Skin and Nail Changes during Cancer Treatment

Skin and Nail Changes during Cancer Treatment

Cancer treatments may cause skin and nail changes. Talk with your health care team to learn what side effects your treatment may cause. While skin problems caused by radiation therapy and chemotherapy are often mild, they may be more severe if you are receiving a stem cell transplant, targeted therapy, or immunotherapy. Let your health care team know if you notice any skin changes so they can be treated promptly.

- Sometimes radiation therapy can cause the skin on the part of your body receiving radiation to become dry and peel, itch (called pruritus), and turn red or darker. Your skin may look sunburned or become swollen or puffy. You may develop sores that become painful, wet, and infected. This is called a moist reaction.

- Some types of chemotherapy can cause your skin to become dry, itchy, red or darker, or peel. You may develop a minor rash or sunburn easily; this is called photosensitivity. Some people also have skin pigmentation changes. Your nails may be dark and cracked, and your cuticles may hurt. If you received radiation therapy in the past, the area of skin where you received radiation may become red, blister, peel, or hurt. This is called radiation recall. Signs of an allergic response to chemotherapy may include a sudden or severe rash or hives or a burning sensation.

- Stem cell transplants can cause graft-versus-host disease (GVHD), which may cause skin problems such as a rash, blisters, or thickening of the skin.

- Some types of immunotherapy can cause a severe and sometimes extensive rash. Your skin may be dry or blister.

- Some types of targeted therapy may cause dry skin, a rash, and nail problems. If you develop a rash, it is important to talk with your doctor before stopping targeted therapy.

Immunotherapy to Treat Cancer
Immunotherapy is a type of cancer treatment that helps your immune system fight cancer. The immune system helps your body fight infections and other diseases. It is made up of white blood cells and organs and tissues of the lymph system.

Immunotherapy is a type of biological therapy. Biological therapy is a type of treatment that uses substances made from living organisms to treat cancer.

How does immunotherapy work against cancer?

As part of its normal function, the immune system detects and destroys abnormal cells and most likely prevents or curbs the growth of many cancers. For instance, immune cells are sometimes found in and around tumors. These cells, called tumor-infiltrating lymphocytes or TILs, are a sign that the immune system is responding to the tumor. People whose tumors contain TILs often do better than people whose tumors don’t contain them.

Even though the immune system can prevent or slow cancer growth, cancer cells have ways to avoid destruction by the immune system. For example, cancer cells may:

- Have genetic changes that make them less visible to the immune system.

- Have proteins on their surface that turn off immune cells.

- Change the normal cells around the tumor so they interfere with how the immune system responds to the cancer cells.

Immunotherapy helps the immune system to better act against cancer.

What are the types of immunotherapy?

Several types of immunotherapy are used to treat cancer. These include:

- Immune checkpoint inhibitors, which are drugs that block immune checkpoints. These checkpoints are a normal part of the immune system and keep immune responses from being too strong. By blocking them, these drugs allow immune cells to respond more strongly to cancer.

- T-cell transfer therapy, which is a treatment that boosts the natural ability of your T cells to fight cancer. In this treatment, immune cells are taken from your tumor. Those that are most active against your cancer are selected or changed in the lab to better attack your cancer cells, grown in large batches, and put back into your body through a needle in a vein.

T-cell transfer therapy may also be called adoptive cell therapy, adoptive immunotherapy, or immune cell therapy.

- Monoclonal antibodies, which are immune system proteins created in the lab that are designed to bind to specific targets on cancer cells. Some monoclonal antibodies mark cancer cells so that they will be better seen and destroyed by the immune system. Such monoclonal antibodies are a type of immunotherapy.

Monoclonal antibodies may also be called therapeutic antibodies.

- Treatment vaccines, which work against cancer by boosting your immune system’s response to cancer cells. Treatment vaccines are different from the ones that help prevent disease.

- Immune system modulators, which enhance the body’s immune response against cancer. Some of these agents affect specific parts of the immune system, whereas others affect the immune system in a more general way.

Which cancers are treated with immunotherapy?

Immunotherapy drugs have been approved to treat many types of cancer. However, immunotherapy is not yet as widely used as surgery, chemotherapy, or radiation therapy. To learn about whether immunotherapy may be used to treat your cancer, see the PDQ® adult cancer treatment summaries and childhood cancer treatment summaries.

