When diagnosed with cancer, visiting a dermatologist may be the last thing you think about. However, skin-related conditions caused by cancer treatments are common. To answer all your questions and learn about skincare before, during, and after cancer treatment, we hosted our first Speakers Series event September 2020. We had the privilege to be joined by Dr. Maxwell Sauder, Onco-Dermatologist, who shared his recommendations on caring for your skin and scalp during treatment and beyond.
Dr. Sauder is a board-certified dermatologist in Canada (FRCPC) and the United States (DABD) with additional fellowship training in cutaneous oncology. He is a former faculty member of Harvard Medical School where he focused on skin toxicities of anti-cancer treatments (STATs). He is currently an onco-dermatologist at Princess Margaret Cancer Centre where he assists in the management of complex cutaneous malignancies and STATs. He also practices at Toronto Dermatology Centre where he is the director of the Pigmented Lesion Clinic that uses cutting edge artificial intelligence technology to identify and manage skin cancers or precancerous lesions at the earliest possible stage.
Read our Q&A or watch the videos below discussing Dr Sauder's mantra when it comes to skincare basic principles, the recommended skincare products, shampooings, and what to avoid, how to effectively protect your skin from the sun during treatment, scalp care and advice on how you can minimize hair loss and what the "back to normal" could look like for your skin.
Please note that the information provided is intended as general information and not meant to replace the medical advice you receive from your primary care team. You should always consult your healthcare practitioner with any questions or concerns.
As a general rule, keep your skincare routine as simple as possible - no serums, acids, toners etc.
Historically, the point of toners was that cleansers would strip the essential oil off of the skin, because they were quite strong, and the point of toners is to replenish. If you us a neutral based cleanser followed by a moisturizer, you do not really need that toner.
Serums are very nice, but they tend to have a lot of added ingredients, like retinol. However, some of the ingredients can be helpful like niacinamide, which is an anti-inflammatory, but vitamin C which thought be an anti-oxidant, but can be very irritating ….
Simple rule: Gentle cleanser. Good moisturizer. Great sunscreen.
A: You can have a great product but if it’s in the wrong vehicle then it might not do the job you need - the vehicle is just that: an ointment, a gel, lotion, a cream, etc. These are all different chemistry terms - the best way to equate them is the viscosity – the thickness of the product. In terms of eczema, the strongest vehicle, from a moisturization standpoint, is an ointment. The issue with an ointment is that it might not be cosmetically pleasing as it can be quite greasy and sticky.
The next best thing is a cream. They are rich and thick that have a bit of weight to them when you actually scoop them up or put them in your hand. They might not rub in quite as nicely as a lotion, which people tend to gravitate to because people like pumps. People like to use product that take very little time to apply and lotions take very little time. Lotions have a much higher water content and much less oil content – so the ratio we are playing with to go from an ointment to a cream to a lotion to an oil and even a gel (which has alcohol mixed with oil) can actually be dehydrating rather than hydrating.
A: Absolutely! People going through cancer has skin that is equivalent to eczema. People with eczema have a higher propensity to developing allergies to a product they are using. Even outside of cancer, people who come to my clinic experiencing allergies, I say to them: “ I think you are reacting to xxx product … and they say: “ that product, I’ve been using for the last 20 years “. That is exactly right. No one is born with allergies in their skin. We all need to be sensitized to products first and certain treatments can make your skin more sensitive and therefore make your skin have a greater ability to be sensitized to an allergen. You can use something a million times and the million and one time - boom you become allergic to it.
Key signs you are allergic to something
I also recommend the website www.producteliminationdiet.com . It’s a wonderful resource and Dr. Scott Nicky is fantastic dermatologist. I learn so much from her all the time.
A: Even for me, and I know these products, inside and out and every time I go, I discover new products that I was not aware of.
In general, you want to treat your skin like a person who has eczema – but you don’t necessarily need to get products for “eczema”. Key words are hypo-allergenic, fragrance-free – not scent-free (there is actually a difference) and ideally PH balanced or PH neutral product.
