Let's Learn About CRC
CtDNA Testing For CRC
Clinical Trials
BRAF Talks
RAS Talks
HER2/ERBB2 Talks
All Things Liver
Peritoneal Metastases
The Conference Center: Research Roundups
Rectal Cancer
Anal Cancer
Practical Considerations
Questions? Feedback?

Skin side effects: Dr. Hornick

Doc Talks

In this DocTalk, Dr. Hornick from OHSU discusses skin side effects from colorectal cancer treatments with PALTOWN Scientific Director Dr. Manju George. Recorded in June, 2024.

Manju George 0:00
Hello, everyone, Welcome to Doc talks. I’m Dr. Manju George, the Scientific Director at Paltown Development Foundation. Today we have Dr. Noah Hornick, with us who’s going to talk about skin side effects of colon cancer treatment. So before we start our talk, I’d like to ask Dr. Hornick, how he got into this field and also to tell us a little bit about himself. Welcome.

Dr. Hornick 0:25
Thanks. Sure. So, how I got into Oncodermatology, which is to say that the care for people with skin side effects of chemotherapy is without getting too much into me, I was a researcher before I was before I was a physician, and I was interested in skin disease. And I was in a residency program and training that focused on research and so gave me the opportunity to look for a research lab to work in while I was doing my clinical training. And I encountered two people at the same time, one of whom was Jonathan Leventhal, who’s the oncodermatologist at Yale, and he takes care of people having skin toxicities to their cancer treatments, and sees about 50 patients, is enormously friendly and upbeat and, really takes good care of people, although he sees an unbelievable number of them.

Dr. Hornick 1:20
And at the same time, I encountered Nick Joshi, who is a researcher working on sort of the immunology in a variety of organ systems, but he has a model system that recapitulates features of skin disease that I was seeing in patients who are being treated with Immunotherapy. And so I got into the study of reactions to skin disease in the lab at the same time I got into this- the care for patients who are having skin reactions to their cancer therapies. And the things I really like about that as somebody who’s interested both in taking care of patients, and in research, it pairs really well in both directions. It lets me inform what I’m working on in the lab based on what’s going on with with the patients I’m taken care of. And also, the thinking about the mechanisms of skin reactions is really, really relevant in cancer care, because there are new drugs coming out all the time. And people are getting skin reactions to them. Without any literature, there’s no published articles a lot of the time on the skin reactions that we’re seeing and so we have to infer what we might expect the drugs to be doing based on what their mechanisms are and how similar that is to other drugs that we may have seen skin reactions to previously. And so I think that’s a really interesting and useful way to approach both research and patient care. So that’s how I got into oncodermatology.

Dr. Hornick 2:48
And I’m going to talk a little bit more about what exactly I mean by that. And so I’m at Oregon Health and Science University, this is a picture of our aerial train and the hospital is the building behind it. We’re in Portland, Oregon, and I am the person here who takes care of people having skin reactions to their cancer drugs. So my talk today is going to be really focused on what you might expect in terms of things that can happen to your skin while you’re being treated for colorectal cancer, in the context of what to keep an eye out for, how to talk about it, what some of the common reaction patterns are to some of the common colorectal cancer drugs. And then just a couple of additional little bit about how we take care of those reactions when they happen. Just to give you an overview, if there are any specific areas that I don’t get enough into, then please ask me questions. I mean, there’s tons that we could potentially be talking about here. So I’m going to give you sort of a broad overview first.

Dr. Hornick 3:53
So to get started on that, just wanted to explain a little bit about oncodermatology, because that word even to dermatologists can be a little confusing. This is a sort of an artifact of me, having been trained on the east coast, where oncodermatology largely refers to care for skin conditions related to non skin cancers and cancer therapies, in addition to caring for people with cancers of the skin. The West Coast perception of that word can be slanted toward taking care of melanoma or people with other non melanoma skin cancers. But when I say oncodermatology, and some people use the phrase supportive oncodermatology, most of what I mean is taking care of treatment toxicity as it concerns the skin. And so that largely means looking at cancer associated skin disease. So skin problems that are generated by cancer itself, and then reactions to traditional chemotherapies, targeted therapeutics and Immunotherapy. And today I’m going to be focusing on the latter three areas of this. So if you have something you’re concerned about on your skin, I wanted to give you a little bit of information and my thoughts on what I’m going to ask you about if you see me and for a rash or for something you’re concerned about on your skin in the context of treatment, I’m going to ask you these questions and remembering them is my job and not yours. And so I will always ask these things. But just so you know what I’m going to be interested in, so you know what to keep track of, when you’re encountering something, I thought we would go through some of this stuff.

Dr. Hornick 5:19
So the first thing I’m going to want to know is where is it? And what I mean by that is, is it just in one area? Is it just affecting my left chest or is it in many areas- both of my lower legs, it is all over my upper and lower limbs, it is on my trunk- those are the things I want to know. And important areas, specifically, here are the palms of the hands, the soles of the feet, the face, including any like sores, or pain in your eyes or in your mouth. The genitals, the internal and external genitalia are important for us. And the reason I produce special attention to those areas is because the skin is different in those areas. And the rashes can respect that in a lot of cases, so a lot of things spare the palm soles of genitals and face, a lot of things are unique to the palm soles, genitals or face. And so we really want to know about things and please don’t neglect to mention genital involvement to things if, if it’s embarrassing, believe us, we’ve heard about it before, and we need to know about it, because it can really change what we’re thinking in terms of what a rash does.

Dr. Hornick 6:19
And then we’re going to want to know what the rash looks like. And so to get a little bit into that, the first question that people often ask, is this a rash? Or is it not a rash, or I don’t think it’s really a rash. For me a rash means more than one spot, or more than one thing that has been caused by the same process. And often, we don’t really get to know whether something’s caused by the same process until we’ve got it all figured out. So if you’ve got more than one bump, I’m including it in this or even if they’re flat. So when you’re telling you what it looks like, I want color description. And even for medical students and residents, I tell people not to use their medical terms describing color, but they’re useless. I would much rather people use crayon colors because erythematous could mean a lot of things, but pink means pink. So if you have something that sort of like a pinkish purple or reddish orange, that’s great. I want to know that. I want to know if it’s smooth or, scaly, and when I say scaly, I mean something like maybe dandruff or like dry skin flaking. That’s what I mean by scaly versus crusty, which is like what the scab is like. But smooth versus rough is good, that’s adequate. Is it wet or dry. And when I ask about wet I’m really trying to get at blisters or things that start off trying to be a blister. And pop before you even notice, and so blisters or pustules are really important. And we’ll sort of raise our level of concern a lot of the time. And for those two things, I’m looking for anything that’s full of fluid. If it’s clear fluid, it’s a blister. If it’s white fluid, it’s usually a pustule. But those are the categories of things I’m interested in. And if this is a lot to remember, or you don’t know, you’re not sure or also, if you have something and you’re like is that a rash or a reaction to something and I’m not sure what it’s going to develop into just take some pictures of it, you can always delete them later if it was a mosquito bite, and it goes away. But if you have a bunch of pictures of what’s going on in your skin, that’s really helpful. And if people want to know more about taking pictures of skin, that’s something I can talk about later.

