M Acneiform folliculitis is very frequent, and considered to be an expected effect of the treatment.

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1 FICHE ONE SMILE - GB FT 100 x 210 mm - QUADRI Acneiform eruptions IMPORTANT M Acneiform folliculitis is very frequent, and considered to be an expected effect of the treatment. M It is not true acne (no comedones or microcysts). M The eruption combines papules and pustules on the face and trunk, with functional signs (pruritus, erythema). M It occurs mostly at the start of the treatment (in the first weeks). M It can have a major impact on quality of life. M The treatment is based on oral tetracyclines, local antibiotics and topical steroids. M Additional dermo-cosmetic measures are always necessary.

2 RECOMMENDATIONS IN ADDITION TO MEDIAL TREATMENT M Do not burst the spots. M Do not scrub, as this will cause additional skin irritation. M Apply a moisturizing cream once or twice a day. M Apply a copper-based cream once or twice a day to inflamed lesions to prevent bacterial proliferation and improve healing. M Protect the skin from the sun. INDUCTIVE MOLECULES These eruptions are almost exclusively observed with targeted EGF therapies to inhibit the receptor (or mixed ErB inhibitors), MEK and, less frequently, mtor: cetuximab, erlotinib, gefitinib, panitumumab, pertuzumab, afatinib, lapatinib, semuletinib, trametinib, everolimus, temsirolimus. Création SYMBIOSE

3 Alopecia and its effect on hair IMPORTANT M Alopecia caused by chemotherapy is often considered to be the patient s worst burden. M In a large majority of cases, it is temporary, and the hair grows again after 3 to 6 months. M The hair may look different when it grows again (whiter, more curly). M Patients need support to cope with this side effect. M With targeted therapies, the modification of the appearance of the hair is more evident (curly and brittle hair, loss of color). Alopecia is much more moderate.

4 RECOMMENDATIONS M Daily hydration is recommended if the scalp is dry and itchy. M It is important to protect the skin against the sun with SPF50+ photoprotection. INDUCTIVE MOLECULES Alopecia is caused mainly by conventional chemotherapy, and to a lesser extent by targeted therapies. Création SYMBIOSE

5 Photosensitivity IMPORTANT M Severe photosensitivity reactions are rare, but possible, especially with certain molecules (vandetanib, vemurafenib, fluorouracile). M It must be addressed in the event of photodistributed inflammatory eruptions (on the face, chest, back of the hands). M These are usually reactions caused by phototoxicity or UVA. M In broader terms, patients undergoing chemotherapy or targeted therapies run a significantly higher risk of developing residual pigmentation after exposure to light. M The recommended photoprotection measures must include protection against UVB (exposure to the sun) and UVA (in cloudy weather, in the winter, through windows, etc.).

6 RECOMMENDATIONS M SPF50+ sun creams are highly recommended. M Prefer hypoallergenic, perfume-free sun creams that are resistant to water and perspiration. M Apply the creams to all exposed parts, including the neck and back of the hands. M It is essential to repeat the application every 2 hours. Remind patients to keep a tube within easy reach at all times. INDUCTIVE MOLECULES Chemotherapies that most frequently cause photosensitivity: fluorouracil, capecitabine, dacarbazine, tegafur, vinblastine and less frequently, hydroxyurea, procarbazine, doxorubicin, mitomycin, taxanes, etc. Targeted therapies that can cause sometimes severe reactions: vandetanib, PI3K inhibitors, vemurafenib. The acneiform eruptions caused by EGF receptor inhibitors (cetuximab, panitinumab, erlotinib, gefitinib, afatinib) sometimes seem to be encouraged/worsened by exposure to the sun. Imatinib and dasatinib (BCR-ABL inhibitors) also increase photosensitivity. Création SYMBIOSE

7 Acute radiodermatitis IMPORTANT M Despite recent therapeutic progress, acute radiodermatitis still occurs frequently. M Patients need support and advice throughout the course of treatment by radiotherapy. M The supporting dermatological products must include at least one suitable hygiene product and a well tolerated emollient. Suitable radioprotection must also be recommended. M Ultraradiated skin remains more fragile and more sensitive to trauma and infections for several years after the end of the radiotherapy. M Prolonged surveillance is necessary after the end of the radiotherapy in order to detect any complications, such as chronic radiodermatitis.