A: Lots to avoid – in a pharmacy – especially the acne aisle –over the counter and prescription treatments tend to be quite irritating – is the single biggest side effect that I need to manage as a dermatologist for people that have acne. So, you might see an acne like rash on your skin, but it might not be the right thing to get a strong acne cleanser. Most of these cleansers have acids in them (salicylic acid, lactic acid, alpha/beta hydroxyl acids), which can be irritating to the skin and disrupt the PH. Similarly, a retinol is a vitamin A acid – the retinoid version of it – the acidic version of it, rather than the aldehyde, is a prescription treatment for acne – and then there is the OTC version that is not metabolically active when you put it on your skin. With both of those, the single biggest side effect is dryness, redness, irritation which is exactly what we want to avoid.
A: Where possible, sunscreen should be the last step when applying products to your face. Think of it as a barrier that is going on top of whatever else you put on which ideally (during treatment) is just cleanser, moisturizer and sunscreen. If your sunscreen can act as a moisturizer, even better.
If you are not doing too many outdoor activities, no strenuous activities where you are sweating, then generally, one application in the morning is good. I recommend doing that 365 days, rain or shine – fall, winter, spring and summer. This is because UVA is constant throughout the year, constant throughout the day, and it can come through windows. A lot of anti-cancer treatments can make you more sensitive to UVA.
If you go outside and do physical activities, re-apply frequently and liberally, at least once every 2 hours, after sweating significantly, or after swimming.
To choose your product, the general principals should be:
SPF (Sun Protection Factor), which only measures UVB not UVA, should be at least 30 or higher. It should also say Broad Spectrum or ideally have the UVA with the circle around it which it states that it covers the UVA spectrum.
In terms of how sunscreen works, there are 2 main categories:
Ideally you should be putting on a sunscreen about 20 min before UV exposure in order to get maximum absorption. If you are using a moisturizer first, wait 2-5 mins for the moisturizer to rub in otherwise you get a dilution effect. You could get a 30 SPF working like an SPF 15 because it is spreading out in combination with the moisturizer
A: If it says mineral sunscreen on packaging, its generally going to be zinc or titanium – now it may also have an organic filter in it. Generally, the ones that do say mineral to begin with, they are organic filters that people typically tend not to react to. There could also be a combination of both. There is nothing wrong with organic filters and there are some excellent organic filters that I use personally on a regular basis. Especially for large body surface areas as the zinc or titanium ones do tend to not rub in as well as the chemically organic ones.
A: If you can, put your foundation on first then your sunscreen – I understand that might not be realistic, from a rubbing in perspective. If you are using mineral foundation some of them can actually provide additional SPF protection – so no problem with putting on a sunscreen and then applying your makeup.
A: I love UV protective clothing – love UV hats. Clothing with UPF (SPF version of clothing) is great. I highly recommend it. When I go swimming, I have a rash guard that has UPF 50. But as long as it’s tight knit clothing and darker colours, you don’t necessarily need UPF clothing. If you cannot see through the material, generally speaking, then the sun can’t see through the material. With UPF clothing, such as rash guard, it will thin out over time and will need to be replaced or you can get some washes to re-treat your sun protective clothing. Or you can treat clothing that isn’t sun protected to make it sun protective. From a sun protection perspective, it is not just about sunscreen, it is about utilizing shade and wearing sun protective clothing. A broad-brimmed hat is the best; ideally a wide brimmed hat that goes all around rather than a baseball style hat.
A: Thankfully radiation sites are generally protected by clothing. That skin is extremely sensitive – think of that skin as a really bad flare of eczema. So if you can, I would rely on barrier protections. I would use a moisturizer as long as the skin is not the target – you can use a topical steroid then cover with UV protective clothing. You could use sunscreen, but I would be cautious, because they tend to have more ingredients in them that people could just react to. You want something that is anti-inflammatory for radiation dermatitis.
