Cutaneous Oncology: Clinical Pearls

George Martin, MD

How are you managing your cutaneous oncology patients? Dr Martin provides us with his clinical pearls…

  • Remember that AK patients are not just Medicare patients, we see patients 30-40 years old as well. Also remind older patients that actinic damage is chronic disease and no one therapy will result in a long lasting or permanent cure.
  • When treating AKs, expect side effects based on the MOA of the active ingredient.
  • Treating AKs on the chest? Therapeutic considerations include:  Topical 5-FU cream 0.5/1.5%; Ingenol Mebutate gel 0.5%; and Diclofenac gel 3%., Expect a significant skin reaction to ingenol mebutate 0.05% (not .5%) within 24 hrs that will include blistering and discomfort requiring analgesia when large areas are covered.. 5-FU can be “titrated” and can be used for 7-10  days, discontinued for a month and re-started in a month and used for 2-3 weeks with less of a reaction. DO NOT USE IMIQUIMOD on the chest as it is not FDA approved for the chest and  an result in permanent depigmentation.
  • Managing reactions is key! Utilize analgesia as needed; sunscreen to reduce potential for dyschromia; moisturizers; topical antibiotics as needed; and weekly follow-up.
  • Imiquimod can trigger flu-like symptoms including myalgias and fever before a significant skin reaction such as erosions and ulceration may occur.
  • Ingenol Mebutate has two mechanisms of action: an immediate cytotoxic effect initiated via the PKC pathway which causes swelling  and edema even blistering and weeping and a second MOA involving IL-8 production by rapidly proliferating ketatinocytes and endothelial cells which recruits neutrophils and in vigorous responses can result in sterile pustules.
  •  Counsel patients on anticipated responses and set expectations.
  • Have patients fill prescriptions between Monday to Thursday—less likely to be switched than Fridays or weekends.
  • Have patients start treatments on Sundays, for ingenol mebutate during Mon-Thurs as the immediate reaction to ingenol mebutate may trigger a phone call within 24 hours; this way, reactions occur mid week rather than on weekends.
  • Make sure that surgical sites are well healed and that cryotherapy sites have had a week or two after healing before initiating therapy.
  • Use every adjunct possible except steroids as the immune system plays a role in each modality used.