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Skin Toxicity (2)

Symptom Grade

Low Risk

  • Alopecia < grade 2
  • Bullous dermatitis grade 2 (aecting 10-30% BSA)
  • Dry skin > grade 2
  • Erythema multiforme grade 2 (aecting 10-30% BSA)
  • Erythroderma grade 2 (covering >90% BSA)
  • Pruritus > grade 2 with moderate with skin changes from scratching limiting Instrumental ADL
  • Rash grade 2 covering 10-30% BSA with/without symptoms, limiting Instrumental ADL
  • Skin atrophy > grade 2 (covering > 10% BSA)
  • Skin induration > grade 2

Symptom Grade

Medium Risk

  • Bullous dematitis grade 2 (aecting > 30% BSA)
  • Erythema multiforme grade 3 (>30% BSA oral and genital erosions)
  • Erythroderma grade 3 (>90% BSA)
  • Rash grade > (3 covering >30% BSA) associated with superinfection requiring antibiotics

Symptom Grade

High Risk

  • Steven Johnson syndrome
  • Toxic epidermal necrolysis
  • Bullous dermatis grade 4 (aecting > 30% BSA, blistering with electrolyte/fluid abnormalities)
  • Erythema multiforme grade 4 (>30% BSA elctrolyte/fluid abnormalities)
  • Erythroderma grade 4 (>90% BSA Electrolyte/fluid abnormalities)

Management escalation pathway

  • Treat ambulatory
  • Apply topical steroids as indicated
  • Apply symptomatic treatment to associated symptoms (e.g. itching, dry skin) as indicated second-generation atihistamines
  • If symptoms persist > 6 days Initiate oral methylprednisolone at a dose of 0.5-1mg/kg BW per day in case of steroid responsive

Symptoms resolved to grade 0 or 1

Yes > Continue as in A
No > Continue as in B

Management escalation pathway

  • Treat ambulatory or hospitalize
  • Apply topical steroids as indicated
  • Apply symptomatic treatment to associated symptoms (e.g. itching, dry skin) as indicated second-generation antihistamines
  • Initiate oral/iv methylprednisolone at a dose of 1mg/kg BW per day in case of steroid responsive toxicity
  • Treat with antibiotics as indicated aer taking swaps

Symptoms resolved to grade 0 or 1 aer 4 week of treatment

Yes > Continue as in C
No > Continue as in D

Management escalation pathway

  • Hospitalize on ICU/burn unit
  • Apply electrolyte and fluid control
  • Apply nutritional control initiated antibiotic therapy as indicated
  • Apply general burn unit measures (e.g. sterile handling, antiseptic solution, repeated cultures, pain management …)

Continue as in C

A

Stop topical therapy Taper steroids if given systematically

B

Stop topical therapy Taper steroids if given systematically

C

Taper steroids over >1 month For bullous dermatitis, a long corticosteroid taper is indicated followed by a period of low dose corticosteroids (3-4 months with 4-8 mg/d)

D

Consider increasing the dose of steroids to 2 mg/kg BW
Consider the use of intravenous immune globulins (>3g/kg BW for 1- 3 days)
Consider to use cyclosporine (3-5mg/d) aer assessing the balance risk benefit

Abbreviations

Abbrevations

BSA: Body Surface Area
ADL: Activities of Daily Living
BW: Body Weight
ICU: Intensive Care Unit