8 RECOMMENDATIONS M Tissue repair can be encouraged during radiotherapy, and according to the doctor s recommendations, by applying a copper- and zinc-based cream that helps to repair the epidermis and limits the risk of bacterial proliferation. M Apply gently, by tapping delicately. M Clinical studies have shown the benefits of twicedaily applications, which help patients to better tolerate the radiotherapy sessions. Do not apply any cream less than 4 hours before the session. Création SYMBIOSE

9 Cutaneous xerosis IMPORTANT TREATMENT M Cutaneous xerosis is a clinical situation encountered frequently amongst patients undergoing chemotherapy, targeted therapies or hormone therapy. M It can have a severe effect on the patient s everyday comfort and cause fissures, which can result in superinfections. M It demands symptomatic measures and the long-term use of emollients. M First, the patient must be educated in order to avoid certain situations or factors that encourage dry skin. See the symptoms information sheet on hygiene. M The treatment is based on emollients. They must maintain the water content in the stratum corneum and limit transepidermal water loss. M Prefer perfume- and alcohol-free products with as few ingredients as possible, that have demonstrated that they are well tolerated in different clinical situations. Sterilemanufactured and preservative-free products may be useful in these cases. Keratolytic active ingredients that are not harsh, such as urea (<15%) or ammonium lactate, can also be associated in certain cases. M The ideal dosage is twice daily. M In the event of an associated cutaneous inflammation, moderately to highly active topical steroids must be used for short periods (e.g., valerate or betamethasone dipropionate).

10 RECOMMENDATIONS M For a dry face: - The cream must be spread using the fingertips to apply it on the cheeks, forehead and neck, then from the center to the contour of the face, remembering to cover the neck and chest. M For dry body skin caused by medical treatments: - Apply an emollient once or twice a day. Spread between the two hands and apply to the body in touches. Rub into to skin with the complete surface of the hands for a more gentle application. M In the event of dryness or irritations of the contour of the eyes: - Apply a soothing product to the contour of the eyes every day. Deposit by tapping with the fingertips, then drum until the product penetrates the skin and finish by gently spreading. M For dry lips: - Apply a cold cream stick two or three times a day, even beneath lipstick. In the event of chapping, prefer the more supple texture of a lip balm to cold cream. M In addition to the other emollients: - Recommend a moisturizing mask one to three times a week to favor cutaneous hydration. - Apply a thick layer of the mask and apply spring water compresses to the eyelids while waiting with the mask in place. INDUCTIVE MOLECULES Xerosis is very frequent amongst patients undergoing chemotherapy, targeted therapies or hormone therapy. Création SYMBIOSE

11 Cutaneous fissures IMPORTANT M Fissures, chapping and cracks appear after several weeks of treatment and can have a significant functional impact. M They affect mostly finger flesh, the periungual regions, interphalangeal joints and the heels. M The treatment is based on emollients and cyanoacrylate.

12 RECOMMENDATIONS M These fissures demand attentive treatment once they appear. M Emollients can be applied under occlusion. M Magistral formulations based on 50% glycol propylene or 10% salicylic acid, products based on copper/zinc sulfate, sucralfate and hydrocolloid dressings may be useful. M The application of highly or very highly active topical corticosteroids may also be recommended (e.g. clobetasol ointment) in the absence of any bacterial superinfections. M Liquid cyanoacrylate is probably the most effective treat ment, especially for pain. INDUCTIVE MOLECULES Cutaneous fissures occur almost exclusively with targeted EGF and MEK receptor inhibitor therapies (or mixed ErB or HER inhibitors): cetuximab, erlotinib, gefitinib, panitumumab, pertuzumab, afatinib, lapatinib, semuletinib, trametinib. Création SYMBIOSE

