.

PATIENTS/METHODS

Twelve papulopustular lesion biopsies were selected from patients with colon cancer who had received cetuximab treatment. Immunohistochemistry and immunofluorescence with a confocal laser scanning microscopy were performed.

RESULTS

Filaggrin expression decreased and expression of involucrin, various inflammatory markers (IL-1alpha, TNF-alpha, ICAM-1 and HLA-DR) increased and the expression of pEGFR was markedly downregulated in papulopustular eruptions. In perilesions, decreased pEGFR expression was noted in hair follicles compared with interfollicular epidermis. The increase of IL-1alpha and TNF-alpha was observed in perilesions as in the lesions.

CONCLUSIONS

The early inflammatory events (IL-1alpha and TNF-alpha expression) seen, and the lack of pEGFR in perilesional follicles, indicate that inflammatory events induced by EGFR inhibition may initiate papulopustular eruptions along with the altered differentiations. The decrease of filaggrin may contribute to the pathogenesis of the xerosis caused by cetuximab.

Severe cutaneous reaction to cetuximab with possible association with the use of over-the-counter skin care products in a patient with oropharyngeal cancer

BACKGROUND

The management of locally advanced head and neck cancer remains a challenge to most oncologists and their patients. Treatment with epithelial growth factor receptor inhibitors (EGFRIs) is associated with a good response. Cetuximab, a chimeric monoclonal antibody directed against epithelial growth factor receptor (EGFR), in combination with radiation therapy is indicated for the treatment of locally advanced squamous cell carcinoma of the head and neck. Although a mild acneiform skin rash (Grade 1, 2) is very common in these patients, severe rash (Grade 3) is uncommon.

CASE REPORT

A 61-year-old African American man with locally advanced oropharyngeal cancer was treated with cetuximab and radiation. He developed a sudden flare-up of a skin rash after the 5th cycle of cetuximab following use of over-the-counter (OTC) skin care remedies. The rash manifested with severe maculopapular eruption and erythematous rash, along with desquamation and exfoliation of the skin, mainly on the face and neck area. The patient denied any extraordinary sun exposure. Cetuximab and radiation therapy were held for 1 week and the rash was treated with doxycycline, diphenhydramine, and continued use of natural emollient (Vaseline petroleum jelly). After 1 week, a dramatic improvement of the facial rash was noticed.

DISCUSSION

Our report describes a sudden flare-up of a skin rash (Grade 3) after the 5th cycle of cetuximab following use of OTC skin care remedies, which was unusual for this patient, suggesting a possible relation to the therapy. Skin crucially depends on EGFR for its normal function and becomes extremely sensitive during cetuximab therapy. Topical OTC acne and dry skin remedies can suddenly change the mild acneiform rash into severe skin toxicity associated with marked desquamation and exfoliation. Avoidance of further skin damage caused by topical applications and the use of doxycycline and diphenhydramine show a significant success in the management of skin toxicity.

Chemotherapeutic agents and the skin: An update

Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Review: side effects of approved molecular targeted therapies in solid cancers

Major advances have been achieved in the field of biologically based therapies for cancer in the last few years, and some of the recently approved molecular-targeted therapies are now being used in daily clinical practice. These molecular targets are also expressed in normal cells, which explains the different grades of toxicity, resulting from the disruption of normal cellular function. In general, targeted molecular therapies have good toxicity profiles, but some patients are exquisitely sensitive to these drugs and can develop particular and severe toxicities. In this article, we review the toxicity and safety of various small molecules and monoclonal antibodies used in solid tumors, with discussion of the pathophysiology, correlation with response, and strategies for prevention and management.

Cutaneous reactions related to systemic immunomodulators and targeted therapeutics

The arrival of targeted therapeutics into the oncology clinic, while enthusiastically anticipated, introduced the oncologist to dermatologic events that can pose challenging management issues. The dermatologic effects of these targeted agents appear to be more frequent than those with cytotoxic therapy and are not uniform; that is, different agents have distinct dermatologic toxicities. Interestingly, dermatologic toxicity may correlate with antitumor activity with some of these targeted agents. The correlation of rash with response and survival in particular mandates the development of effective and appropriate management strategies. The nature and challenges of the dermatologic events observed to date with epidermal growth factor receptor inhibitors, multikinase inhibitors, proteosome inhibitors, BCR-ABL tyrosine kinase inhibitors, and immunomodulatory drugs will be addressed in this review.

Two cases of acneiform eruption induced by inhibitor of epidermal growth factor receptor

BACKGROUND

Cetuximab is a member of a new family of antineoplastic agents that inhibit the epidermal growth factor receptor (EGF-R), and which are increasingly being used in the treatment of solid tumors.