Dr. Hornick 8:21
And I’m going to want to know what it feels like. Does it itch? And then if it does it, is the itch just where the rashes or does it itch in places where the skin looks normal? Does it itch before the rash shows up? Does it itch, only when the rash is healing? And then if it hurts, what kind of pain, sharp pain burning pain, aching pain, these are all sorts of different gradations of things. But you know, these are these are these aren’t going to be that hard to remember in the moment. And I will ask, but these are the questions I’m going to ask about feeling. And then it’s also important to know how it changes over time. Does an individual spot when I see a lesion I mean, is it one bump or one spot? And does that change over time? Does it show up as a little pink flat thing that then raises, fills with fluid, pops and then turns brown? Or does it show up as a pink bump that then goes back to normal skin? And how long does that process take? Is it over days to weeks? Does that happened within a couple of hours? It’s also really important what the trajectory is. Did everything show up at once and then it sort of stayed the same. Are you still getting new ones? Is it spreading to new areas? Or did it start small spread widely and then focus in on a couple of all of these are different characteristics that you’re going to want to know about. Also I want to know what you’ve tried and it’s fine to try things it’s also fine not to try things and just to ask but if you’ve put anything on it– moisturizer, Vaseline, some medication you had for something else, Athlete’s Foot Cream, whatever you put on it, we will want to know about that and whether it did or didn’t help. Also same thing for itch. if the itch is keeping you awake at night and you tried Benadryl and that didn’t help, I want to know that.

Dr. Hornick 9:56
And then another thing I wanted to make sure to mention is Neosporin and triple antibiotic ointment, two of the three antibiotics in those topical medications are common causes of contact allergies. So in general, I advise people not to use them unless we are confident something’s infected or particularly worried that it’s going to be. Because something that happens a lot is someone sees something on their skin is worried about it puts on Neosporin has an allergic reaction to the Neosporin and so the spot gets worse. And so they put on more Neosporin. And then it gets worse. And they come in a week or two later, with this big, horribly itchy reaction. And then really important, what else is going on? Did you now or did you recently have any other symptoms and so I’m especially going to always be asking about like fever and chills, cold symptoms, cough, runny nose, sore throat, changes in your vision, pain with swallowing, dark urine, blood in the stool, stomach pain, all of these things are really important. And then have you changed anything recently, and that can be changes to your medications, even stopping some or changing the brand or sun exposure matters. If you just spent the weekend at the lake, then that can really trigger some rashes, and then also exposure to sick people, sometimes people will get a virus and have only a skin reaction. And sometimes you will get a virus and have something that doesn’t include a skin reaction, and people won’t connect them in their mind. But if you’ve been around a sick child or grandchild recently, that’s something I want to know. And so that’s again, that’s all my job to ask and the job of your healthcare providers to ask. So if you don’t remember all that, that’s completely fine. But I just wanted to give you a run through of the things we’re interested in a rash.

Dr. Hornick 11:39
Now I’m gonna talk about some of the more common reaction patterns that we see in a lot of the drugs that are used to treat colon cancer. These reactions are not unique to the drugs I’m going to talk about. And these are not an exhaustive list of all of the reactions that people can have to the drugs that I am going to talk about. So just because it’s not included, doesn’t mean it’s not a real association. But there’s a lot of things that can happen or have been reported a couple of times, and I’ve tried to focus on the most common ones. So starting with the traditional chemotherapy medications, oxaliplatin is an alkylating agent, which is not important except that it tends to share reaction types with other alkylating agents. And these can include toxic erythema of chemotherapy. And that phrase is a sort of umbrella term that’s used to refer to direct damage to the skin by the action of the drug. So traditional chemotherapy drugs kill rapidly dividing cells, that’s how they treat cancer. And that also is how they produce their side effects because they will affect anything else that’s rapidly dividing. And that often includes the skin. Toxic erythema of chemotherapy, as I said, is an umbrella term. So it includes a bunch of different reaction patterns and some of the more common ones for oxaliplatin are this sort of large dying area that you can see in this photo, or these little bumps, these are the same process, but in a much smaller, more concentrated area. And these tend to be because the drug is concentrated in the sweat to be excreted and it kills the cells around the sweat glands. Oxaliplatin can also cause hair loss that’s most commonly temporary, which is of course one of the very common reactions to chemotherapy. But oxaliplatin has been reported to occasionally cause persistent hair loss, which can be a problem that we we see. it will also cause nail changes. Some people get these sort of longitudinal brown stripes, which are called melanonychia, but are harmless that do develop with oxaliplatin therapy. And more common than that are these white transverse lines that are called mees lines. But these are again related to the drug causing damage to rapidly dividing cells. The fingernails grow from this area at the base out and they don’t do as good a job of producing a nail when you’re receiving chemotherapy. So you get these little white lines that happen with each cycle and the striping will stop as soon as you finish therapy. People also– I don’t have a photo for this– people will also get allergic or anaphylactic reactions to like the sort of throat tightening the like real, severe bee sting reaction people worry about. You can get that to oxaliplatin and that is something that the risk of that happening increases with the number of cycles given. And this is sort of the same thought process as the Neosporin. A lot of people will say well, I’ve been using this one for years I’ve never had a problem. Exposure of broken skin to Neosporin increases the likelihood of you developing an allergic reaction to it. And the same is true for oxaliplatin, the more times you get it, the more likely it is that you’ll develop an allergic reaction to it. And this is often limited to hives, but it can progress to include facial swelling or throat tightening and so it’s something we need to know about. And we can usually manage with just medication around the time of infusion with steroids antihistamines.

