Daily skin care habits and the risk of skin eruptions and symptoms in cancer patients.

Received 15 November 2011; revised 29 March 2012; accepted 10 April 2012 Background !ancer patients are at high risk "or skin problems because rapidl# proli"erating skin cells are susceptible to anticancer therapies$ %o&ever' the e""ects o" dail# skin care habits on development o" skin problems in cancer patients have rarel# been studied$ (atients and methods )e conducted a surve# o" dail# skin care habits and the presence o" skin problems in *++ cancer patients$ Results %ot &ater bath ,1 h signi"icantl# increased the risk o" de"inite eruptions -odds ratio ./R0 1$092 and the risk o" itching or pain on the skin ./R 1$340$ 5iligent use o" moisturi6ers did not decrease the risk o" de"inite eruptions and s#mptoms' and dail# bathing' scrubbing o"" the skin &hile bathing' and sun protection did not in"luence the risk o" de"inite eruptions and s#mptoms$ 7ubgroup anal#sis o" 1*4 breast cancer patients sho&ed results similar to the total results' including that hot &ater bath ,1 h signi"icantl# increased the risk o" de"inite eruptions ./R 4$110$ !onclusions Being a cross8sectional stud#' our stud# could not prove causalit#$ %o&ever' at the present stage o" kno&ledge' avoidance o" hot &ater baths o" protracted duration should be "irst emphasi6ed in patient education to prevent skin problems in cancer patients$ 9e# &ords bath' cancer' eruptions' itching' moisturi6er' skin care habits introduction !ancer patients are at high risk "or skin problems because rapidl# proli"erating skin cells are susceptible to anticancer c#toto:ic agents and radiation therap#$ ;o overcome the nonspeci"ic damage o" normal cells b# c#toto:ic agents' targeted agents have been developed and are increasingl# used; ho&ever' the most &idel# used targeted agents are epidermal gro&th "actor receptor .<=>R0 inhibitors' &hich notoriousl# induce acnei"orm rash in ?15@A100@ -12$ 7kin lesions can cause cosmetic problems leading to impairment in the Bualit# o" li"e and poor patient compliance' more dose dela#s' and even discontinuation o" antineoplastic therap# -2' 42$ (revious studies on skin problems in cancer patients have e:clusivel# "ocused on the adverse e""ects o" chemotherapeutic agents and radiation therap#$ Among them' skin to:ic e""ects o" <=>R inhibitors and radiation therap# have been the most studied; ho&ever' "e& controlled trials have been conducted to determine the best treatment -2A122$ 7#stemic minoc#cline has been reported to decrease the severit# o" cetu:imab8 induced acnei"orm rash -112' and pre8emptive skin treatment including do:#c#cline has been sho&n to be more e""ective "or panitumumab8induced skin to:ic e""ects than reactive treatment -122$ 5ail# skin care management in cancer patients has rarel# been investigated$ Although e:perts have recommended the use o" moisturi6ers and sunscreens and avoidance o" e:treme temperatures during anticancer chemotherapies or radiation therap# -2' 4' 102' no reports have provided evidence "or desirable skin care

methods in the dail# li"e o" cancer patients$ Actuall#' sunscreen use did not decrease the risk o" <=>R inhibitor8induced rash in a placebo8controlled trial -142$ A recent revie& anal#6ed "our reports regarding &ashing o" the portal skin under radiation therap# and concluded that gentle &ashing &ith mild soap can be bene"icial' &hich is limited to the management o" the radiated skin onl# and not general skin care methods -102$ ;o evaluate the risk o" skin eruptions and s#mptoms according to skin care habits in cancer patients' &e conducted a surve# in *++ cancer patients' using a digital surve# s#stem$ patients and methods patients !ancer patients &ho visited 7eoul National Cniversit# !ancer %ospital &ere allo&ed to "reel# participate in the surve#$ ;he ans&ers o" *++ cancer patients &ere collected anon#mousl# "or a period o" 3 months' "rom March to /ctober 2011$ Approval &as obtained "rom the <thical Revie& !ommittee o" 7eoul National Cniversit# %ospital .