METHODS

We have observed new secondary side effects. We present here 2 patients with acneiform eruption secondary to the administration of cetuximab (IMC-C225, Erbitux). The diagnoses of these patients were adenocarcinoma.

RESULTS

Histologically, a superficial purulent folliculitis and disordered differentiation with focal parakeratosis were observed. The follicular eruption responded favorably to treatment with 5% benzoyl peroxide and 4% erythromycin gel. These lesions healed within a few days after treatment.

CONCLUSION

The cutaneous adverse effects of cetuximab are similar to other EGF-R-targeted agents and result from direct interference with the functions of EGF-R signaling in the skin.

Classification and management of skin, hair, nail and mucosal side-effects of epidermal growth factor receptor (EGFR) inhibitors

Inhibitors of epidermal growth factor receptor (EGFR) are commonly used as therapeutic agents in oncology. In contrast to currently used oncological treatments, these inhibitors almost always cause skin- and skin adnex toxicity. About 85% of treated patients develop to a more or lesser extent an acneiform eruption. Xerosis cutis and painful nail disorders occur in, respectively, 35% and 10-15% of all treated patients. Also hair and mucosal changes have been reported, although to a lesser extent. These skin- and skin adnex toxicities are reversible after withdrawal of treatment, but are seldom a reason to stop or interrupt therapy. This review outlines the classification, the pathogenesis and therapy of these skin, hair, nail and mucosal changes due to EGFR inhibition. Informing the patient and management of these side-effects is very important to reduce discomfort and as such to increase compliance to therapy.

Three case reports of hand-foot syndrome with gefitinib

Hand-Foot Syndrome (HFS) is commonly reported in treatment with liposomal doxorubicin (LD) and capecitabine. We present 3 cases of HFS recall with gefitinib after previous LD therapy. The first 2 cases, in patients with head and neck cancer previously treated with paclitaxel and LD, developed on subsequent therapy with gefitinib. One patient had previously developed HFS on LD and the other had not. In both patients HFS resolved after stopping gefitinib. The third case is of a patient with ovarian cancer, also treated with gefitinib after LD, who developed HFS recall which resolved after gefitinib withdrawal. HFS can occur with gefitinib in patients who have been previously exposed to agents known to cause HFS.

Treatment of gefitinib-associated folliculitis

Gefitinib (Iressa), an epidermal growth factor inhibitor approved for treatment of advanced nonsmall cell lung carcinoma, is associated with an acneiform distributed folliculitis. Treatment attempts for this folliculitis have been noted in the literature, but photodocumentation of results has not been reported. We report 3 consecutive cases of gefitinib-associated folliculitis with photodocumentation of their treatment responses to combination therapy with topical metronidazole and oral tetracyclines.

Mechanisms of cutaneous toxicities to EGFR inhibitors

The increased target specificity of epidermal growth factor receptor (EGFR) inhibitors (EGFRIs) is associated with the reduction or abolition of nonspecific and haematopoietic side effects. However, coincident inhibition of receptor activity in tissues that depend on EGFR signalling for normal function has undesirable consequences. Because of the key role of EGFR signalling in skin, dermatological toxicities have frequently been described with EGFRIs. The resultant significant physical and psycho-social discomfort might lead to interruption or dose modification of anticancer agents. There is an urgent need for an improved understanding of these toxicities to develop adequate staging systems and mechanistically driven therapies, and to ensure quality of life and consistent antineoplastic therapy.

Description and management of cutaneous side effects during cetuximab or erlotinib treatments: A prospective study of 30 patients

BACKGROUND

Drugs such as cetuximab or erlotinib, which inhibit the epidermal growth factor receptor, are increasingly being used in treatment of solid tumors. This has led to the appearance of new secondary effects.

OBJECTIVE

We sought to describe the cutaneous side effects and their management in patients with cancer treated with cetuximab or erlotinib.

METHODS

We clinically examined 30 patients determining type, frequency, treatment, and evolution of side effects.

RESULTS

Most patients presented with a cutaneous reaction consisting of a follicular eruption, typically appearing in seborrheic areas within the first 15 days of treatment. Painful fissures in palms and soles and paronychia were the second most common cutaneous toxicities. We also noticed an alteration in hair growth at several months' follow-up. As these secondary effects responded well to treatment, few patients discontinued the antineoplastic therapy because of cutaneous toxicity.

LIMITATIONS

This was a prospective but uncontrolled study.

CONCLUSION

Although these new targeted therapies have low systemic toxicity because of their high specificity, cutaneous side effects are common and may be serious.