Dr. Hornick 14:56
Then Xeloda or Capecitabine, depending on where you’re at the pronunciation varies, and 5 fluorouracil. So these are antimetabolites, they work in the same way capecitabine turns into 5FU after you take the pill. And so they’re exactly the same drug when they get to the circulation of your body. They can also cause toxic erythema of chemotherapy. But much more prominently affects the palms and soles with a condition that we call hand foot syndrome, which can be quite painful and lead to thickening of the skin to the point that it’s hard to use your hands or feet. It can also cause intertriginous eruption of chemotherapy, which is again under that same umbrella, this is all damage done directly by the chemotherapeutic drug to skin cells. But again, being concentrated in sweat glands and in the armpits or groin, it can cause a an exanthem, which is sort of the classic “maculopapular”, drug rash, its bumps and flat areas of pink to red that can cover the whole body usually starting on the trunk and spreading outward. They can cause nail inflammation, so we call this paronychia, which is not always infected, but can become infected, the damage is to the lateral folds of the nails. This can also be quite painful. They can cause sun sensitivity and cause sunburns. I’ve sort of glossed over hyperpigmentation, but it often will affect palms and soles after or even during hand foot syndrome. But some we will often warn you to stay out in the sun when you’re on these drugs, because you’ll sunburn much more easily. And then I have to get a little dermatology to talk about the inflammation of actinic keratoses. So people with a lot of sun damage will develop skin cancer, and but they will also develop these things that aren’t skin cancer, but are sort of one step on the road towards skin cancer called actinic keratoses. If you’ve been to the dermatologist and have a history of sun damage, you’ve had some stuff frozen probably. And that probably that’s what we most commonly do to treat these things. Only about one in 500 a year will turn into a skin cancer but we try not to give them the chance. And so we freeze them when you come in to see us. If you have a lot of them, and we don’t want to freeze a whole big area of your body, we will sometimes give you the topical version of 5FU to apply which treats all of them at once. And, so they’ll get inflamed and then sort of resolve to go back to normal skin. As you might guess, when when you when you 5FU by IV or when you take capecitabine by mouth, we treat all of the actinic keratoses on your body at the same time, and they can get really inflamed. And this can be really alarming. But ultimately, it’s potentially helpful. And it means you have you need less dermatology treatment in at least in the next couple of years. But again, it can be painful and alarming. So this is something we see often, especially when people have a history of a lot of sun exposure. And then people will also get radiation recall on these medications. So if you’ve been treated with radiation in the past, you can get a basically a repeat of the skin reaction to radiation in the same area that was irradiated while you’re on capecitabine or 5FU. So I don’t have photos for irinotecan because it’s mostly the things that we’ve already talked about. But it’s a different class of medication, it tends to have fewer skin side effects than those other medications, although you can get inflammation in the skin folds or hand foot syndrome with irinotecan. It can also cause the nail inflammation that I described, and it can cause hair loss. Um, that was the total of the things I wanted to talk about for cytotoxic chemotherapy. Again, I’m just sort of giving the quick overview of the most common things. So there’s certainly things I didn’t discuss, and we can get back to them later if you’d like.

Dr. Hornick 18:52
But I wanted to talk a little bit about targeted therapeutics because in particular, EGFR inhibitors are one of the most common reasons that colon cancer patients come to see me. And so I wanted to make sure to spend some time on them. The most common reaction reaction we see with EGFR inhibitors, which for colorectal cancer mostly is panitumumab and cetuximab, is this papulopustular or acneiform skin reaction. And that can affect the face, the chest, the back the arms, the same areas that get acne really, although this isn’t technically acne, so I tend to try to call this papulopustular rather than acneiform. And there’s a couple of reasons for that. One is because it’s I’m being a little bit pedantic and trying to be more accurate, but another one is that a lot of the things that people use to treat acne are not helpful and in some cases are harmful when you’re treating reactions to EGFR inhibitors. So getting away from using the word acne to talk about them, I think is generally a good idea.

Dr. Hornick 19:45
This usually shows up quickly after treatment and within the first few weeks and the classical teaching is that the reaction tends to improve with time even when people stay on the medication. I’ve certainly seen people have really severe reactions to EGFR inhibitors that don’t really improve with time. So I don’t tend to tell people to expect that. It’s just a nice thing if it actually happens. But classically, it’s supposed to get better over time. Itch and dryness can be a major feature, of this is obviously not itch and dryness in the photo but you can maybe see a little bit around the edges of this rash. It can be a feature of EGFR inhibitors, and that can really go all the way into frank eczema, just red, scaly, itchy patches. That’s part of the reason that I try to avoid using traditional acne treatments to treat people on EGFR inhibitor is because the eczema type of presentation and the itch are contributed to by drying of the skin and a lot of standard acne therapies are drying intentionally so that makes that worse. You can also get nail inflammation and nail changes is a really common side effect of EGFR inhibitors that looks very much like the photo that I showed earlier. But can affect all fingers and toes and can really limit the use of hands and feet, which is one of the one of the major reasons that –if the skin is going to interfere with you staying on this drug that’s one of the more common ways for that to happen. Hair loss and hair changes can definitely also happen on EGFR inhibitors and that’s what this photo of is somebody who got really pronounced exuberant eyelash growth while on an EGFR inhibitor. They can also cause sores in the mouth and they can be a cause of acquired zinc deficiency. So a lot of times I recommend my patients take just a normal over the counter zinc supplement if they’re on an EGFR inhibitor.

Dr. Hornick 21:39
Bevacizumab and regorafenib or both VEGF inhibitors, Regorafenib is not as selective it treats its other kinases also, but these are both intended to target the vascular endothelial growth factor or VEGF, at least in part, and their prominent reaction particularly for Regorafenib is hand foot skin reaction. And that the name of that reaction is a failure of dermatology, because it is not the same as hand foot syndrome and it is almost exactly the same name. But you can see why you would want to call it hand foot skin reaction. It produces these thick plaques, usually on the hands and feet. And this is very related to pressure. So the more you use your hands and feet and the areas that are bearing the most pressure of your hands and feet are the areas that are most likely to get these reactions. These drugs can also cause edema and swelling locally, they can cause slow poor or slow wound healing, they can cause flushing again, mouth sores or just dryness.

Dr. Hornick 22:46
BRAF inhibitors have have a bunch of different potential skin side effects. They treat the same pathway as MEK inhibitors which have different side effects. But I’m going to talk about BRAF inhibitors first, often they’re co administered, but I’ll talk a little bit about that. But BRAF inhibitors can cause this granulomatous dermatitis, which is what you’re looking at on the right here. It’s not the most common reaction, but it is not rare and it is unique to BRAF inhibitors. This tends to not be painful or itchy, it just sort of shows up over the trunk. Because they cause sun sensitivity, they can also cause squamoproliferative lesions, which is sort of an umbrella term again, that includes both verrucous keratoses, which is what’s in the top row here. And those are benign things that we don’t need to do anything about. And then it also includes keratoacanthoma (KA) and squamous cell carcinoma, which are skin cancers, which look almost identical, are on the lower panels. And the these were a major concern when we first started putting people on BRAF inhibitors because people can get quite a lot of skin cancer on them, to the point that they’re needing– and these are cured with surgery, with local surgery, but after 10 or 12 of them and especially when they’re right next to the eye like this, that’s still a major problem. And so can be a concern for patients that are on these drugs. The BRAF inhibitors can also lead to hair loss or hair texture or color changes, it can lighten or darken hair or it can become curly when it wasn’t previously. They can also cause palmoplantar keratosis and hand foot skin reaction that can generate a whole bunch of new moles or lead to keratosis pilaris, which is sort of rough skin colored bumps usually on the upper outer arms or the sides of the hips. And then MEK inhibitors which again on that same pathway, cause a papulopustular reaction very similar to what EGFR inhibitors do and they do it for the same reason. These drugs will act on the same pathways at different points. But MEK inhibitors cause papulopustular reaction, mouth sores and nail inflammation, just like EGFR inhibitors.