What are the side effects of immunotherapy?

Immunotherapy can cause side effects, many of which happen when the immune system that has been revved-up to act against the cancer also acts against healthy cells and tissues in your body.

Learn more about immunotherapy side effects.

How is immunotherapy given?

Different forms of immunotherapy may be given in different ways. These include:

- intravenous (IV)

The immunotherapy goes directly into a vein.

- oral

The immunotherapy comes in pills or capsules that you swallow.

- topical

The immunotherapy comes in a cream that you rub onto your skin. This type of immunotherapy can be used for very early skin cancer.

- intravesical

The immunotherapy goes directly into the bladder.

Where do you go for immunotherapy?

You may receive immunotherapy in a doctor’s office, clinic, or outpatient unit in a hospital. Outpatient means you do not spend the night in the hospital.

How often do you receive immunotherapy?

How often and how long you receive immunotherapy depends on:

- your type of cancer and how advanced it is

- the type of immunotherapy you get

- how your body reacts to treatment

You may have treatment every day, week, or month. Some types of immunotherapy given in cycles. A cycle is a period of treatment followed by a period of rest. The rest period gives your body a chance to recover, respond to immunotherapy, and build new healthy cells.

How can you tell if immunotherapy is working?

You will see your doctor often. He or she will give you physical exams and ask you how you feel. You will have medical tests, such as blood tests and different types of scans. These tests will measure the size of your tumor and look for changes in your blood work.

What is the current research in immunotherapy?

Researchers are focusing on several major areas to improve immunotherapy, including:

- Finding solutions for resistance.

Researchers are testing combinations of immune checkpoint inhibitors and other types of immunotherapy, targeted therapy, and radiation therapy to overcome resistance to immunotherapy.

- Finding ways to predict responses to immunotherapy.

Only a small portion of people who receive immunotherapy will respond to the treatment. Finding ways to predict which people will respond to treatment is a major area of research.

- Learning more about how cancer cells evade or suppress immune responses against them.

A better understanding of how cancer cells get around the immune system could lead to the development of new drugs that block those processes.

- How to reduce the side effects of treatment with immunotherapy.

How do you find clinical trials that are testing immunotherapy?

To find clinical research studies that involve immunotherapy visit Find NCI-Supported Clinical Trials or call the Cancer Information Service, NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

NCI’s list of cancer clinical trials includes all NCI-supported clinical trials that are taking place across the United States and Canada, including the NIH Clinical Center in Bethesda, MD.

What is targeted therapy?

Targeted therapy is the foundation of precision medicine. It is a type of cancer treatment that targets proteins that control how cancer cells grow, divide, and spread. As researchers learn more about the DNA changes and proteins that drive cancer, they are better able to design promising treatments that target these proteins.

What are the types of targeted therapy?

Most targeted therapies are either small-molecule drugs or monoclonal antibodies.

Small-molecule drugs are small enough to enter cells easily, so they are used for targets that are inside cells.

Monoclonal antibodies, also known as therapeutic antibodies, are proteins produced in the lab. These proteins are designed to attach to specific targets found on cancer cells. Some monoclonal antibodies mark cancer cells so that they will be better seen and destroyed by the immune system. Other monoclonal antibodies directly stop cancer cells from growing or cause them to self-destruct. Still others carry toxins to cancer cells.

Who is treated with targeted therapy?

For some types of cancer, most patients with that cancer will have a target for a certain drug, so they can be treated with that drug. But, most of the time, your tumor will need to be tested to see if it contains targets for which we have drugs.

Testing your cancer for targets that could help you and your doctor choose your treatment is called biomarker testing. See Biomarker Testing for Cancer Treatment on this site for more information.

You may need to have a biopsy for biomarker testing. A biopsy is a procedure in which your doctor removes a piece of the tumor for testing. There are some risks to having a biopsy. These risks vary depending on the size of the tumor and where it is located. Your doctor will explain the risks of having a biopsy for your type of tumor.

How does targeted therapy work against cancer?

Most types of targeted therapy help treat cancer by interfering with specific proteins that help tumors grow and spread throughout the body. They treat cancer in many ways. They can:

- Help the immune system destroy cancer cells. One reason that cancer cells thrive is because they can hide from your immune system. Certain targeted therapies can mark cancer cells so it is easier for the immune system to find and destroy them. Other targeted therapies help boost your immune system to work better against cancer.

