Type

Clinical manifestations

Treatment

Papulopustular (acneiform) rash

Grade 1: Papulopustular eruption <10% of BSA

Topical treatment: Low-potency topical glucocorticoids (eg, 2.5% hydrocortisone cream bid ± topical 1% clindamycin gel or solution), moisturizer

Grade 2: Papulopustular eruption 10%-30% of BSA; limiting iADLs

Topical treatment: 2.5% hydrocortisone cream bid, moisturizer

Systemic treatment: Oral antibiotics with good anti-inflammatory properties, such as doxycycline or minocycline 100 mg PO bid for 7-14 days to assess response and treat for ≥4 weeks

Antipruritic treatment: Oral antihistamines (eg, hydroxyzine, cetirizine)

Analgesic treatment: Acetaminophen, ibuprofen

Grade 3:

– Papulopustular eruption >30% of BSA

– Limiting ADLs

Dose modification or discontinuation of EGFR inhibitors until severity of skin rash decreases ≤grade 2

Topical treatment: 2.5% hydrocortisone cream bid, moisturizer

Systemic treatment: Doxycycline or minocycline 100 mg PO bid for 7-14 days to assess response and treat for ≥4 weeks + prednisone 0.5 mg/kg for 7 days

Antipruritic and analgesic treatment: As above

Grade 4:

– Involvement of >30% BSA with serious consequences

– Erythroderma (skin desquamation and ulcerations)

– Discontinuation of EGFR inhibitors and transfer to specialized burn treatment facility

– Consider dermatology consultation for treatment with low doses of oral retinoids (eg, isotretinoin or acitretin)

Dry skin (xerosis)

Pruritus and dry skin

General recommendations: Avoid excessive skin exposure to water and soap

Emollients: 5%-10% urea and other preparations

Antipruritic treatment: Oral antihistamines (eg, hydroxyzine, cetirizine)

Fissures

Emollients: 5%-10% urea and other preparations

Inflammation of fingertips

Emollients: 5%-10% urea, intermittent topical treatment with medium-potency glucocorticoid (eg, fluticasone, betamethasone)

Paronychia

General recommendations: Preventive measures (loose footwear, antiseptic baths)

Topical treatment: Topical high-potency glucocorticoids (eg, clobetasol propionate for 2 weeks) ± topical antifungal agent (eg, ketoconazole cream bid for 2 weeks)

Treatment of infection: Cephalexin (500 mg PO qid) or cloxacillin 500 mg PO qid for 7 days