Dr. Hornick 24:55
The BRAF inhibitors and the MEK inhibitors work at different points in the same pathway in ways that sort of make up for each other’s problems. And that isn’t helpful to the cancer if you’re treating with both drugs, but it is helpful to all of this all of the different skin reactions. If you give a MEK inhibitor and a BRAF inhibitor together, you get much milder and much lower rates of the papulopustular eruption that you get with the MEK inhibitor. Your rate of phototoxicity, which is one of the common reactions to BRAF inhibitors goes from 22 to 4%, you get almost no skin cancers compared to what you get on the BRAF inhibitors alone. And then also the the hand foot skin reaction rates go way, way down. So we really advocate for giving both of these things at the same time. And in fact, there is a company that’s working on making a topical BRAF inhibitor to give for the papulopustular reaction of patients that are only on MEK therapy. And so that’s what I was going to cover in terms of the targeted therapeutics angle.

Dr. Hornick 25:59
And then Immunotherapy is an enormous topic, I often give an entire talk just on reactions to Immunotherapy because as I wish I remember who said this, but there was a conference a few years ago where somebody said in front of the Academy of Dermatology that checkpoint inhibitors cost dermatology and that’s essentially true. Basically, anything that happens to your skin after you’ve been on a checkpoint inhibitor could be due to the checkpoint inhibitor, and we have no real good way of determining what is and isn’t. So there are a ton of different reactions to Immunotherapy, I’m only going to talk about ones that I think really are directly caused by the drug. And they’re very common, we see a lot of people that are having skin reactions to these drugs. And they come across a large range of types. So there’s a recent paper that discussed defining the different types of reaction to checkpoint inhibitor therapy, one of the problems with figuring out exactly what’s going on and all of these rashes is that a lot of people will not see dermatology or will not have their rash fully characterized. And so a lot of the information we have a lot of the data that we’ve collected over the years about skin reactions to Immunotherapy lists things just as rash or as an incompletely characterized rash. So this paper that came out this year in the Journal of Immunotherapy of cancer is trying to establish how to decide what category to put a rash that patient on Immunotherapy develops into and what the different subtypes of those broader types are. And while I think this is a great idea, I still think that we’re going to need more dermatologic involvement in the treatment and in the treatment of patients on Immunotherapy. And so in order to get people adequately characterized, because their their broad overarching category types are here listed on the left, there are 10 of them. And then there are subtypes of each of those. And if you’re not used to looking at rashes and differentiating them into a bunch of different classes that can be really challenging thing to do. And so I’m a big advocate for getting a dermatology involved in the care of people with rashes related to their cancer therapy as early as possible. It’s not always possible in a lot of institutions, there isn’t somebody like me who devotes a lot of time to this and saves patient spots for them. So even taking photos and then sending them for an electronic consultation, if that’s available can be really helpful. But just to talk a little bit about the different types of reaction people get. We have photos of all of the 10 This is all from that that same article, but the psoriasiform looks just like psoriasis. And although there are a lot of different subtypes of psoriasis, usually it can be one of the more recognizable types because psoriasis itself is quite common, that’s in picture a here on the left. Lichenoid is named for its relationship to Lichen Planus which is a fairly common skin disease but not as common as psoriasis. And that’s in the center panel here. Pemphigoid is the most common blistering reaction to Immunotherapy. And it usually shows up first as just pink bumps that are extremely itchy and can look a bit like hives. But instead of going away within a couple hours like a hive usually will, they will stick around and progress to blisters.

Dr. Hornick 29:08
I’ll talk a little bit more about that later. Vitiligo is focused, really well defined lightening of areas of the skin. Grover’s disease is another common skin disease outside the context of Immunotherapy and it’s a bunch of itchy bumps that usually focus around this the the border between the chest and the abdomen so and a band that goes around the back, so the middle of the back to the basically the bottom of your solar plexus. That’s the area that Grover’s likes and it’s these little pink itchy bumps. Eczematous reactions are dry skin and itchy patches that look just like eczema like a lot of kids have. You can get an exanthem which this is not my favorite photo of it again, usually it starts on the chest but it’s that sort of classic drug rash that is pink to red bumps and flat areas that shows up shortly after the administration of the medication. People sometimes also get a typical squamous proliferations, which is a mouthful of a term, but it basically is referring to that sort of same process I was talking about with BRAF inhibitors where they can get these verrucous keratoses. Or sometimes they’ll look like skin cancers under the microscope. Although usually we treat this eruption with topical steroids or injected steroids rather than with surgery. And then erosive mucocutaneous eruptions. This is again a sort of a lumping term, but they’re describing things that are on the spectrum of Stevens Johnson Syndrome, which is a name that people are afraid of, because it can lead to widespread loss of skin, which is obviously dangerous. But it can be more mild in the context of checkpoint inhibitor therapy. There’s a different subtype of it that has been characterized that is really slowly progressive and then tends to get better without as much treatment and sometimes doesn’t even require you to stay off of checkpoint therapy.