<8110*801184320$ As &e did not collect an# personal in"ormation "rom the participants' &ritten consent reBuirements &ere &aived b# the !ommittee$ questionnaire ;he Buestionnaire consisted o" three parts' including the Buestions about underl#ing cancers' current skin problems' and skin care habits' as "ollo&s 10 Cnderl#ing cancers A0 )hich cancer do #ou haveD 7elect among the "ollo&ing list$ A =astric cancerE;h#roid cancerE!olorectal cancerEBreast cancerE Fiver cancerEFung cancerE(rostate cancerECterine cervi: cancerE Bladder cancerEF#mphomaERenal cancerE%ematologic cancerE /ral cavit# cancerE%ead and neck cancerEMusculoskeletal cancerE Brain cancerE7pine cancerEAdolescent cancerE(ancreatic cancerE Biliar# cancerE7kin cancerE=#necologic cancer other than cervi: cancerECrological cancer other than bladder cancer$ B0 %o& long have #ou been treated "or that cancerD 7elect among the "ollo&ing list$ A >or less than 1 #earE>or 1A5 #earsE>or more than 5 #ears 20 (resence o" skin problems A0 5o #ou have de"inite skin eruptionsD GesENo B0 5o #ou "eel itching or pain on the skinD GesENo 40 7kin care habits A0 5o #ou use moisturi6ers ever# da# or ever# time a"ter bathing .use moisturi6ers diligentl#0D GesENo B0 5o #ou bathe ever# da#D GesENo !0 5o #ou have a hot &ater bath "or more than 1 hourD GesENo 50 5o #ou scrub o"" #our skin &hile bathingD GesENo <0 5o #ou use sun protection methods' such as sunscreens' a cap' or a parasol' &hen #ou are doing outdoor activitiesD GesENo 7crubbing o"" the skin &hile bathing is 9oreaHs uniBue bathing culture' &idel# accepted among 9oreans$ Although scrubbing o"" the skin can

damage the skin barrier' man# 9oreans still scrub their skin because the# think it cleans the skin$ ;here"ore' &e included the Buestion about scrubbing habit to evaluate its e""ect on development o" skin problems$ ;he participants &ho said InoH to each Buestion &ill be re"erred to as the control group "or the positive respondents "or that Buestion$ digital survey system /ur hospital' 7eoul National Cniversit# !ancer %ospital' has digital in"ormation displa#s .5J5s0 &ith touch screens' named I7mart %elperH .>igure 10' "or giving patients in"ormation about their reservations o" clinics and e:aminations' medical in"ormation about cancers' and guidance o" convenience "acilities in the hospital$ (articipants &ere allo&ed to submit their ans&ers to the Buestionnaire b# themselves' using touch screens o" the 5J5s$ ;he set o" ans&ers o" each participant &as saved in the database onl# &hen all o" the Buestions &ere ans&ered$ )e also gave in"ormation about current recommendations "or dail# skin care' including the use o" moisturi6ers and sunscreens and avoidance o" e:treme temperatures -2' 4' 102$ )e e:pected the in"ormational aspect o" our surve# s#stem to help recruit participants$ statistical analysis )e carried out descriptive anal#sis and univariate anal#ses to evaluate the relationship o" skin care habits and the presence o" de"inite eruptions and itchingEpain' using the (earson K2 test$ ;hen' to estimate the relative risk o" de"inite eruptions and itchingEpain according to skin care habits' multivariate logistic regression anal#ses &ere carried out &ith the variables &hich sho&ed clinicall# relevant results in univariate anal#ses to be independent "actors "or the development o" skin problems$ Results &ere e:pressed as odds ratios ./Rs0 &ith 95@ con"idence intervals .!Js0$ All anal#ses &ere carried out using JBM 7(77 7tatistics 19 .7(77' Jnc$' !hicago' JF0$ ;&o8sided ( L 0$05 &as considered statisticall# signi"icant$ results ;he ans&ers o" the participants are summari6ed in ;able 1$ ;he presence o" de"inite skin eruptions and itchingEpain on the skin &as signi"icantl# related .( L 0$0010$ 7event#8t&o percent o" the participants &ith de"inite eruptions also reported the presence o" itchingEpain' and 19$+@ o" the participants &ith itchingEpain also had de"inite eruptions$ %o&ever' 50$1@ o" the participants &ith itchingEpain did not have de"inite eruptions' sho&ing that itchingEpain on the skin can develop &ithout the prereBuisite o" de"inite eruptions$ risk of definite skin eruptions according to skin care habits Cnivariate anal#sis revealed signi"icant correlations o" hot &ater bath ,1 h and diligent moisturi6er use &ith the presence o" de"inite eruptions .>igure 2A0$ (articipants &ho took hot &ater baths ,1 h sho&ed a signi"icantl# higher incidence o" de"inite eruptions compared &ith the control group .( L 0$0010$ !ontrar# to our e:pectations' diligent