13 Hand-foot syndrome IMPORTANT M Hand foot syndrome may be caused by certain chemotherapies and certain targeted therapies. M The clinical presentation differs, depending on the cause: more localized and hyperkeratotic with targeted therapies, more diffuse and erythematous with chemotherapies. M Nevertheless, there are a number of points in common: hand foot syndrome is always bilateral and occurs on the palms and/or soles. M It has a significant and sometimes severe impact on the patient s quality of life. M Hand foot syndrome demands regular support and assessment. M It may sometimes be necessary to adapt the doses of the anti-cancer treatment.

14 RECOMMENDATIONS M Avoid the traumas of everyday life to the hands and feet: M Avoid long walks, wear suitable and wide shoes that are well cushioned, prefer cotton socks, avoid overly hot baths, etc. M Wear cotton gloves for everyday activities (gardening, cooking, etc.) and latex gloves to wash the dishes. M To reduce cutaneous thickening of the hands and feet: - Apply a moisturizing and keratolytic cream based on urea and salicylic acid every day, concentrating on the heals and weight-bearing parts of the feet. M Podology support is often recommended. INDUCTIVE MOLECULES Chemotherapies that frequently cause hand and foot syndrome: capecitabine (50%), liposomal doxorubicin (30 à 50%), fluorouracil, tegafur. Chemotherapies that may cause hand and foot syndrome: irinotecan, doxorubicin, docetaxel, cytarabine, hydroxyurea, methotrexate, etoposide, cyclophosphamide, vinblastine, cisplatin, vinorelbine Almost all the targeted therapies that cause hand and foot syndrome are represented by molecules with an antiangiogenic activity (directed against the VEGF and PDGF receptors) and/or with a RAF inhibiting activity: regorafenib (60%), sorafenib (34%), sunitinib (19%), axitinib (29%), pazopanib (5%), vemurafenib (20%), dabrafenib. Création SYMBIOSE

15 Hygiene IMPORTANT M Gentle hygiene is essential when undergoing the medical treatment so as to avoid accentuating the side effects. M Soaps, liquid or solid, cause excessive drying and irritation and are not recommended for washing. Prefer gels or soap-free dermatological cleansers. They protect the ph of the skin, do not cause drying and have a powerful superfatting effect.

16 IMPORTANT M Washcloths and sponges must be avoided at all costs. Wash using the hands, which are more gentle and cleaner. M Wash in water between 32 C and 34 C: - Overly hot water dries the skin and reactivates inflammations. M Rubbing with a towel increases cutaneous inflammations. It is advisable to dry the skin by delicately tapping, especially in irritated regions. M Apply a suitable emollient after showering. Création SYMBIOSE

17 Spring water to soothe and calm IMPORTANT M Spring water is naturally soothing, calming and antiirritating. It is ideal for sensitive skin. M It should be used: - In cases of cutaneous irritation and inflammation (in particular post-radio-therapy) to soothe itching due to targeted therapies and chemotherapy. - In the event of acneiform eruptions. M Prolonged spraying enhances the calming powers of spring water. The skin on the face and body is calmed quickly. M Compresses are a handy way of keeping the spring water in contact with the skin: - Soak a white, perfume-free paper tissue in spring water. - Apply the compress and spray for improved impregnation. Spray regularly while holding the compress against the skin for 15 minutes.

18 IMPORTANT M Compresses are also strongly recommended on irritated or inflamed parts of the body, especially after radiotherapy or in the event of itching. - It is recommended to spray regularly while holding the compress against the skin for 15 minutes. M Keep the spray in the refrigerator to increase the calming effect of the spring water and to temporarily anesthetize the skin against sensations of burning or itching. Création SYMBIOSE