Dr. Hornick 31:02
To talk a little bit more about some of the most common ones of these. So the eczematous eruptions tend to be later. So these things show up, like I said, we can’t rule out the Immunotherapy as being a cause once you’ve been on it, because it sort of affects the way in which your immune system responds to your own cells. But eczema does tend to show up later as a reaction to checkpoint inhibitors four to 18 months after starting the medication. And although that’s often mild, it can present in a bunch of different versions of eczema. So nummular dermatitis is a kind of eczema that’s a little round like, a coin shaped, this is what the term means, patches of itchy eczema skin. Asteatotic is just referring to dryness and so that can be eczema presenting as skin that gets drier and drier until in some areas it’s so dry that it gets inflamed because the skin barrier isn’t able to function well anymore and you get patches of eczema over the driest areas. Dyshidrosiform another medical specific term but really this is referring to the the kind of eczema that affects mostly hands and feet and preferentially like the sides of the fingers. It looks like tiny tiny little blisters and in little clusters and it doesn’t necessarily look like eczema. So it’s worth recognizing– if you’ve got too much a little itchy blisters on the sides of your fingers that’s probably actually eczema. And then these can occur in different combinations. Psoriasiform is also later, it can show up more than a year after you’ve started the medication. And this is most often classic plaque psoriasis, which is the sort of elbows and knees well defined red, scaly plaques, but it can also cover the entire body or it can present with multiple different subtypes at the same time. It can cause psoriatic arthritis. Inverse psoriasis refers to sort of red scaly, but the scaly is not always present because the inverse effects the folds so it’s called inverse because usually psoriasis is on the extensor surfaces of joints, whereas inverse is on the flexor surfaces of joints and that can affect the groin or the neck or the armpits and isn’t something that always looks exactly like psoriasis. Palmoplanar psoriasis affects the palms and soles as you might guess, from the name. It can be specific to that, that’s what this photo is of is somebody who’s got a palmoplanar, actually pustulosis, a combination of palmoplanar and pustules but, and you can see the leg is not necessarily not nearly as severely affected as the sole of the foot. Pustular psoriasis has tiny microscopic pustules in it, even when it’s like the most common version of plaque psoriasis, but some psoriasis is very prominently pustular and you can see many medium to large pustules that get all crusty. And then erythrodermic just refers to when it covers the entire body. That also does happen with psoriasis related to checkpoint inhibitor therapy. Pemphigoid reactions to checkpoint inhibitors tend to be late. They’ve been reported as early as two weeks into therapy but they’ve also been reported as long as two years after starting and they will sometimes show up after you stop the treatment. A lot of these things persist after the end of Immunotherapy and so that can be a problem that we wind up having to deal with for a longer period of time. Pemphigoid is something we worry about because the blistering can affect mucous membranes and if it gets into the mouth or the esophagus or the eyes that obviously has real concerning consequences. So we tend to stop Immunotherapy use steroids for this is on a systemic basis. Not always but we worry about it. And then you can also develop pemphigoid as a sort of transition from other skin reaction patterns. So we see people that have lichenoid reaction, which is that sort of I’ll talk about it next but the sort of scaly bumps and then overtime develops into a blistering reaction. Lichenoid, again sort of covers the whole spectrum of timeframes, including after stopping treatment. But this is one of the more common reactions we see, it’s usually mild, it’s itchy, but usually it just affects a few areas and responds well to topical treatments, but sometimes it’s really widespread. Sometimes it affects the scalp and causes scarring and hair loss, and sometimes it will cause ulcerations in the mouth or in the genitals. And those regions, when they get involved can make can be a) harder to treat and b) more problematic to the patient. And so this is sometimes a reason we have to stop therapy. Lichenoid is frustrating to treat because there aren’t very many good treatments once it gets beyond topical steroids for the skin.

Dr. Hornick 35:46
So in terms of taking care of your skin to sort of try to prevent as much of this as possible. And these these instructions are in general applicable to everybody that’s on therapy or a reason to for a lot of cases. But if you have the opportunity to optimize your skin before you start therapy, that’s going to be helpful. If particularly you’re going on a traditional chemotherapy agent that can cause hand foot syndrome, or if you’re going on a kinase inhibitor that can cause hand foot skin reaction, you’re going to want to minimize corns and calluses because that friction and that the thickened areas of skin are going to be more prone to having those problems once you do start therapy. So getting those minimized or treated or removed with help from podiatry, if necessary will help improve the likelihood that you’ll not get those problems once you’re on therapy. And then if you have any other skin conditions, if you have existing psoriasis or you have existing eczema or you have some other skin issue that that you’ve treated and is sort of not a huge problem, it might become worse, particularly with Immunotherapy. So it’s worth checking in with your dermatologist, your primary care provider or if you don’t have one of those, getting one to talk about your skin conditions before you go on therapy just to minimize the likelihood that you get a flare. Moisturizing regularly is good advice for everybody. But particularly people on drying medications, which includes most of the things that I’ve talked about. And that’s going to include avoiding alcohol based lotions. If a moisturizer dries down to the point that you can’t feel that there’s moisturizer on your skin within a couple of minutes, that’s probably because it contains a lot of rubbing alcohol. And while that is nice to apply, it winds up being more drying than moisturizing for your skin. So we would prefer that you use heavier, thicker, topical moisturizers which is going to be creams or ointments. Any brand is generally good Vaseline is one of the best moisturizers, but or generic vaseline is fine. But the thing that they do is not give your skin moisture, they provide an additional layer to prevent moisture from getting out. So the most useful time to put this stuff on is right after you get out of the shower or the bath. That’ll help lock in the moisture that you’ve just put in by soaking yourself in water and make sure you get the maximum benefit of being coated in goo. If you’re at risk for hand foot syndrome or hand foot skin reaction if you’re on other medications that does that, wearing loose clothing, so these are all friction reducing plans, but wearing loose clothing and avoiding hot temperatures and using urea based creams on the hands and feet are all going to help limit the risk of developing those things. The urea, there’s also ammonium lactate, but we mostly mostly use urea for this is a is something we call a keratolytic, it dissolves the proteins that make up the surface of the skin. So it thins thicker areas of skin. And we’re using that to to prevent the buildup of calluses or the formation of these sort of thick plates that can cause cracking, which is really painful.

Dr. Hornick 38:58
And you can overdo it you people usually don’t but it is possible to to use so much of this that it starts to stink to apply. And if that happens, then you can take a couple of days off until it doesn’t seem to apply anymore. It just means you’ve you’ve done a good job in the skin is as thin as your skin is comfortable. For short term infusions for medications that you get as an infusion over 30 minutes to a few hours. If you can tolerate having scalp cooling with either ice packs or a scalp cooling device, or holding cold packs in your hands and feet that will reduce the amount of chemotherapy or other drugs that gets delivered to those areas. And so reduces the risk of you developing reactions in those areas. So that’s not always possible because either it hurts to hold ice packs for two hours or because you’re on capecitabine and you’re taking it as a pill every day and you can’t constantly have a cold hat on. But when you can do it it can be helpful. Just keeping your eye on your skin is a good eye idea and that will let you let us know what’s going on. If you keep your team informed, then we’re going to be better able to stop things, it’s much easier to get something to quiet down when it’s early and to keep it quieted down than it is to get control of something once it’s affecting your whole body. And so I’m not saying that you need to send in My Chart messages to your oncologist every time you get a mosquito bite, but for sure if you’ve noticed something that’s different about your skin, and you’re going in for a visit, I know most people see their doctors pretty often while they’re on therapy. It’s always worth mentioning while you are already in the room, and if there’s anything you’re worried about, certainly always send us a message.