Follikuläre Arzneimittelreaktion auf Cetuximab

Cetuximab belongs to a newly developed group of anti-cancer drugs, which have an inhibitory effect on the epidermal growth factor receptor (EGF-R). EGF-R plays a major role in the homeostasis of the epidermis and epidermal appendages. In addition, EGF-R is expressed on a variety of carcinomas of different origin and is thought to be partly associated with tumor progression. For this reason, inhibition of EGF-R seems a promising anti-cancer therapy, as shown in a few clinical trials. As a side effect of the therapy, a follicular rash often develops in the seborrheic areas; this cutaneous reaction is associated with longer survival. We present a typical case and discuss the important features of the follicular rash occurring after EGF-R inhibition.

[Skin signs associated with epidermal growth factor inhibitors]

BACKGROUND

Inhibitors of epidermal growth factor receptors (EGFR) constitute a new alternative treatment for patients presenting certain advanced stage solid cancers (bowel, breast, ovary). Adverse cutaneous effects of these drugs are now starting to be described.

OBSERVATIONS

Our study involved 2 men and 2 women with no previous history of acne included in a treatment protocol comprising EGFR inhibitors. Mean age was 52 years. The primary cancers were breast, ovary, bowel and unidentified. The EGFR inhibitors used were gefitinib (ZD1839) (2 cases), carnetinib (Cl1033) and cetuximab (IMC-C225). Skin lesions appeared after 7 days and included erythematous papules and follicular pustules of the face, back and upper chest. No comedons were seen, and there were no nodules or cysts. The severity of the rash resulted in discontinuation of treatment in 2 patients with complete disappearance of skin lesions in both cases. In one patient, reduction of the dosage of gefitinib (IMC-C225) led to gradual resolution of the rash. Histological examination of papules and pustules concluded on an acute suppurative folliculitis. Smears and cultures ofa nasal lesion and pustules revealed coagulase-positive Staphylococcus aureus in 2 patients. Combined doxycycline 100 mg daily and benzoyl peroxide was prescribed for 3 months and a favourable outcome was achieved after a mean 2 weeks.

DISCUSSION

EGFR inhibitors act by inhibiting mechanisms oftumour proliferation in certain cancers at advanced stages or refractory to other treatments. Our findings in these four patients are similar to the published cases in terms of rapid onset of monomorphous, papulopustular, follicular eruption without comedons. Rapid response to cyclines and benzoyl peroxide is also reported in literature. This treatment must be instituted rapidly and patients must be informed about the cutaneous side-effects of EGFR inhibitors before the start of therapy. The pathophysiology of these eruptions is still unknown. Skin signs are probably due to interaction with EGFR functions, including overexpression of EGFR in keratinocytes and hair follicles.

Efectos cutáneos de los inhibidores del receptor del factor de crecimiento epidérmico

Epidermal growth factor receptor (EGFR) inhibitors are a new group of drugs used in the treatment of several malignancies. Three molecules are approved at the moment: gefitinib and erlotinib for the treatment of non-small-cell lung cancer, and cetuximab for colorectal cancer. These drugs originate cutaneous side effects with a high frequency: acneiform rashes, paronychia and generalized xerodermia. In this paper we review these common side effects and how to manage them.

Gefitinib: an adverse effects profile

Gefitinib, an epidermal growth factor receptor inhibitor, is currently approved for use in patients with advanced non-small cell lung cancer who have failed previous chemotherapy or who are not suitable for chemotherapy in > 30 countries. The approved dose in patients with non-small cell lung cancer is 250 mg/day. The most common adverse effects are rash, diarrhoea, acne, dry skin, nausea and vomiting. Most of the effects are mild-to-moderate in nature and do not require discontinuation of therapy. The severity of many of these effects is dose-related with grade 3-4 effects more likely at a dose > 250 mg/day. The most severe adverse effect is interstitial lung disease (ILD), which occurs in approximately 1% of patients worldwide except for Japan where the incidence of ILD is 2%. ILD is fatal in approximately one out of three of the cases. The most common adverse effects associated with chemotherapy, myelosuppression and alopecia, are not commonly seen with gefitinib monotherapy.

Phase II trial of gefitinib 250 mg daily in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

PURPOSE

An objective response rate of 11% was reported in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) treated with 500 mg daily gefitinib although the recommended dose in lung cancer is 250 mg. This study evaluated the efficacy and toxicity of 250 mg daily gefitinib in patients with recurrent and/or metastatic SCCHN.

EXPERIMENTAL DESIGN

Phase II trial with objective response rate as the primary end point. Measurements of quality of life and levels of serum vascular endothelial growth factor and transforming growth factor-alpha were assessed before and during therapy.