moisturi6er users also sho&ed a signi"icantl# higher incidence o" de"inite eruptions than the control group .( M 0$0010' &hich appears to have resulted "rom a signi"icantl# higher proportion o" diligent moisturi6er users in the participants &ith de"inite eruptions than in those &ithout de"inite eruptions .>igure 40$ 5ail# bathing' scrubbing o" the skin &hile bathing' and the use o" sun protection methods &ere not signi"icantl# related to the presence o" de"inite eruptions .>igure 2A0$ ;hen' to estimate the relative risk o" de"inite eruptions according to skin care habits' &e carried out multivariate logistic regression anal#sis &ith the variables that sho&ed clinicall# relevant results in univariate anal#sis$ Based on current dermatologic kno&ledge' it &ould be inappropriate to think that diligent moisturi6er use can increase the risk o" skin eruptions$ ;here"ore' &e did not include diligent moisturi6er use in the model$ )e included the other "our variables' hot &ater bath ,1 h' dail# bathing' scrubbing o"" the skin &hile bathing' and the use o" sun protection methods' as independent "actors "or development o" de"inite eruptions$ <ven a"ter correction "or the other "actors' onl# hot &ater bath ,1 h sho&ed a signi"icantl# higher risk o" de"inite eruptions$ ;he /Rs and 95@ !Js are sho&n in ;able 2$ risk of itching or pain on the skin according to skin care habits 7imilar to the results o" de"inite eruptions' univariate anal#sis revealed signi"icant correlations o" hot &ater bath ,1 h and diligent moisturi6er use &ith the presence o" itchingEpain .>igure 2B0$ ;he participants taking hot &ater baths ,1 h sho&ed a signi"icantl# higher incidence o" itchingEpain compared &ith the control group .( M 0$0010$ 5iligent moisturi6er users also sho&ed a signi"icantl# higher incidence o" itchingEpain than the control group .( M 0$0130' &hich is thought to have resulted "rom a signi"icantl# higher proportion o" diligent moisturi6er users in the participants &ith itchingEpain than in those &ithout itchingE pain .>igure 40$ 5ail# bathing' scrubbing o" the skin &hile bathing' and the use o" sun protection methods &ere not signi"icantl# related to the presence o" itchingEpain .>igure 2B0$ ;o estimate the relative risk o" itchingEpain according to skin care habits' &e carried out multivariate logistic regression anal#sis &ith the "our variables &hich sho&ed clinicall# relevant results in univariate anal#sis hot &ater bath ,1 h' dail# bathing' scrubbing o"" the skin &hile bathing' and the use o" sun protection methods$ A"ter correction "or the other "actors' onl# hot &ater bath ,1 h sho&ed a signi"icantl# higher risk o" itchingEpain$ ;he /Rs and 95@ !Js are sho&n in ;able 2$ analysis in breast cancer participants ;he most "reBuent cancer in our participants &as breast cancer$ ;he number o" breast cancer participants &as Buite high at 1*4' and there"ore' &e carried out subgroup anal#sis "or breast cancer participants$ ;he results &ere