A: We have not touched on radiation too much, but this is an area that can cause significant short term and long-term sequelae. For most of the cancers, the skin is not the intended target, unless you have a skin care cancer that is being treated by radiation. But, for example, if you have breast cancer and the breast has to be radiated, or you’ve got a metastasis on your spine that needs to be radiated, to give you some relief, so as long as the skin is not the primary target, definitely moisturizing before, during and after the treatment. There are also some centers that have a protocol to use a topical steroid, which can significantly reduce the inflammation on your skin. In that case, it does not affect the end target. The skin, in most cases, is an innocent bystander that the radiation needs to pass through in order to get to the intended target.
A: Prescription based topical steroid, general radiation oncologist would provide this or if they are part of a multi-disciplinary team like I practice at PMH, then I could provide that as well.
A: It’s a whole other can of worms… there are some very specific treatments, targeted treatments in particular, that can cause an acneiform eruption in the skin – which means an acne-like reaction that can be driven by a couple of different things. Typically, the EGFR inhibitors (used in colorectal cancers) or the MEK inhibitors (used for melanoma) produce this acne gone wild on people. So for that, you actually need medical intervention, so nothing in the pharmacy aisle is going to help.
Now, we also know, that people with an underlying tendency for acne, will have their acne come out when they are stressed. Your body is going to be stressed both physically and especially psychologically when going through the cancer journey. So, if that is the case and you are not on these specific treatments that have acne as a side effect, then there are things that can be done. However, I would encourage them to talk to their physicians, not necessarily their medical oncologist but their medical oncologists first to see if this is a reaction common associated with the treatment they are on and if it’s not, and they had an underlying tendency for acne and it’s just flaring right now, talk to your family doctor or ask for a referral to a dermatologist because there are a lot of good interventions we can do and there are many types of acne. So, depending on the kind of acne, there are a lot of different products and/or prescriptions we can recommend.
A: There are interventions for sure, but at the same time people are inundated with medical appts and they are literally dealing with a fight for your life and there are so many things you have to achieve in your day. On top of that, your body is being bombarded with these anti-cancer treatments that’s just making you tired and so maybe another appt with another doctor. isn’t that feasible. But if it is, I certainly encourage people to have that discussion.
We have good data that the skin impacts quality of life in the cancer journey and 2/3 people, when surveyed, the skin effects of their treatments were far worse than they expected. On average, 50% of people will experience a treatment interruption or discontinuation because of the skin. When it is affecting your anti-cancer treatment, which is when I would reach out to a dermatologist specialized in cancer, like myself or general dermatologist, that are more and more getting familiar with these anti-cancer reactions. In a lot of cases, going back to the acneiform eruptions from EGFR inhibitors, these rashes are an indication that they are working and fighting the cancer. So, it is the exact opposite time you want to come off these types of treatments.
A: Hair is an appendage of the skin and we know that many traditional chemotherapy agents result in hair loss, something called Anagen Effluvium. There are definitely some strategies to try and minimize it that but when you talk about itchy scalp, I would break it up with itchy scalp with hair or without hair.
Baseline for both is an anti-dandruff shampoo. A shampoo with either selenium sulfide, ketoconazole, or zinc pyrithione - common anti-dandruff treatments. Use about 2x week, massage into the scalp and let them sit for 2-5min. Think about it as a treatment for your scalp –they are very anti-inflammatory so they can be very soothing. No more than 2x week because they can be a little drying to the scalp which is the opposite of what we want.