Dr. Hornick 40:44
This is not a specific list of treatment options, because there’s too much there to cover. But this is just sort of a list of the things that we do use sometimes. So the kinds of treatments we use to take care of these kinds of skin conditions. We use a lot of topical steroids and there are 50 plus different versions of topical steroids. They vary in vehicle, so lotions or creams or ointments or liquids. And we usually try to choose something that is in a strength that is appropriate for the body area we’re treating. So if you run out of something that we gave you for your body, and you want to use some of your face medication for it, just check in and make sure we’re giving you an appropriate strength for that. Usually we try to do two week courses here. But that’s mostly to minimize side effects and will often go beyond that if necessary. There are other topical measures that we use, and they are really specific to the reaction being treated. Non steroidal anti inflammatories, like Protopic, or tacrolimus, or Pimecrolimus, those are fairly general purpose things. But other than that, they’re going to be pretty specific to the particular skin reaction that you’re having. That can include things that are otherwise anti inflammatory, that numb pain, that are related to or are directly vitamin D or vitamin A, we use antibiotics a lot, we use anti itch creams or topical minoxidil. For some things, we’ll use light therapy for itch, some inflammatory conditions. Light Therapy is actually really, really very early, very helpful. But it can require a lot from you in terms of, you have to be treated two to three times a week for it to work, and it usually takes a month or more to really get going because we have to start at a low dose and then slowly increase the dose of light, so we don’t give you sunburns. But if that’s a hurdle that can be cleared, it can be really helpful for inflammatory skin conditions or for itch. And then for pills, there’s a whole lot of them, especially for itch. We, we don’t understand itch as a species, we’re not we’re not good at it, we can’t describe it well, in terms of its mechanism we have a lot of different pathways that we think are involved. But it’s still complicated. And so we use a lot of different drugs, and none of them are uniformly effective. But all of the ones that we try work for some people, so we tend to just choose something that’s not more likely to cause a lot of side effects, and not likely to interact with your other drugs and then see how it goes and then cycle through until we find something that works for you. So that can be frustrating. But there are also a lot of treatment options, which is in a way reassuring. We’ll use a lot of antibiotics by mouth for papulopustular reactions, we have some pills we use for hair loss. Sometimes we’ll use Otezla or Apremilast for psoriasis. And then for lichenoid psoriasis, we’ll use acitretin. And then we try to avoid using systemic steroids in people that are on Immunotherapy. Because we worry that they interfere with the action of the drug against the cancer. Although the studies about that are conflicting, we still try to avoid using prednisone when we can it can be really, really helpful in a lot of these conditions. I certainly do use a lot of prednisone, but I try not to on people on immunotherapy. And then there are specific injectables for psoriasis for pemphigoid, and for the eczematous reactions that we like to use. The one treatment type that isn’t on here is for the fingernail and toenail problems, the inflammation around the fingernails and toenails. When that gets really severe, sometimes we can do surgical approaches. So we’ll remove the edges of the nail. And that can make that problem go away. But it’s obviously not a trivial thing to do. And it can cause permanent change to the nail. So it’s not always worth it, especially if it affects all fingers and toes. But it is an option that we sometimes use. And that I think covers all of the things that I wanted to get out today. And so again, I’m going back to oncodermatology, as taking care of malignancy associated skin disease and then reactions to these three different types of cancer treatment. But the goal here is to explain and anticipate the different adverse events that people might get while they’re on treatment, prevent them when we can, preserve patient’s quality of life and to support and enable better cancer outcomes for the people that are on these drugs. So thanks for listening to me. And I’m happy to take any questions that people have.

Manju George 45:08
Yeah, Dr. Hornick, that was great, thank you so much. And it was wonderful to hear that you’re also doing some research and then seeing patients and what you see in there, in the clinic drives what you do in your research. So thank you for all the work that you do. There are some questions in chat. So I’ll ask those questions. So is it is it true that some of the chemo and other treatments can cause skin sensitivities or allergies way after the treatments are done?

Dr. Hornick 45:48
Yes. That is true.

Manju George 45:53
And why is that?

Dr. Hornick 45:55
Well, so the mostly there, I’m talking about the immunotherapies. And the reason that the reason that they do that is because the the way those drugs work is they interfere with mechanisms that block T cell activation at different stages of that process. And what you’re basically doing is adjusting the way in which brakes on a process work. But we don’t know where that process was in its development when we interfered with the mechanism of stopping it. So there’s a bit of randomness to how long it takes for a reaction to develop to an antigen or to specific protein or, or feature of what’s going on in your body that your immune system doesn’t like or was prepared to not like. And so that can happen really quickly as early as a couple of weeks after, or it can take months years to develop in sort of the same way that a lot of people won’t develop autoimmune diseases until later life, once you’ve sort of removed the impediments to developing that autoimmune type of condition. It may happen right away, or it may take a while. And there’s also some evidence that that can also be the case with response of tumor to Immunotherapy that it can it can start later then in some people than others. And we don’t really understand what controls the rate at which those things happen. But that I think is why

Manju George 47:28
Okay, okay, thank you. I kind of want to say this as a comment. You’ve shown lots of pictures and this has been a very exhaustive overview of everything that happens. So I just don’t want people to be scared seeing all of this and believing that, they might get all of it. So do you want to comment something about this? Though this is an exhaustive list, it’s kind of hard for patients to understand that these are everything that you might see, but not necessarily something one patient might experience.

Dr. Hornick 48:05
Right. Yeah.I mean, most people are not on all of these medications, and or at least certainly not all at the same time. But also like we some of these are fairly common, a lot of them are rare. I just wanted to provide a representation across the most common associations so that people that are having a reaction have some indication of what it might be due to or, or what it looks most like. But yeah, certainly, well, people with Immunotherapy tend to get more in terms of number of reactions than people on other medications. Even the people on those medications usually have one or at most two skin reactions. I’ve never seen anybody that had all of this stuff. I’ve never seen anybody that had three different reaction patterns in the same patient. I’ll see people that have one reaction to their Immunotherapy and one reaction to their capecitabine, or I’ll see people that have the papulopustular reaction to an EGFR inhibitor and the nail inflammation, but that’s kind of the upper limit of what I usually see. Most people people don’t get anything and then the people that do get things usually get one thing.

Dr. Hornick 49:18
Okay, thank you so much. How common are people who specialized in oncodermatology? I think that this is the first time I’ve heard such a term. And then, when should they be consulted?

