Oncology Patients and Skin Care

by Johnnette du Rand, Karey Hazewinkel York and Annet King

Skin care treatments for oncology patients can be intimidating – and dangerous – if you are not properly educated. Begin to understand how you can help oncology patients in this Q&A, held recently on IDI’s Facebook page. Featuring IDI’s own Annet King and specialized experts Johnnette du Rand and Karey Hazewinkel York of Greet the Day (GTD), this article will provide you with the basics to help you help cancer patients in your area.

Q: I know that oncology patients are more sensitive, can you really give them facials?

A: You absolutely can. Cancer is appropriately taught as a contraindication during preparatory training and is an advanced field of study that requires specialized knowledge.

Q: Can you give us any general information about skin care and oncology patients?

A: There are no one-size-fits-all answers in deciding which services should be avoided when providing treatments on oncology clients, however excessive heat, extractions, stimulating products, and strong exfoliants (physical or chemical) are on the no-go list for clients in active cancer treatment and recent recovery. Although massage and skin care treatment modifications are clearly required for the person in active treatment and recent recovery, it is the long-term side effects that are often overlooked and underestimated, and it’s imperative that skin therapists understand these considerations.

A clear understanding of the information and a solid education foundation for the therapist is key. Everything is individual-specific, as it depends on type of cancer, type of medical treatments, time out of treatment, and the client’s experience of side effects. Safety first is the first rule.

Less is more. Use The International Dermal Institute’s guidelines for THE LESS RULE. Less heat includes reduction in, if any, use of steam, infrared, or steamed towels. Less friction such as exfoliation, European massage, or extractions. Less product to keep it simple. Less time on skin service with more time spent on options such as hand and foot massage, acupressure points, reflexology, etc.

Hydrating treatments, such as cooling gel masques and soothing gentle massage, will help. Essential oils are often beneficial too, some clients however may be overly sensitive to their aromas. If you do introduce aromatherapy to your service use blended formulations, and check in with your client at the start of service as their sensitivity to fragrance can easily change day to day.

Q. What training / certification is involved to be able to treat oncology patients?

A: We are often asked about certification, and if the question is, “Will I have a certificate?” then the answer is yes, you will have a certificate of completion. The meaning of certification though is a larger, very important topic, and infers a certificate of accomplishment.

In general, all therapists everywhere should be intimately familiar with the client safety / lymphedema information. GTD offers an advanced practice one-day class through IDI. At a minimum, preparatory training for skin and massage therapists who want to work with oncology clients should include an understanding of how cancer starts and spreads, primary clinical considerations and required modifications, cancer treatments and their side effects, product considerations, supervised experience working with oncology clients, and ideally an internship for extended hands-on experience.

Therapists should look for nationally accredited training through reputable organizations such as International Society for Oncology Estheticians (ISOE) and Society for Oncology Massage (S4OM). S4OM has set the standard in establishing guidelines for required curriculum content, and both organizations regard the accredited 24-hour programs as the absolute minimum requirement for therapists wanting to work with this medically sensitive clientele.

What the GTD 3-day program can do for you is provide you with a clear and well-informed knowledge base helping you understand and apply the critical hands on modifications required for people in, or with a history of cancer treatment. This is the basic level of training accepted by S4OM and ISOE and teaches the fundamental components required for the therapist to work safely. It is the starting point, the essential cornerstone, for all work related to oncology skin treatments and massage.

For therapists who would like to open their doors to clients in active cancer treatment and recent recovery, and these clients most often just happen into your practice without you anticipating them, you should complete an ISOE/S4OM approved 24-hour program to your training goal.

Thereafter, if you’re looking to move beyond foundation level knowledge and to specialize in this field, then you should continuing to develop your skills through direct practice hours and related advanced education such as:

    • Supervised client clinics
    • Advanced treatments
    • Risk management practices
    • Ethics
    • Professionally boundaries
    • Presence at end-of-life
    • Mentorship engagement

If appropriate to your specialized field of interest your advanced studies should also include in and out patient internships, and scar tissue mobilization and manual lymphatic drainage (MLD), specifically for people with a history of cancer treatment.

Undertaking this during the next few years will have you well prepared for the time when a formalized, internationally accepted, certification standard is in place.

Q: What resources can I turn to for general information about skin care and oncology patients?

A: Visit the following resources.

Greet the Day
http://greettheday.org/

Society for Oncology Massage
http://www.s4om.org/

International Society of Oncology Estheticians
http://www.oncologyesthetics.net/

The International Dermal Institute (detailed information coming soon)
http://www.dermalinstitute.com/us/

Q: Should my consultation card ask whether lymph nodes have been removed and the location?