- Stop cancer cells from growing. Healthy cells in your body usually divide to make new cells only when they receive strong signals to do so. These signals bind to proteins on the cell surface, telling the cells to divide. This process helps new cells form only as your body needs them. But, some cancer cells have changes in the proteins on their surface that tell them to divide whether or not signals are present. Some targeted therapies interfere with these proteins, preventing them from telling the cells to divide. This process helps slow cancer’s uncontrolled growth.

- Stop signals that help form blood vessels. Tumors need to form new blood vessels to grow beyond a certain size. In a process called angiogenesis, these new blood vessels form in response to signals from the tumor. Some targeted therapies called angiogenesis inhibitors are designed to interfere with these signals to prevent a blood supply from forming. Without a blood supply, tumors stay small. Or, if a tumor already has a blood supply, these treatments can cause blood vessels to die, which causes the tumor to shrink. Learn more about Angiogenesis Inhibitors.

- Deliver cell-killing substances to cancer cells. Some monoclonal antibodies are combined with toxins, chemotherapy drugs, and radiation. Once these monoclonal antibodies attach to targets on the surface of cancer cells, the cells take up the cell-killing substances, causing them to die. Cells that don’t have the target will not be harmed.

- Cause cancer cell death. Healthy cells die in an orderly manner when they become damaged or are no longer needed. But, cancer cells have ways of avoiding this dying process. Some targeted therapies can cause cancer cells to go through this process of cell death.

- Starve cancer of the hormones it needs to grow. Some breast and prostate cancers require certain hormones to grow. Hormone therapies are a type of targeted therapy that can work in two ways. Some hormone therapies prevent your body from making specific hormones. Others prevent the hormones from acting on your cells, including cancer cells.

Are there drawbacks to targeted therapy?

Targeted therapy does have some drawbacks. These include:

- Cancer cells can become resistant to targeted therapy. For this reason, they may work best when used with other types of targeted therapy or with other cancer treatments, such as chemotherapy and radiation.

- Drugs for some targets are hard to develop. Reasons include the target’s structure, the target’s function in the cell, or both.

What are the side effects of targeted therapy?

Targeted therapy can cause side effects. The side effects you may have depend on the type of targeted therapy you receive and how your body reacts to the therapy.

The most common side effects of targeted therapy include diarrhea and liver problems. Other side effects might include problems with blood clotting and wound healing, high blood pressure, fatigue, mouth sores, nail changes, the loss of hair color, and skin problems. Skin problems might include rash or dry skin. Very rarely, a hole might form through the wall of the esophagus, stomach, small intestine, large bowel, rectum, or gallbladder.

There are medicines for many of these side effects. These medicines may prevent the side effects from happening or treat them once they occur.

Most side effects of targeted therapy go away after treatment ends.

Learn more about side effects caused by cancer treatment and ways to manage them.

What are other risks of targeted therapy?

Since your tumor may be tested to find targets for treatment, there may be risks to the privacy of your personal information. The privacy of all information found from these tests is protected by law. But, there is a slight risk that genetic or other information from your health records may be obtained by people outside of the medical team.

What can I expect when having targeted therapy?

How is targeted therapy given?

Small-molecule drugs are pills or capsules that you can swallow.

Monoclonal antibodies are usually given through a needle in a blood vein.

Where do I go for targeted therapy?

Where you go for treatment depends on which drugs you are getting and how they are given. You may take targeted therapy at home. Or, you may receive targeted therapy in a doctor’s office, clinic, or outpatient unit in a hospital. Outpatient means you do not spend the night in the hospital.

How often will I receive targeted therapy?

How often and how long you receive targeted therapy depends on:

- Your type of cancer and how advanced it is

- The type of targeted therapy

- How your body reacts to treatment

You may have treatment every day, every week, or every month. Some targeted therapies are given in cycles. A cycle is a period of treatment followed by a period of rest. The rest period gives your body a chance to recover and build new healthy cells.

How will targeted therapy affect me?

Targeted therapy affects people in different ways. How you feel depends on how healthy you are before treatment, your type of cancer, how advanced it is, the kind of targeted therapy you are getting, and the dose. Doctors and nurses cannot know for certain how you will feel during treatment.

How will I know whether targeted therapy is working?