Dr. Hornick 49:33
Not common, unfortunately, it’s I mean, it’s a pretty new subspecialty and it doesn’t have an official board exam for it. There isn’t an official fellowship for it. I spent a year hanging out with John Leventhal to get my training in it. But really all that’s required to be an oncodermatologist is being a dermatologist, being interested in making time but the making time is really important. I wasn’t the first person at Oregon Health and Science to be interested in these reactions, but I was the first person to put to aside– well, it’s my entire schedule– but to put aside patient appointment slots so that when I get a referral from oncology, I can see the patient within the week. And that really matters a lot. Because if you get a referral to dermatology, and it takes three months, that doesn’t help. And so there aren’t that many of us usually there are people at larger cancer centers, they’re there a lot in the Northeast, MD Anderson has a bunch of people. There are people at the larger centers in California. And, and there’s me here. There are people that are interested in Seattle, but I don’t know what their clinic structure is. And I’ve been trying to figure it out, but I haven’t solved that yet. But so in general, ideally, your oncologist will have a good relationship with a dermatologist, they don’t have to be a particular specialist in this and they don’t necessarily have to have appointment slots available all the time. But it would be great if your oncologist had a dermatologist, they could send a message to if they have a concern or, or if they want to get general advice. That’s not always possible, unfortunately. But when you can get a dermatologist involved, the evidence is that outcomes are better when you get a dermatologist involved earlier, because we’re a lot more comfortable with skin disease and oncologists are usually not trained in it, they just sort of have to acquire a comfort level with skin rashes based on what they see over time. And so the studies show that when you have a skin condition treated just by an oncologist, they tend to be more hesitant, they’ll stop drug or lower dose much more readily than patient that’s seen by a dermatologist will have that done. Plus, you have a lot to talk about already with your oncologist and having somebody whose job is just to manage the skin problems just to take take that burden of conversation and then not that it’s a burden, but I would prefer that people just talk to their oncologist about the overall picture and about specific things that I can’t help with. But anything skin related, I want to hear about. And so early is better, but if it’s not possible, I understand it’s not possible. And um, if people have general questions they want, their oncologist to ask me I’m happy to take emails from them.

Manju George 52:35
Okay, and then what about seeing a regular dermatologist? And do you think it’s a good idea to tell them what medications you’re on? Would that help?

Dr. Hornick 52:43
Yes, definitely yes. If you have an regular dermatologist, then they can be your oncodermatologist and in most contexts, because there won’t be somebody like me who’s specifically focused on that. So it’d be good to be able to have someone who just cares about your skin and that is the majority of the situation here. It’s if you have an existing dermatologist, then that is a person that you can just send a message to and they will know what’s going on with you and help out with the skin and they’re going to be much more comfortable helping with psoriasis or eczema, even if it’s caused by a checkpoint inhibitor, than your oncologist will so yeah, definitely, if you have a dermatologist that you’re seeing for another reason, definitely get them involved. And they will certainly need to know what cancer you’re being treated for, what drugs you’re on. And particularly because often like your cancer therapies will be delivered as an infusion and won’t be in your drug list that comes up automatically in the electronic chart and so you’re going to need to tell them what you’re on or at least that you’re getting treatment and how to get in touch with your oncologist.

Manju George 53:43
Okay, great. Thank you.

Dr. Hornick 53:47
Should I go through some of the chat things? There’s a bunch of questions in the chat. Okay. Yeah. I can I can answer.

Manju George 53:55
The next question is women remove facial hair and get manicures. Are there any special considerations or advice on how to continue these during treatment?

Dr. Hornick 54:06
Yeah, I I don’t it sort of depends on the treatment and it depends on what your usual mechanism is. Plucking is generally not that harmful, shaving is usually fine. Particularly if you’re having problems with irritation from shaving, you can use like bump fighter razors or their razors that have like an extra level of guard so that they don’t go quite as close to the skin be less irritating. Manicures–we really don’t want anybody pushing your cuticles back. So please don’t do that. It’s not wrong to get a manicure but it does mean that I can’t see what’s going on with your nails. So it will make it very hard for me to tell what the situation is if there is a problem and there is a gel or acrylic nail overtop of it I’m won’t be able to know. Plus that process can damage the nail and we won’t necessarily know what the issue is from. So less is more from my perspective. But you know, I also want people to live and enjoy their lives. And so I don’t want to make anything more miserable than it has to be. Just if you were having problems with an area I would limit manipulation to it is the broad rule.

Manju George 55:30
Okay, thank you so much. There’s one question about what can be used to treat lesions on the scalp like dry, itchy, crusting due to EGFR inhibitors, especially when people have long hair and then applying creams to the scalp is not ideal.

Dr. Hornick 55:47
Topical steroids come as liquids and I usually start with product called, I think it’s still only available as Derma smooth as the brand but it’s fluocinolone oil. And that is a topical steroid oil that I like a lot. The reason I like that one is because the other formulations tend to be in solution like there’s a very strong topical steroid called clobetasol that comes in a liquid and that goes on scalp easily. But because it’s not that soluble in water, there’s a lot of rubbing alcohol in there and particularly for the EGFR reactions in the scalp and that can be really painful to apply. So I tend to start with the the fluocinolone oil. If that doesn’t work, there are ways you can dissolve tacrolimus pills in water and apply them to the scalp. But all this is prescription and I’m happy to provide some information on that if somebody’s oncologist or dermatologist wants to do that and isn’t comfortable with what the instructions should be because it’s pretty unusual. But you get a capsule and you open it up and you dissolve it in water and then you apply some to the scalp and keep the rest in the refrigerator. But yeah, same kinds of anti inflammatories and then antibiotics can also be helpful for the for the scalp, so doxycycline my mouth or cephalexin my mouth.

Manju George 57:11
Okay, is it okay, we’re almost at time, do you have a couple of minutes or do you have to leave right now?

Dr. Hornick 57:16
Yeah, no, I’m fine. We can keep going.

Manju George 57:19
Okay, so the next question is, what are the timing of treating the EGFR rash? Is it good to do something prophylactically? Or should you wait for the skin issues to arise?

Dr. Hornick 57:32
So usually, we like to treat prophylactically, there’s gonna be an asterisk on what I’m about to say. So I’ll get back to that, at the end remind me if I don’t say it. But so in general, the advice to oncologists is to start people on doxycycline when they start panitumumab, cetuximab, or an EGFR inhibitor, to prevent or minimize the severity of the papulopustular reaction that people can get. Similarly, I think it’s good manage if you have any nail or cuticle issues that you have the opportunity to deal with ahead of time, it is good to deal with that ahead of time. But the asterisk is that there’s a little bit of conflicting evidence in terms of what I guess I should say, there’s evidence that disruptions to the microbiome, which is to say the bacteria that live in your gut can be problematic in terms of response to cancer therapy. The preponderance of evidence, I think still lands on it being better to use antibiotics to manage the papulo pustular reactions, because those often make it hard to deal with therapy for a lot of people and and being able to limit that and keep people on their medications, I think is more important. But some oncologists don’t agree with me on that point. And I think there are reasonable objections. So in general, I tell people to start doxycycline, the oncologists here tell people to start doxycycline, if they can’t tolerate doxycycline, because it makes their stomach upset, or it gets stuck in their throat, which are definitely problems that happened with doxycycline, then we switched to Keflex. And if there’s problems with that, I have one patient that I’ve had to go to Bactrim with, but the antibacterial action of those medications has a real impact on the papulopustular reaction. And so I think that it’s important to try to get some of that benefit for people that are having that reaction.