generall# similar to those o" the total participants and are summari6ed in ;able 1$ !ompared &ith the total participants' breast cancer participants sho&ed a lo&er proportion o" de"inite eruptions and itchingEpain$ >rom univariate anal#sis' the participants taking a hot &ater bath ,1 h sho&ed a signi"icantl# higher incidence o" de"inite eruptions compared &ith the control group .( M 0$0010; other skin care habits did not sho& a signi"icant relationship &ith the presence o" de"inite eruptions .>igure 1A0$ No skin care habits &ere signi"icantl# related to the presence o" itchingEpain' although the participants taking a hot &ater bath ,1 h sho&ed a higher incidence o" itchingEpain than the control group .>igure 1B0$ Cnlike the results o" the total participants' diligent moisturi6er use &as not signi"icantl# related to the presence o" de"inite eruptions or itchingEpain in breast cancer participants$ )e carried out multivariate logistic regression anal#ses "or the development o" de"inite eruptions and itchingEpain &ith the same variables used in the anal#ses o" the total participants$ A"ter correction "or the other "actors' hot &ater bath ,1 h still sho&ed a signi"icantl# higher risk o" de"inite eruptions$ ;he /Rs and 95@ !Js are sho&n in ;able 2$ discussion Jn the current stud#' &e evaluated the risk o" de"inite eruptions and itching or pain on the skin according to skin care habits in general cancer patients$ >rom our results' hot &ater bath ,1 h signi"icantl# increased the risk o" de"inite eruptions about "our times and itchingEpain nearl# t&ice$ (reviousl#' no studies have "ocused on the e""ects o" hot &ater baths on the risk o" skin to:ic e""ects in cancer patients$ Jn the medical "ield' hot &ater baths have been used "or reducing pain and muscle spasms in rheumatic diseases as a part o" spa therapies; ho&ever' the scienti"ic rationale and the action mechanism are still unclear and a subNect o" debate -11A1+2$ ;he main e""ects o" hot &ater baths on the skin appear to be thermal' &ater8contact' and h#drostatic e""ects$ ;hermal stimuli have been kno&n to induce the e:pression o" in"lammator# c#tokines and matri: metalloproteinases and to increase reactive o:#gen species' the number o" mast cells' and the e:pression o" tr#ptase b# mast cells in the skin -132$ Jn addition' increased blood "lo& "ollo&ing increased temperature in the skin ma# bring more in"lammator# mediators to the skin$ Fong time e:posure o" the skin to hot &ater ma# &ash out natural moisturi6ing "actors and stratum corneum intercellular lipids' &hich can cause dr# skin and disruption o" the skin barrier$ !onsidering the "act that dail# bathing itsel" did not increase the risk o" de"inite eruptions or s#mptoms in our results' high temperature and protracted e:posure to &ater appear to be signi"icant "actors that increase the risk o" skin problems$ %#drostatic pressure during a &ater bath has been reported to result in increased diuresis and natriuresis -1*A202' &hich can cause deh#dration o" the bod# and also the skin$ All these changes can contribute

to the development o" skin eruptions and s#mptoms in cancer patients taking e:cessivel# long hot &ater baths$ %o&ever' being a cross8sectional stud#' our stud# could not prove causalit#$ )e cannot e:clude the possibilit# that patients having skin problems &ere more likel# to take hot &ater baths o" protracted duration' &hich calls "or "urther prospective studies$ %o&ever' as previousl# mentioned' hot &ater baths can cause the scienti"ic changes &hich ma# harm a patientHs skin health$ ;here"ore' at the present stage o" kno&ledge' cancer patients should be educated not to take hot &ater baths o" protracted duration' &hich should be "irst emphasi6ed in patient education than the traditionall# emphasi6ed ones' including the use o" moisturi6ers and sunscreens$ Moisturi6ers are products &hich are e:pected to increase skin h#dration and to strengthen the skin barrier$ ;he use o" moisturi6ers has been universall# emphasi6ed in populations &ith a high risk o" skin problems such as patients &ith chronic skin diseases' including atopic dermatitis and senile dr# skin -212' and also in cancer patients receiving <=>R inhibitors or radiation therap# -2' 4' 102$ !ontrar# to our e:pectations' diligent use o" moisturi6ers did not decrease the risk o" de"inite eruptions or itchingEpain in our stud#' and even higher proportions o" de"inite eruptions and itchingEpain &ere observed in the diligent moisturi6er users compared &ith the control group$ Jt appears to have been a &rong model &hich set