While you are receiving targeted therapy, you will see your doctor often. He or she will give you physical exams and ask you how you feel. You will have medical tests, such as blood tests, x-rays, and different types of scans. These regular visits and tests will help the doctor know whether the treatment is working.

Ask Your Health Care Team about Skin and Nail Changes

- What skin and nail changes might I have, based on the cancer treatment I am receiving?

- Which symptoms can be managed at home? Which symptoms need urgent medical care?

If you have a severe, extensive, blistering, or painful rash and are receiving immunotherapy, call your doctor to get their advice. It’s especially important to call about rashes that involve the eyes or a mucous membrane, such as your mouth, caused by immunotherapy.

Make note of all problems you should call your health care team about.

Skin changes:

Acne (Acneiform eruptions)

Bed sores (pressure ulcers)

Blisters

Burning or skin pain

Dry skin

Hand-foot syndrome (palmar-plantar erythrodysesthesia)

Hyperpigmentation (darker areas of skin, tongue, and joints)

Hypopigmentation (patches of skin that are lighter)

Itchy skin (pruritus)

Keratoacanthoma (dome-shaped skin growth)

Peeling, flakey, or crusty skin

Photosensitivity (sunburn easily)

Rash

Red or darkened skin

Sores that are painful

Swollen skin

Nail changes:

Cracked nails

Cuticles that are swollen and/or painful

Nail infections (acute paronychia)

Yellow nails

Ways to Prevent or Manage Mild Skin and Nail Changes during Cancer Treatment

Talk with your health care team to learn if you should manage these problems at home. Depending upon the treatment you are receiving, your health care team may advise you to take these steps:

- Use only recommended skin products. Use mild soaps that are gentle on your skin. Ask your nurse to recommend specific skin products. If you are receiving radiation therapy, ask about skin products, such as powder or antiperspirant, that you should avoid using before treatment.

- Prevent infection: Radiation therapy can cause skin in the treatment area to peel, become painful, and wet. Most often this happens in areas where the skin folds, such as around your ears, breast, or bottom. Try to keep the area clean and dry so it does not become infected. Your nurse will talk with you about how to clean the area and may prescribe special dressings that you can apply to the area and/or antibiotics.

- Moisturize your skin. Use recommended creams or lotions to prevent your skin from becoming dry and itchy. Irritated skin can become infected. Ask about special creams or ointments for severely dry, itchy, or painful skin.

- Protect your skin: Use sunscreen and sun-protective lip balm. Wear a loose-fitting long-sleeved shirt, pants, and a hat with a wide brim when outdoors to prevent sunburn. If you are receiving radiation therapy, don’t use heating pads, ice packs, or bandages on the treatment area. You may want to shave less often and use an electric razor or stop shaving if your skin is tender and sore.

- Prevent or treat dry, itchy skin. Avoid products that list alcohol or fragrance as an ingredient, since they can dry or irritate your skin. Your nurse may suggest you add colloidal oatmeal to your baths, as it can reduce itching. Take short showers or baths in lukewarm, not hot, water. Put on skin cream or ointment that is recommended by your nurse after drying off from a shower but while your skin is still a little damp. Apply a cool washcloth or ice to dry, itchy skin.

- Prevent or treat minor nail problems. Keep your nails clean and cut short to avoid accidentally tearing them. Protect your hands and nails by wearing gloves when you wash the dishes, or clean the house, for example. Avoid getting manicures and pedicures. Don’t wear tight-fitting shoes. Ask your nurse to recommend products that can be used to treat nail problems.

- Learn about treatments for irritating or painful skin rashes: Sometimes skin problems need medical treatment. Your rash may be treated with a medicated cream (topical corticosteroids) or with medicine that you take as a pill (oral corticosteroids or antibiotics).

Talking With Your Health Care Team about Skin and Nail Changes

Prepare for your visit by making a list of questions to ask. Consider adding these questions to your list:

- What skin-and nail related side effects are common for the type of treatment I’m receiving?

- Are there steps I can take to prevent any of these problems?

- What problems should I call you about? Are there any problems that need urgent medical care?

- When might these problems start? How long might they last?

- What brands of soap and lotion would you advise me to use on my skin? On my nails?

- Are there skin and nail products I should avoid?

- Should I see a dermatologist so I can learn more about how to prevent or manage skin problems?