Managing skin damage induced by doxorubicin hydrochloride and daunorubicin hydrochloride

The pathophysiology and mechanisms of toxicity of anthracycline-induced skin damage are reviewed, and the various available therapeutic interventions are discussed. Skin ulcers caused by the vesicant antineoplastic agents doxorubicin hydrochloride and daunorubicin hydrochloride begin slowly, and the extent of the tissue damage produced is often underestimated. Within a week, untreated infiltrations of these agents can advance to serious indurations and ulcerations, causing extensive damage to underlying structures such as tendons and bones. Two theories have been proposed to explain the mechanism of action of anthrocycline-induced tissue damage; one holds that doxorubicin-DNA complexes form causing cell death, and the other holds that these agents are reduced to free radicals that can cause cell-membrane damage. Nonpharmacologic treatment of extravasation consists of stopping the infusion at the first sign of a problem and attempting to aspirate fluid and drug back through the same needle. The application of ice packs for the next 24-72 hours is recommended. A variety of pharmacologic approaches have been evaluated to ameliorate tissue damage. Corticosteroids, sodium bicarbonate, beta-adrenergic agents, and dimethyl sulfoxide have been used with some success. Patients who do not respond to initial conservative treatments should be referred to a plastic surgeon for skin grafting and reconstruction. The best treatment for anthracycline toxicity is prevention.