Dr. Angela Lamb discusses breast cancer treatment side effects that affect the hair, skin, and nails, including the dermatologists’ role on the multidisciplinary team.
Angela Lamb, MD, Associate Professor of Dermatology, Assistant Vice Chair of Clinical Operations, and Medical Director of the Faculty Practice Access Center, Mount Sinai, New York City
“I started the subspecialty [of treating cutaneious disorders in patients undergoing cancer treatment] at Mount Sinai. They have the robust Dubin Breast Center, and they saw that I was taking great care of patients and started sending patients my way,” said Angela Lamb, MD, who presented “Caring for Patients on a Multidisciplinary Breast Cancer Team—Pearls and Precautions,” at the Masterclasses in Dermatology in Sarasota, Florida.
Breast cancer patients have a variety of concerns, including side effects from chemotherapy and estrogen receptor inhibitor medications, said Dr. Lamb.
“Oncologists are incredibly savvy and can manage these on their own, but we want them to know that we are partners and members of the team, and often we have access to treatments that may not be top of mind.”
Additionally, dermatologists use compounding pharmacies for the treatment of hair loss and pigmentation. Oncologists do not have access to those relationships, she said.
When doing skin checks on breast cancer patients, Dr. Lamb said she educates them about when it’s necessary to contact their oncologist or dermatologist.
“I tell them, ‘I really need to hear from you if there is a lump or bump in the breast area or any rash in the breast area.’ It’s to help the patient strategize: Are we going to do a biopsy or try and treat and have you return?”
Skin Care
In general, the goal is to help patients get their skin where they want it to be during and after treatment, said Dr. Lamb.
“There are a variety of chemotherapy medications, including the more traditional cytotoxic chemotherapy agents, which tend to result in hair loss, mucositis, and nail changes. Those are changes where sometimes the patient is ill and we want to dose-reduce. But then there are some categories of medications where we want to help the team to treat through.”
The newer epidermal growth factor-inhibitor medications used to treat breast cancer are not the classic cytotoxic chemotherapeutic agents. They tend to result in different reactions, such as nonspecific maculopapular rashes, dyspigmentation, and often a pustular acneiform reaction on the face.
“Those are all things we can manage. Particularly the acneiform type of reaction—if patients don’t get that they are actually not responding to treatment. So, there are reactions that are expected, and we don’t want to dose-reduce the patient. We just want to help them manage their way through it. Sometimes [for pustular acneiform] we give oral antibiotics or topical antibiotics.”
It’s important that dermatologists are partners on the team for managing side effects of cancer treatment because, while oncologists treating these patients might think of more conventional treatment approaches, like topical steroids, dermatologists are aware of others, which enables them to think outside the box, according to Dr. Lamb.
“There are newer categories of medication, including topical Janus kinase (JAK) inhibitors or even biologics like dupilumab, which we’ve used to treat especially itching while (or after) using medications to treat breast cancer.”
Hair Loss
Breast cancer patients also often experience hair loss during treatment, particularly with the more classic cytotoxic treatments, said Dr. Lamb.
“There are a variety of things you can do during treatment. There is cold capping, which works with variability. I’ve had some patients who were able to save their hair with cold capping and some not as much. People do tend to lose some density, but the cold capping can be helpful.”
Patients might also experience changes in hair quality from estrogen receptor and aromatase inhibitors, like tamoxifen, said Dr. Lamb.
“They feel like their hair is thinner, not as voluminous, not as lush. Often, that’s hormonal.”
Rather than shrug it off, Dr. Lamb said she tries to actively manage those patients.
“We can do a variety of things. Depending on a patient’s tolerance, side effect profile, and risks that they’re willing to take. We start with topical agents, usually topical minoxidil. We can do 5%, 7%, sometimes up to 10%. We also use oral minoxidil. I usually start at a dosage of 1.25 mg/day, and we can go down or up based on their tolerance. We can also do platelet-rich-plasma (PRP) on those patients. I use a mesotherapy technique to inject that back into the scalp, and we actually can mix that with minoxidil.”