diligent moisturi6er use as an independent "actor and the presence o" skin problems as a dependent "actor$ Jnstead' the presence o" skin problems appears to have "illed a role as an independent "actor' leading participants to use moisturi6ers diligentl#$ ;his &as demonstrated as a signi"icantl# higher proportion o" the diligent moisturi6er users in the participants &ith skin problems than in those &ithout skin problems$ )e carried out subgroup anal#sis "or 1*4 participants &ith breast cancer' the most "reBuent cancer in our participants$ !ompared &ith the total participants' breast cancer participants sho&ed lo&er proportions o" de"inite eruptions and itchingEpain$ %o&ever' &e cannot sa# that breast cancer patients sho& a lo&er incidence o" skin problems compared &ith the general cancer population' because &e did not surve# all patients in the hospital but onl# the patients &ho voluntaril# participated in our digital surve#$ Jnstead' "emale patients &ith breast cancer might have had more interest in skin care in"ormation provided b# our surve# s#stem' even &ithout skin problems$ %igher proportions o" diligent moisturi6er users and sun protection users in breast cancer participants than in the total participants also appear to be related to the "emale predominance in breast cancer patients$ 7imilar to the total

participants' hot &ater bath ,1 h signi"icantl# increased the risk o" de"inite eruptions in breast cancer participants$ %o&ever' the increased risk o" itchingEpain b# hot &ater bath ,1 h lost its signi"icance in breast cancer participants' &hich possibl# resulted "rom lo& statistical po&er due to the lo& number o" participants$ )e demonstrated the use"ulness o" a digital surve# s#stem in the current stud#$ )e could collect a high number o" ans&ers easil# &ithout additional e""orts to give and gather the Buestionnaire papers and to manuall# insert the data into a data "ile$ ;his kind o" digital s#stems also can be made to share patient in"ormation &ith electronic medical record s#stems' enabling more in8depth anal#sis' and &e are planning to do those sorts o" studies in the "uture$ /ur stud# has several limitations$ Being a cross8sectional stud#' our stud# could not prove causalit# and could not e:clude the bias that past or present skin problems might have in"luenced current skin care habits$ ;he presence o" de"inite skin eruptions &as sel"8reported and not con"irmed b# ph#sicians$ )e did not gather in"ormation about age' gender' and &hat treatment each participant &as on; there"ore' &e could not adNust "or age' gender' and treatment8related "actors$ 7election bias can be present because the patients &ho are not "amiliar &ith electronic devices &ould not have participated in our surve# and patients su""ering "rom skin problems &ould have been more likel# to participate in the surve#$ /ur surve# &as done over 3 months' "rom spring to "all' not including &inter season$ ;here"ore' &e cannot sa# it is sa"e to stop using moisturi6ers also in &inter' as moisturi6ers can relieve skin dr#ness in the &inter season$ >urther studies throughout all seasons are needed to con"irm our results$ )e used the term Idiligent use o" moisturi6ersH based onl# on the "reBuenc# o" moisturi6er use' &ithout a Buantitative assessment o" moisturi6er used per da#$ 7unscreen use ma# not have caused a di""erence because people do not sunbathe as much &hen the# have cancer or even as part culturall#$ 9oreans do not sunbathe as much as !aucasians do$ %o&ever' &e think a large number o" participants can overcome some o" these biases$ Jn conclusion' avoidance o" hot &ater baths o" protracted duration should be "irst emphasi6ed in patient education to prevent skin eruptions and s#mptoms in cancer patients$ /ur &ork has signi"icance as the "irst step to evidence8based skin care in cancer patients' and &e encourage "urther &ork in this "ield not onl# "or skin health' but also "or the emotional Bualit# o" li"e "or cancer patients$ disclosure ;he authors declare no con"licts o" interest$