RESULTS

In 70 patients, 1 (1.4%) partial response was observed. Median progression-free survival and overall survival were 1.8 and 5.5 months, respectively. Quality of life scores improved transiently during the first weeks of therapy before returning to baseline. Median vascular endothelial growth factor and transforming growth factor-alpha levels were above the normal range but were not predictive of outcome. Four patients experienced grade 3 drug-related adverse events. Rash of any grade was observed in 64% of subjects. Correlation between disease control (partial response + stable disease), progression-free survival, and overall survival and grade of cutaneous toxicity was observed (P = 0.001, 0.001, and 0.008 respectively).

CONCLUSIONS

Gefitinib monotherapy at 250 mg in recurrent and/or metastatic SCCHN seems to have less activity than was previously observed for 500 mg daily. A dose-response relationship may exist for this agent in SCCHN and grade of cutaneous toxicity attributable to gefitinib is a clinical predictor of better outcome.

Management of Rash and Other Toxicities in Patients Treated with Epidermal Growth Factor Receptor—Targeted Agents

Inhibition of the epidermal growth factor receptor (EGFR) represents one of the most important avenues for research and development in the field of cancer therapy. The EGFR is a member of the ErbB receptor tyrosine kinase (TK) family, which also includes ErbB-2 (HER2/neu), ErbB-3 (HER3), and ErbB-4 (HER4). Current EGFR therapies available for use include monoclonal antibodies, such as cetuximab, and small-molecule EGFR TK inhibition by agents such as erlotinib. Side effects of these agents include dermatologic manifestations without the bone marrow suppressive properties of chemotherapy. Understanding of rash and how it relates to EGFR inhibitor toxicity and, perhaps more importantly, EGFR inhibitor response must be more clearly defined with clinical trials. The optimum management of rash in patients receiving anti-EGFR therapy remains somewhat controversial; this is secondary to imprecise classification of rash as well as the lack of clinical trials to determine the most appropriate treatment algorithm for these patients. We propose a treatment strategy to help aggressively treat dermatologic side effects allowing patients to continue receiving therapy without dose interruption or drug discontinuation.

Erupción acneiforme por inhibidores del receptor de crecimiento epidérmico

One of the fundamental aims of oncological research is the search for molecules with greater efficacy against tumors and less toxicity than the usual chemotherapeutic agents. Epidermal growth factor receptor inhibitors are a new group of drugs which, because of their more specific effect against neoplastic cells, seem to meet these characteristics. Skin eruptions are one of the most frequent adverse effects associated with their use, secondary to the drug's direct inhibitory effect on homeostasis of the epidermis and of the pilosebaceous follicle. Several cases of cutaneous toxicity in patients treated with epidermal growth factor receptor inhibitors have recently been published. We present three cases of acneiform eruptions attributable to different drugs in this family (cetuximab, gefitinib and erlotinib).

Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors

The last few years, new therapies targeting the epidermal growth factor receptor (EGFR) have shown their efficacy in the treatment of several types of cancer. Monoclonal antibodies against the EGFR (e.g. cetuximab, panitumumab) or EGFR tyrosine kinase inhibitors (e.g. gefitinib, erlotinib) are generally well tolerated and do not have the severe systemic side-effects usually seen with cytotoxic drugs. A considerable number of patients treated with these EGFR inhibitors, however, develop dermatological side-effects, most frequently an acneiform eruption but also xerosis, eczema, fissures, telangiectasia, hyperpigmentation, hair changes and paronychia with pyogenic granuloma. These skin effects appear to be mechanism-based linked to the inhibition of EGFR action but the exact pathophysiology remains elusive. Left untreated these dermatological side-effects could represent a threat to patient compliance. Therefore effective management is mandatory. Mild cases of acneiform eruption respond well to topical anti-inflammatory acne therapy, whereas tetracyclines are needed to treat moderate to severe cases. This review outlines the broad spectrum of cutaneous side-effects of EGFR inhibitors, discusses possible underlying mechanisms and provides practical guidelines for the management based on literature data and on personal experience.

Erupción acneiforme secundaria a cetuximab

C225 (cetuximab) is a monoclonal antibody that targets the epidermal growth factor receptor (EGF-R). It is used for the treatment of solid malignant tumors in advanced stages. It works against tumors by inhibiting cell proliferation, angiogenesis and the formation of metastases, as well as by promoting cell apoptosis. We present the case of a 64-year-old male patient affected with a colon neoplasm with hepatic metastases, for which treatment with cetuximab was indicated. He came to our department because of a skin eruption with papules and pustules located on the face, neck, presternal area and upper back, but with no cysts or comedones. The biopsy was compatible with an acneiform eruption. The patient was treated with minocycline, 100 mg/day for 2 weeks, with the clinical symptoms responding favorably. When he was given further doses of cetuximab, he once again presented with new eruptions, but of lesser intensity. Because of the high frequency with which this adverse effect appears, it is recommended that cetuximab be included on the list of drugs causing acneiform eruptions.