Skin, Nail, and Hair Changes During Chemotherapy

Skin and nails are made of fast-growing cells. That is exactly what chemotherapy targets. So many of these changes show up together, and they usually improve once treatment ends. Most are uncomfortable rather than dangerous. But a few are not, and the difference is worth knowing.

Chemotherapy can cause dryness, itching, redness or darkening of the skin, peeling, and a minor rash. It can also increase sun sensitivity and change pigmentation.

Other treatments cause their own patterns:

• Radiation therapy can cause dryness, peeling, itching, redness or darkening, swelling, and a sunburned look.
• Targeted therapy causes dryness, rash, and nail problems.
• Stem cell transplants can lead to graft-versus-host disease, with rash, blisters, or thickening of the skin.

Did you have radiation therapy in the past? Some chemotherapy drugs can trigger a reaction in the area that was treated. This is called radiation recall.

Dryness and itching are the most common complaints. The basics genuinely help. Moisturize with creams and lotions your team recommends. Apply them while your skin is still damp. Use lukewarm water rather than hot. Avoid products containing alcohol or fragrance. Colloidal oatmeal baths can ease itching.

Photosensitivity means you sunburn easily. It can happen after sun exposure that never used to bother you. Prevention is straightforward: sunscreen, protective clothing, and a hat. This matters year-round, not only on obviously sunny days.

Hyperpigmentation shows up as darker areas of skin, tongue, and joints. It can look dramatic, particularly along veins used for infusions, or across knuckles and finger joints. It is a pigment change, not damage.

Nail changes are common. They are easy to dismiss, and worth mentioning early. Chemotherapy can cause darkened and cracked nails and painful cuticles. Reported nail changes include:

• Ridges and lines. Beau's lines are horizontal ridges or grooves across the nail. Mees' lines and Muehrcke lines are other banding patterns.
• Weaker nails. Thinning or reduced strength, leading to breakage.
• Discoloration. Yellowing, discoloration, or over-pigmentation on the nails or nail beds.
• Nail lifting. The nail plate lifting or falling off, known as onycholysis.
• Painful nail beds. Delicate, sensitive nail beds or cuticles.
• Infection. Paronychia — infection around the nail — which is more likely if nails are cracked or open.
• Slowed growth. Nails may grow more slowly, or stop growing for a while.

Some chemotherapy drugs are particularly associated with nail changes. They include vincristine, paclitaxel, fluorouracil, etoposide, daunorubicin, bleomycin, cyclophosphamide, dacarbazine, and methotrexate. Immune checkpoint inhibitors can affect nails. So do targeted drugs, especially EGFR inhibitors and antiangiogenic agents (drugs that block the growth of new blood vessels).

Do you have pain and swelling around the nail? Daily vinegar soaks are one suggested measure — equal parts white vinegar and water — along with over-the-counter anti-inflammatory medicines. For weak nails, a water-soluble nail lacquer or a prescription nail polish may help, and biotin has been suggested. An infected nail may need antibiotics, antifungals, steroid ointment, anti-inflammatory medicines, or other treatment. Severe lifting occasionally requires surgical removal of the nail.

Most nail changes are temporary. But some can last long after treatment ends, or can even be permanent.

Painful redness and swelling on the palms of the hands and soles of the feet is a distinct side effect. It is called hand-foot syndrome, or palmar-plantar erythrodysesthesia. It is managed differently from ordinary dryness. See our page on hand-foot syndrome during cancer treatment.

Hair loss is a separate topic with its own practical decisions, including scalp cooling. Our pages on hair loss during cancer treatment and cold caps cover it in detail.

Let your health care team know if you notice any skin changes, so they can be treated promptly. Tell your team about nail symptoms even if they are not painful or bothering you. Tell them as soon as you notice any change, expected or unexpected.

Rashes may be treated with a medicated cream (topical corticosteroids). They may also be treated with medicine you take as a pill (oral corticosteroids or antibiotics). Radiation can produce a moist reaction, where sores become painful, wet, and infected. That is another reason not to wait and see.

• Call your care team without waiting, at any hour, if your temperature reaches 100.4°F (38°C) or higher while you are on chemotherapy. CDC treats a fever during chemotherapy as a medical emergency, because your white cell count may be too low to fight the infection and it can turn life-threatening fast. Do not take acetaminophen first. If you cannot get through quickly, go to an emergency department and tell them you are on chemotherapy.
• Call 911 or go to an emergency department if a rash blisters or peels away in sheets, or comes with mouth, eye or genital sores and a fever.
• Call your care team the same day if you are on immunotherapy and a rash turns severe, widespread, or painful. Rashes that reach the eyes, or a mucous membrane such as the mouth, matter even more.
• Call your care team the same day if the skin around a nail is hot, swollen, and oozing, or a treated area of skin turns wet, raw, and sore. Infection during treatment needs urgent attention.
• Call your care team within a day or two if a nail lifts away or splits, the nail bed stays tender, or itching and dryness are keeping you awake.

Hand-Foot Syndrome During Cancer Treatment, Radiation Burns and Skin Changes, Immune-Related Side Effects, and Side Effects of Cancer Treatment.

• National Cancer Institute, Skin and Nail Changes during Cancer Treatment
• American Cancer Society, Nail Changes
• National Cancer Institute, Infection and Neutropenia during Cancer Treatment
• Centers for Disease Control and Prevention, Fever and Cancer Treatment