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Many cancer drugs dry the skin; some cause an acne-like rash, sore nail folds or red, painful hands and feet. Gentle washing in lukewarm water, a thick fragrance-free moisturiser, gloves for housework and careful nail trimming help; with some targeted drugs the team prescribes preventive creams from day one. Tell the team early about a rash or sore nails, and urgently about a rash with wheezing.
The MASCC EGFR inhibitor guideline (2011, the most recent MASCC guideline on this that could be read) is the only graded source read in full. For acne-like rash it recommends prevention from the start of treatment: hydrocortisone 1% with moisturiser and sunscreen, plus doxycycline 100 mg twice daily (or minocycline 100 mg daily) for the first 6 weeks, on randomised data (systemic tetracyclines level II, grade A; topical regimen level II, grade C). For dry skin it recommends tepid bathing with mild moisturising soap or bath oil, regular moisturising creams, and avoiding extreme temperatures and direct sun (level III, grade B); thick occlusive emollients in a tub, avoiding alcohol-containing lotions, retinoids and benzoyl peroxide. For fissures, protective footwear and avoiding friction (level III, grade B). For paronychia, dilute bleach soaks (level II, grade A), comfortable shoes, careful nail trimming and gloves for cleaning. For hand-foot syndrome, a 2026 comparison of six guidelines found five of six advise avoiding chemical and physical stress to the hands and feet and using alcohol-free moisturiser; only ESMO, BC Cancer and eviQ recommend oral celecoxib for capecitabine. NCI's patient booklet (2023) gives matching ungraded advice. The ESMO 2021 dermatological toxicity guideline could not be read.
Why: The acne-like rash appears in the first weeks in most people on these drugs, and starting treatment before it appears makes it milder.
“Hydrocortisone 1% combined with moisturizer, sunscreen, and doxycycline 100 mg bid for the first 6 weeks is recommended based on randomized data.”
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · Systemic (minocycline or doxycycline): II A; topical (hydrocortisone 1% with moisturiser and sunscreen): II C (MASCC Table 3)
Why: Hot water and long soaks strip the skin's oils and make dryness and cracking worse.
“Avoiding bathing in excess and using tepid water as opposed to hot water is recommended.”
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · III B (MASCC Table 8, xerosis prevention)
Why: Thick creams hold water in the skin better than thin lotions.
“Moisturizers should be occlusive, emollient creams that are generally packaged in a jar or tub rather than a lotion that can be pumped or poured.”
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · III B (MASCC Table 8, xerosis treatment)
Why: Alcohol and acne treatments dry the skin further; the rash from these drugs is not ordinary acne.
“Topical retinoids and benzoyl peroxide gels are not recommended due to their drying effect”
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · III B (MASCC Table 8: alcohol-containing lotions, retinoids and benzoyl peroxide listed as not recommended)
Why: Pressure and small injuries around the nails trigger painful inflammation of the nail folds.
“Wearing comfortable shoes, trimming nails but avoiding aggressive manicuring, and wearing gloves while cleaning (e.g., household, dishes) are recommended to minimize periungual trauma.”
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · Expert opinion (MASCC: no randomised trials of paronychia treatment)
Why: Friction and heat worsen hand-foot syndrome and the deep cracks that some drugs cause in fingertips and heels.
“Regarding prevention, five of six guidelines (83%) advised avoiding chemical and physical stressors to the hands and feet and using alcohol-free moisturizer.”
Supportive Care in Cancer 2026 · Consensus across five of six guidelines (comparison study; recommendation grades not given in the abstract)
Why: Nail fold infection needs checking, and hand-foot syndrome of grade 2 or worse usually means pausing the drug until it settles.
“Let your doctor or nurse know if your cuticles are red and painful.”
National Cancer Institute (US) 2023 · Not graded (patient booklet)
Why: These can be signs of an allergic reaction or of the drug leaking out of the vein, which need treating straight away.
“Tell your doctor or nurse right away if you wheeze or have trouble breathing along with:”
National Cancer Institute (US) 2023 · Not graded (patient booklet)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
For EGFR inhibitors, preventive treatment from the first day (hydrocortisone 1% with moisturiser and sunscreen, plus a tetracycline for 6 weeks) is the best-supported step, on randomised data (MASCC 2011: systemic II A, topical II C). General skin and nail care (tepid bathing, thick fragrance-free emollients, no alcohol-based products, gloves, comfortable shoes, careful nail trimming) rests on level III evidence and expert opinion, and the guidelines agree on it. For hand-foot syndrome the guidelines agree on avoiding friction and heat and using alcohol-free moisturiser, and on pausing the drug at grade 2 or 3 (all but ONS), but disagree on drugs: only ESMO, BC Cancer and eviQ recommend oral celecoxib to prevent capecitabine hand-foot syndrome. The ESMO 2021 guideline, which is the most recent comprehensive one, could not be read, so its grades are not reproduced here.
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 · Supportive Care in Cancer 2026 · National Cancer Institute (US) 2023
Where it differs: Adds a prescribed anti-inflammatory tablet to prevent hand-foot syndrome on capecitabine.
Evidence: Recommended by ESMO, BC Cancer and eviQ but not by ONS, UKONS or the UK North Cancer Alliance, according to the 2026 comparison of six guidelines.
Where it differs: Cools the hands and feet during infusion to prevent hand-foot syndrome.
Evidence: ESMO and ONS recommend cooling for taxanes; BC Cancer and eviQ for all agents (2026 comparison abstract).
Where it differs: Soaks fingers or toes in very dilute bleach (about 0.005%) to prevent infection of inflamed nail folds.
Evidence: MASCC 2011 Table 10: level II, grade A for prevention of paronychia, from a non-EGFR, non-cancer study.
MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011
Where it differs: For itchy, dry or peeling skin, sprinkle cornstarch and take a colloidal oatmeal bath when the whole body itches.
Evidence: Patient booklet advice, not graded; MASCC lists colloidal oatmeal among occlusive emollients for dry skin (level III, grade B).
National Cancer Institute (US) 2023 · MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Preventive tetracycline (minocycline or doxycycline) for EGFR inhibitor rash | Level II, grade A (MASCC Table 3) | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| Preventive hydrocortisone 1% with moisturiser and sunscreen for EGFR inhibitor rash | Level II, grade C (MASCC Table 3) | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| Tepid bathing and regular moisturiser to prevent dry skin; avoid extreme temperatures and direct sun | Level III, grade B (MASCC Table 8) | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| Protective footwear and avoiding friction to prevent fissures “Wearing protective footwear or covering the fingertips to avoid friction can prevent skin fissures and aid healing.” | Level III, grade B (MASCC Table 9) | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| No randomised trials of paronychia treatment; recommendations are expert opinion “Similarly, there have been no randomized controlled studies evaluating therapies for paronychia.” | As stated by MASCC | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| No randomised trials of prevention or treatment of EGFR inhibitor dry skin “To date, there are no existing randomized clinical trials assessing the prevention or treatment of EGFRI-induced xerosis.” | As stated by MASCC | MASCC Skin Toxicity Study Group (Supportive Care in Cancer) 2011 |
| Pause the drug for grade 2 or 3 hand-foot syndrome and continue when it improves “All guidelines except ONS recommended dose suspension with grade 2 or 3 HFS and continuation when resolved or improved.” | Agreed by five of six guidelines (all except ONS), per the 2026 comparison | Supportive Care in Cancer 2026 |
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