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Healthy living after treatment of childhood, adolescent, and young adult cancer

Skin Health after Cancer Treatment
The skin is the largest organ in the body and it is the body’s first line of defense against outside invaders. It also keeps
the body temperature normal and stores water, fat, and vitamin D. This important organ requires care and monitoring.
Treatment for childhood cancer sometimes causes damage to the skin.
Who is at risk?
• Survivors who received radiation to any part of the body, including total body irradiation (TBI).
•Survivors with chronic graft-versus-host disease (GVHD) following bone marrow or stem cell transplant.

What problems can occur?
The following are possible long-term skin effects that may be seen after cancer therapy.
Telangiectasias
These small blood vessels on the surface of the skin are commonly referred to as “spider veins,” and in the cancer
survivor they can occur in the field of radiation. Telangiectasias are caused by changes to the lining of blood vessels
resulting from radiation. These do not typically cause any health problems and require no specific care.
Fibrosis
Fibrosis is caused by scarring of the lining of blood vessels, resulting in a “woody” skin texture. The skin may not beas flexible in the fibrotic area and may be more easily injured. Care of fibrotic skin should include routine moisturizing
and avoidance of trauma. Because the blood supply is not as good in fibrotic skin, healing may be slow after cuts andscrapes, so avoiding these when at all possible is important.
Scleroderma
People who have chronic GVHD following bone marrow or stem cell transplant sometimes develop scleroderma. In thiscondition, the donor white blood cells do not recognize the patient’s skin cells as their own, and begin to attack them.
This causes the skin to become stiff and inflexible. This may happen anywhere on the body, but if it happens to the skinaround joints, it can make the joints less mobile. The therapy for scleroderma is treatment of the underlying GVHD. It isalso important to avoid injury to this skin, since healing time will be prolonged.
Vitiligo
Vitiligo is loss of pigment on patches of the skin. This can occur after bone marrow or stem cell transplant from aperson other than yourself (allogeneic transplant) and may be due to GVHD or other autoimmune reactions seen aftertransplant. In this situation, the white blood cells do not recognize certain normal skin cells (melanocytes) and so they
attack and destroy them. Melanocytes are the cells in the body that control skin color. Without melanocytes, the skin has
a milky white appearance. Vitiligo usually occurs only in patches. The therapy for vitiligo is treatment of the underlying
GVHD or autoimmune process. Even the skin because the damage to the melanocytes may be permanent. While all skinshould be protected from sun, skin that has lost its pigment is very vulnerable, and sunscreen should always be applied
to these areas before going outdoors.
Hyperpigmentation
Hyperpigmentation is a darkening of the skin that may occur after radiation or some types of chemotherapy.
The chemotherapy agents most commonly associated with hyperpigmenation include bleomycin, busulfan,

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Healthy living after treatment of childhood, adolescent, and young adult cancer

cyclophosphamide, dactinomycin, 5-flourouracil, hydroxyurea and methotrexate. The dark discoloration can occur on
the skin or nails. There is no specific treatment for hyperpigmentation associated with cancer therapy, but it usuallycontinues to fade over time without any treatment.
Skin Cancers
People who have received radiation are at risk for developing skin cancers, usually in the radiation field. Other riskfactors include light skin color, chronic sun exposure, severe sunburn, atypical moles or a large number of moles on
the body, and a family history of skin cancer. The good news about skin cancer is that if it is diagnosed early, it isusually very treatable. There are three major forms of skin cancer:• Basal cell carcinoma (BCC) is the most frequent form of skin cancer. BCC usually appears as a rough, raised,area of skin. As the BCC progresses, it may become an ulcer or sore that does not heal. BCC can occur anywhereon the skin, but is seen most frequently in areas of sun and/or radiation exposure. Protecting your skin from thesun is the most important thing you can do to avoid developing BCC. Treatment for BCC is surgical removal of theaffected skin. BCC can spread to surrounding tissues but does not usually spread throughout the body and is not
usually life threatening.
• Squamous cell carcinoma (SCC) is another form of skin cancer that can develop from exposure to sun orradiation. Its appearance is similar to BCC, usually an ulcerated sore that does not heal. SCC can be moreaggressive than BCC and can spread more readily to surrounding tissues and even to other parts of the body.
With early surgical treatment SCC is usually curable, so it is important to report any suspicious sores to yourhealthcare provider right away.
• Melanoma is a much more serious form of skin cancer. Unlike BCC, left untreated it can spread to other organs
and can be lethal. Melanoma often arises from moles. The key to successful treatment of melanoma is early
diagnosis. Moles should be monitored for changes. Monitoring of moles can be remembered using the “ABCD”
warning signs:
A is for Asymmetry (one half of the mole looks different than the other half)
B is for Border (moles that have an irregular, scalloped or poorly defined border)
C is for Color (variations in color from one area of the mole to another, such as different shades of tan andbrown or black, or colors such as white, red, or blue within a mole)
D is for Diameter (moles larger than 6 millimeters – about the diameter of a pencil eraser – should beevaluated).
If you notice any of the “ABCD” warning signs, have your healthcare provider check the mole. Moles that have any ofthese warning signs usually need to be removed.
What monitoring is needed?
If you have any of the following risk factors, you should routinely check your skin for changes, and have athorough skin examination by a healthcare provider at least once a year:• You received radiation to any area, including total body irradiation (TBI)• You underwent a hematopoietic cell transplant• You have ever had skin cancer or melanoma, or you have a family history of skin cancer or melanoma• You have “dysplastic” (atypical) moles•You had a severe sunburn at a young age

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Healthy living after treatment of childhood, adolescent, and young adult cancer

What can I do to keep my skin healthy?
The most important thing to remember in caring for your skin is to protect it from the sun. Here are some things youcan do:• Wear protective clothing or sunscreen at all times when your skin is exposed to the sun, even on cloudy or hazydays. The American Cancer Society recommends a sunscreen with an SPF (sun protection factor) of 15 or higher.
• Sand, snow, concrete, water and high altitudes all increase the risk of sun damage—take extra caution toprotect your skin in these environments.
• Do not attempt to tan your skin—avoid tanning booths.
• Avoid outdoor activities from 10 am to 2 pm when the sun’s rays are most intense (11 am to 3 pm during
daylight savings time). Plan outdoor activities in the early morning or late afternoon hours.
• Reapply sunscreen frequently or use a water-resistant sunscreen when swimming or perspiring heavily. This
will not only help to protect you from developing skin problems but will also help you to maintain a youthfulappearance.
If you have any questions or concerns about your skin, contact your healthcare provider. Take good care of your skinand it will take care of you!
Written by Kathy J. Ruble, RN, MSN, CPNP, AOCN®, Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, MD.
Reviewed by Amelia DeRosa RN, BSN, CPON®; Kayla L. Foster, MD, MPH; and Christine Yun MSN, PNP, CPON®.

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or youngadulthood.
Disclaimer and Notice of Proprietary Rights
Introduction to Late Effects Guidelines and Health Links: The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers and accompanying Health
Links were developed by the Children’s Oncology Group as a collaborative effort of the Late Effects Committee and Nursing Discipline and are maintained and updated by the Children’s
Oncology Group’s Long-Term Follow-Up Guidelines Core Committee and its associated Task Forces.
To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified health provider with any questions you may have regarding a
medical condition and do not rely on the Informational Content. The Children’s Oncology Group is a research organization and does not provide individualized medical care or treatment.
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