Manju George 57:32
Okay, this is a different sort of question. So do you have any recommendations for treating the scar, the skin scarring that comes from multiple surgery?

Dr. Hornick 59:46
Yeah. So it depends on what the problem with the scar is. If the problem is pain or hypertrophic scars, which is to say scars that are thick and big and that go beyond the area of the of the incision that was made for the surgery, those were usually inject with steroid, which is kind of an unpleasant process to have done. But it really can do a lot to flatten and thin out those scars. And so the if the scars hurt, then that’s usually what I would recommend doing. You can also treat scars, both for texture and for color with laser. And that can be quite helpful. The only issue with that is that it can be a challenge to get coverage for that therapy from insurance and the improvement can take a number of treatments, so sometimes we’re talking about a significant cost. Some centers will have mechanisms to help people pay for that or, or we’ll do free laser clinics in certain circumstances for people that can’t pay for it. But that’s on a case by case basis and institution by institution basis. So it depends on what’s available in your area. But so, silicone sheets shortly after an incision will help to limit scarring, there’s some evidence for that. Vitamin E, there’s sort of not great evidence for that, but it’s very unlikely to hurt just like opening up vitamin E capsules and rubbing that on the on the scar. And then steroid injection, laser, and for really severe or if you have a lot of pain related to when sometimes people will do a scar revision surgically, they’ll cut out the scar and try again. But obviously, that’s not a zero risk proposition. So we tend to try not to do that unless the scars are really creating a big problem.

Manju George 1:01:35
Okay, this is a curious question from Julie. So why do patients lose their fingerprints, while on treatment, like especially I think we’ve heard about capecitabine doing that.

Dr. Hornick 1:01:49
So that is mostly related to just the damage to the skin, the basal, the bottom layers of skin, where it’s generating your skin from, the markings that make up a fingerprint are made by the specific region of the skin cells that are growing and dividing in that area. And you’re sort of resetting everything at once and you’ll get a lot of a lot of peeling and so you can lose the the general structure of how that fingerprint was generated. It’s a sort of like a scar but it’s not exactly a scar.

Manju George 1:02:36
Okay, interesting. What is a good product to put on skin that is peeling from a rash, not blisters and there are no blisters,

Dr. Hornick 1:02:46
Moisturizer. So Vaseline is great. I don’t personally like Vaseline on me because I don’t like feeling greasy like that. Other ointments that are dimethicone based are my personal preference, and are also real thick and heavy and will do a good job. But the creams from like Cerave , Cetaphilset, What is the other one? I’m thinking Neutrogena, Eucerin, Aquafor like there’s a whole industry of brands and I have no particular horse in that race. The important thing is that you like putting it on and so are willing to put it on and that it doesn’t make any other part of your your self care difficult. So, I like to have people use things that are a sunblock and a moisturizer together there are a lot of different companies that make something like that so that you don’t have to apply 2 different things just sort of try and simplify things as long as it’s comfortable for you, if you like the way the Vaseline makes you feel it’s wonderful.

Dr. Hornick 1:03:50
So that was this recent trial, I think from India, the D-TORCH trial where they found that the diclofenac was good for hand foot sndrome. So the question is about that, you said that the rego skin side effects even we call them hand foot reaction, they are very different from HFS. So do you know if diclofenac would work for that also, is there any evidence out there?

Dr. Hornick 1:04:12
There isn’t data I think it’s certainly a reasonable thing to try and the D-TORCH trial is is good information and our oncologists have started prescribing diclofenac for people that are going on to capecitabine, but the reason I didn’t get into it is just because it’s something that the oncologist has to do, it’s not something a patient can apply. But so it does seem to lower rates and severity of hand foot syndrome. For hand foot skin reaction. I think there’s no harm in doing it. The only asterisk on that is that there’s a contraindication with people with a history of asthma. Those drugs by mouth certainly can cause bad asthma flares. And so nobody would do that. And it seems unlikely just to think about that putting it on your hands and feet would trigger an asthma response. But there have been a number of case reports where people have had bad asthma attacks after applying to diclofenac for orthopedic reasons, this is information from the 90s. But so for those patients, I still don’t think it’s worth worth doing. But for everybody else yeah, why not?

Manju George 1:04:12
Okay. So that’s a great piece of information to know. Because we’ve been talking about it in Colontown. And so you’re saying that if you have prior history of asthma, then you should use diclofenac carefully?

Dr. Hornick 1:05:45
Well, I mean, officially I would say don’t use it, if you have a history of asthma, because the risk of causing an asthma attack is potentially life threatening. I will say that the likelihood of that happening is low. So if it’s something that you’re interested in doing, if you’ve had bad hand foot before, and you need to go back on therapy, or if you are interested in it, if you’ve had really severe hand foot skin reaction, and you haven’t been able to use your hands, and you have a history of asthma, then I don’t think it’s absolutely against the rules, but it’s definitely a conversation you need to have with your doctors before you do.

Manju George 1:06:31
Okay. Okay. Thank you so much. What else? I think we have covered everything. So I just want to remind all the people listening, that we have a skin toxicity guide, it’s a recent document on Colontown University where we have addressed all the common skin side effects. And we’re hoping that Dr. Hornick’s talk would be a great addition to it. And this has been this has been very informative. It’s, it’s a very exhaustive talk, and we have not had one on this. So thank you so much for providing us all this information.

Manju George 1:07:15
You’re very welcome! Happy to be helpful.

Manju George 1:07:20
I was wondering that maybe we should also tell oncologists that maybe it’s of a value for them to listen to the talk as well, because I feel that it would be of great value to have someone to refer to when they have things that they need advice for patients.

Dr. Hornick 1:07:41
Yeah, they’re certainly welcome to contact me. But there’s also I would say the website is unfortunately in need of some help, but the oncodermatology society is our professional organization and has a list of people in other parts of the country if people want oncodermatologists closer to them.

Manju George 1:08:02
Okay, Thank you very much,

Dr. Hornick 1:08:05
of course.

Manju George 1:08:07
Okay, bye

Dr. Hornick 1:08:08