Symptom: Skin, Dry

Initial Grading Reminder

CTCAE For Skin, Dryness:

Grade 1: Covering <10% BSA and no associated erythema or pruritus
Grade 2: Covering 10-30% BSA and associated with erythema or pruritus; limiting instrumental ADLs
Grade 3: Covering >30% BSA and associated with pruritus; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you normally have dry skin? If so, when (e.g., wintertime)? When did the dryness start/get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

Are there cracks or any bleeding? What have you been doing/using/applying to help the dryness?  Is it itchy? Have you been scratching it? Is it widespread? Is it interfering with your normal daily activities? Is it keeping you awake at night?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you also have a rash? If so, is it over more than 50% of your body? Is your mouth involved? Do any of the lesions look infected? Are you very fatigued?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with new-onset moderate or worse (or worsening) dry skin should be seen.

    Patients with any of the red-flag symptoms also should be seen immediately.

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    Nursing Assessment of Potential Causes

    Skin Toxicities - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is there an obvious rash?
    • Is the patient scratching during the visit?
    • Is skin integrity intact?
    • Are there skin changes?
      • Xerosis
      • Changes in skin pigment or color
    • Is there oral involvement of the rash?
    • Does the patient have pruritus with or without rash? Is there a rash with or without pruritus?
    • Are symptoms interfering with ADLs?
    • With sleep?
    • Have symptoms worsened?
    • Is there a history of dermatitis, pre-existing skin issues (psoriasis, wounds, etc.)?
    • Laboratory abnormalities consistent with other etiologies (e.g., eosinophils on complete blood count, liver function abnormalities)

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear unwell?
    • Changes in weight since last visit
      • Appear heavier? Thinner?
    • Changes in hair texture/thickness?
    • Appearing hot/cold?
    • Does the patient look fatigued?
    • Appetite/weight changes?
    • Hot or cold intolerance?
    • Change in energy, mood, or behavior?
    • Palpitations?
    • Increased fatigue?
    • Bowel-related changes?
      • Constipation/diarrhea
    • Skin-related changes?
      • Dry/oily
    • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
    • High TSH with low free T4 consistent with primary hypothyroidism
    • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
    • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
    • Other immune-related toxicity?
    • Prior thyroid dysfunction?

    Differential Diagnosis

    What do you suspect is the cause of  the dry skin?