Increasingly effective treatments have ensured that survival from most  forms of cancer has improved significantly in recent years Mortality rates  from cancer fell by 26% in the US from 1991 to 2015, creating an estimated 16 million current cancer survivors, a number expected to grow to 20.3 million by 2026.1 The 5-year relative survival rate for all forms of cancer is currently at an all-time high of 69.3%.1 But these gains come with significant and often long-lasting consequences from cancer treatments such as surgery, radiation, chemotherapy, as well as long-term hormonal therapies for ovarian, breast, and prostate cancers. As the first line of immune defense and the largest organ system in the body, the dermal system is particularly traumatized by cancer therapies.

The dermatologic consequences to cancer treatment are broad and vary by therapy and patient. Chemotherapies, and pharmacologic and radiologic treatments, have a lasting impact on immune function in the months and years following cancer that leaves patients vulnerable to bacterial, viral, and fungal infections of the skin from surgical scars, at catheter sites and from tubing pressure sores. Skin composition is generally altered by chemotherapy, contributing to immune compromise, while radiation treatments cause permanent damage and changes to skin cells that promote bacterial and fungal growth.2

Many cancer patients, particularly women, experience premature aging due to loss of skin elasticity, collagen, and excessive dryness, the result from hormonal changes caused by chemotherapeutic agents and/or hormonal therapies.2 Breast cancer is the most common cancer diagnosis worldwide, and the treatments produce a full range of cutaneous effects, in addition to the significant scarring and body-altering challenges of mastectomy and lumpectomy surgeries.


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Among drug therapies for cancer, immune checkpoint inhibitors so important to management of advanced malignancies are associated with significant immune-related adverse events that most frequently target the skin.3 These include severe inflammatory reactions, most commonly maculopapular rashes, pruritus, psoriasis, and lichenoid eruptions.3

And so, dermatology visits are increasingly devoted to helping cancer survivors reckon with the consequences of treatment, driving earlier treatments and proactive strategies for longer-term management.

Oncodermatologic Management

Aesthetic treatments have become important to reducing the appearance and discomfort of surgical scars, as well as keloids, lymphoedema, fibrosis, pigmental disorders, alopecia, and other cutaneous responses to cancer therapies. The most common of these include dermal fillers, botulinum toxin, and laser therapies.

Scar Reduction Treatments

In the months after surgery, scar revision options include dermabrasion, microneedling and subcision, punch excision and grafts, fillers, nonablative fractional lasers, ablative and fractional ablative lasers, and platelet-rich plasma (PRP). These may be employed separately or together to reduce discomfort, psychological distress, and to offer the patient a sense of recovery to a normal life after cancer.

Dermal fillers, including autologous grafts of fat or collagen, or synthetic materials are considered safe and effective for reducing depressed scars and scar revision surgery.4 “I use dermal fillers to not only improve volume loss but to help with asymmetry after treatments such as surgery and radiation—there is also improvement in skin quality as well,” explained Anthony M. Rossi, MD, FAAD, a clinician at  Memorial Sloan Kettering Cancer Center and New York Presbyterian Hospital in New York, NY.

Corticosteroid injections can be used to manage or prevent hypertrophic scars and keloids, according to a 2019 review by Peng et al,5 and provide additional benefits to decrease swelling and allowing for quicker wound healing. “This injection is typically intradermal or transdermal, taking care not to inject any deeper to avoid causing tissue atrophy,” they advised. Hypertrophic scars and keloids also respond well to pressure therapy. Low-dose fractionated radiotherapy after surgical excision of a keloid may be used as a last resort, due to a slight risk for malignancy, but is generally considered safe and effective.5

Minimizing Hyperpigmentation Scars

Discoloration of the skin around surgical scars is common and often resolves with time. Depending upon the natural skin tone and the treatments used, however, it may remain prominent, and in the patient’s opinion, require further treatment. Laser therapies such as pulsed dye, potassium titanyl phosphate, or Nd:YAG lasers are all pigment-specific and have shown some benefits, while microneedling or collagen PRP induction therapy and topical hydroquinone  can also improve scar hyperpigmentation to varying degrees.5

Managing Other Post-Treatment Disorders

Botulinum Toxin is approved for many uses outside of cancer and is often used off-label in post-cancer treatment. According to Dr Rossi, it can be effective in correcting asymmetry and help with areas of fibrosis such as in the neck post radiation. He noted it is useful to help relax spastic muscles as well. However, the use of fillers and botulinum toxin are associated with some side effects. “Similar to use on-label there are common adverse events such as bruising, infection, nodularity. However, in radiated skin or skin that has had surgery and reconstruction there is more compromise of the skin so we take caution to go slowly,” Dr Rossi said.

In a study of patients with breast cancers in which the skin was significantly damaged by radiation treatments, Dr. Rossi found that radiation-induced telangiectasias were significantly improved by laser therapies.6 “Not only did the laser improve the skin changes and look of the skin but the patients’ quality of life improved in all domains. In all, 16 patients reached the 50% RIBT clearance threshold during the study period, and 11 of these patients (69%) completed follow-up HR-QOL questionnaires. Patients showed statistically significant improvements in emotional and functional Skindex-16 HR-QOL domains and in overall Skindex-16 HR-QOL score. Breast-Q scores also improved significantly, illustrating a decrease in specific physical and cosmetic concerns common to radiated breast skin.” 

These therapies have benefits beyond simple cosmetic repairs, with significant impacts on patient outcomes. “I have seen improved quality of life in many domains including physical, emotional, and social domains,” Dr Rossi said. 

References

1. Hulvat MC. Cancer Incidence and Trends. Surg Clin North Am. 2020 Jun;100:469-481. doi: 10.1016/j.suc.2020.01.002

2. Rossi AM, Hibler BP, Navarrete-Dechent C, Lacouture ME. Restorative oncodermatology: Diagnosis and management of dermatologic sequelae from cancer therapies. J Am Acad Dermatol. 2021 Sep;85:693-707. doi:10.1016/j.jaad.2020.08.005

3. Geisler AN, Phillips GS, Barrios DM, et al. Immune checkpoint inhibitor-related dermatologic adverse events. J Am Acad Dermatol. 2020 Nov;83:1255-1268. doi:10.1016/j.jaad.2020.03.132

4. Proietti I, Skroza N, Mambrin A, et al. Aesthetic Treatments in Cancer Patients. Clin Cosmet Investig Dermatol. 2021 Dec 4;14:1831-1837. doi:10.2147/CCID.S342734

5.  Lee Peng G, Kerolus JL. Management of Surgical Scars. Facial Plast Surg Clin North Am. 2019 Nov;27(4):513-517. doi:10.1016/j.fsc.2019.07.013

6. Rossi AM, Blank NR, et al. Effect of laser therapy on quality of life in patients with radiation-induced breast telangiectasias. Lasers Surg Med. 2018 Apr;50(4):284-290. doi:10.1002/lsm.22780