If you still have your hair and are still itchy and red underneath, you may require a prescription of an anti-inflammatory lotion – which would be a liquid that you can massage into the hair quite easily. They are generally topical steroid lotions, that can be used, which I recommend using every night until the itchiness or the dryness goes away OR minimum of twice a week and then start slowly decreasing from every day to every other day for a couple of weeks, then 2x a week and then down to once a week and even trying to stop all while continuing the anti-dandruff shampoo. I equate any type of inflammation in the skin to basically like a fire. So, if you douse out the fire, and you do not keep dousing it out, there are still embers burning and if you stop treatment, it can light back up. You really want to do a kind of prolonged tapered off anti-inflammatory treatment. Now if you are talking about a scalp with no hair that’s itchy, I would again recommend the anti-dandruff shampoo but then you could use your moisturizer for your body, so a good cream or balm on the scalp.
A: It definitely has some anti-inflammatory properties to it as well as anti-microbial activities, so anti-bacterial. The only issue with it is that some people can develop allergies to tea tree oil specifically. So, I’m not opposed to it but if you think things are getting worse when you are using it, you might start to think that maybe you’re actually reacting to it. Also, most of the shampoos with tea tree oil in them have a lot of fragrance which people can react to as well. This is why I tend to like the more traditional anti-dandruff shampoo but tea tree shampoo can be anti-dandruff and anti-inflammatory.
A: Depends on treatment, again traditional chemotherapies are associated with Anagen Effluvium, definitely anti-dandruff shampoo twice a week. You want to give your hairs the best possible environment to grow in. I do recommend Minoxidil (it is the active ingredient with 5% foam), Rogaine is the brand name, twice a day for men and once a day for women. There are versions for men and women, but there is NO difference between the two, just marketing and instructions and price So, I often tell people to get the men’s version and use it once a day if they are female. Vitamin supplements also. All 3 of those products are in the same section of the pharmacy, usually on the same shelf or right beside each other.
For certain chemotherapies, there are products like the “cool cap” that cools the scalp during the infusions and does have data behind it to support the reduction in hair loss associated with chemotherapy.
A: There can be very general changes like brittle nails, cracking nails, longitude and lines in the nail, horizontal lines, which are called Beau’s lines, which can happen from stressful events, hospitalizations, or significant treatments. They are also very specific reactions from specific classes of medications such which can cause huge inflammation of the fingernail bed which is very painful. Our nails are very important; they give us the ability to grasp onto things and really without our nails it’s very difficult to have that tactile strength in order to do basic things like writing with a pencil or pen, opening a jar or typing on a phone. So these can be distressing and can have a huge effect on quality of life. Again, EGFR inhibitors, they are famous for causing inflammation around the nails that lead to treatment discontinuation.
Back to Basics – gentle cleanser, moisturizer even around the nails and try to avoid trauma where you can. If you are more in the general changes like brittleness and breaking, there are some nail strengthening lacquers you can get at big pharma behind the counter with pharmacist with no prescription required. It’s like a clear nail polish you can apply that increases the strength of the nails and gives you back some of that tactile strength. Sometimes you can take some supplements – but there is a lot of literature out there about biotin and some data suggesting that super physiological doses of biotin can affect some of our lab tests, so I generally tend to stay away from high doses of biotin, even though it’s OTC and something that is readily available.
There are a couple of products that are vitamin supplements for hair growth, which can be found in the hair aisle, in the anti-dandruff section. The vitamin supplements have a combination of ingredients that can strengthen the hair. Hair is very similar to the nail, so the nails can respond in the same manner.
A: Broad question with broad answer – it really depends on the type of treatment. If it is a hormonal type, then the skin will have significant lasting changes.
Traditional chemotherapy, very shortly after finishing treatment, and the reactions have subsided, the skin will go back to normal.
What to do: Gentle cleanser / Good moisturizer / Great sunscreen
A: Good question. Wait until you think your skin is getting close to back to normal – that could be a couple of weeks or a couple of months, or a couple years depending on the intervention. When you think it feels like back to normal, then I would slowly re-introduce products into regimen. Incorporate one new product for one week, make sure you don’t react and if it seems fine then go to the next one and do so until you have added all your products. You can also find info on the website www.producteliminationdiet.com . It’s a wonderful resource and Dr. Scott Nicky is fantastic dermatologist. I learn so much from her all the time.