A: Many clients don't recognize the long term implications of lymph node removal, especially when they are many years out of cancer treatment AND in particular if lymph nodes came back as negative for cancer cells. It is therefore worth noting that clients often withhold pertinent information from written consultation forms, and the MOST valuable information therapists most often get is from key verbal intake questions, not just with oncology clients, but all clients.

Q: I would like to learn more about post-radiation skin care and products that are non-occlusive that can work to manage this skin concern. Although I am familiar with products that manage symptoms such as Silvadene and Domeboro soaks, I would like to learn about some other more "elegant" skin soothing products and techniques that can be used on a day-to-day basis to manage symptoms and basic skincare.

A: UltraCalming™ by Dermalogica is a popular system for cancer patients undergoing treatment and post treatment because it helps to replace a compromised barrier and is very soothing to the skin; many skin therapists use it and recommend it. Barrier Repair (in the UltraCalming™ line) is an anhydrous silicone product that has great barrier protection properties without being occlusive. I also recommend AGE Smart® to post radiation clients. Super Rich Repair and UltraRich Body Cream are excellent for dry skin. Find out more on www.dermalogica.com.

Q: Any thoughts about Ascorbic Acid on pigmented skin post chemo/radiation?

A: Skin care products that contain a highly active, but stable, form of Ascorbic Acid such as Magnesium Ascorbyl Phosphate (MAP) can be used on pigmented areas if the skin is healthy and healed. Also be certain to wear sunscreen daily for added protection.

Q: Since you shouldn't wax a client who is using steroids, what is best method for facial hair removal, especially since clients tend to get increased hair growth (and fuzzy) with the steroids?

A: If the client is being treated with steroids they cannot be waxed as steroids thin the skin. I would suggest a depilatory cream with a thin layer of barrier protectant beneath. Shaving is a possible option although not if there is any concern regarding compromised immunity such as when blood cells are compromised or at risk of being compromised, as they frequently are during active treatment. Shaving is also not advised in a quadrant where lymph nodes have been compromised due to the risk of infection, and the potential of triggering or aggravating lymphedema. This concern will remain prevalent even many years after completion of treatment. The client’s doctor can confirm when regular waxing treatments may resume.

Q: Are there any acupressure points that should be avoided when performing the massage portion of a facial with a client undergoing cancer treatment or post-treatment? And with pressure point massage, is there any aspect of lymph drainage that would come into play that would be necessary to be aware of on patient?

A: There are no one-size fits-all treatment guidelines regarding skin treatments, massage, or acupressure point protocols. And there is only so much information one can safely share in an informal forum without creating more of a risk for the client, and the therapist. Acupressure modalities and lymph drainage are both very effective treatment modalities, and any therapist using them should complete appropriate training to ensure safe applications with oncology clients. Anybody who is in, or who has a history of cancer treatment, deserves to have the benefit of an oncology-trained therapist who can safely adjust their protocols to meet their specific considerations. If you are interested in lymphatic work, research an MLD class specific for clients with or at risk for lymphedema (see Norton, Vodder and/or Klose Training).

Q: I find it difficult charging cancer clients for skin treatments, but at the same time I need the income. What are your thoughts on how to charge?

A: I completely understand your feelings, and your need to pay rent. Cancer treatment is expensive and we never know how much of that burden is falling onto our clients’ shoulders. There are a number of options open to you to make a meaningful contribution to this client population. You could consider offering a sliding scale to your clients when they are going through cancer treatments, shorter treatments that cost less, donating two services a month, or volunteering a few hours a month in a local cancer center as part of the Look Good Feel Better program run through the American Cancer Society, or as a volunteer for Greet The Day providing hand massage for patients receiving chemotherapy treatments in outpatient infusion centers.

Q: Because compromised skin is so susceptible to damage and can often become extremely sensitized, what methods of protection do you recommend, aside from soft, breathable coverings? Are there any brands of SPF that you are especially fond of for the patient to use when the area doesn't need to be covered any longer?

A: Recommend physical sun protection (i.e. Zinc Oxide and Titanium Dioxide), sun hats, and clothing with added UV protection.

Q: If a client is experiencing phlebitis at the injection site, I assume heated mitts and massage of the arm should be avoided. Anything else? What length of time should I wait before resuming heated mitts/massage?

A: You are correct in avoiding heated mitts and massage. Phlebitis is inflammation of the vein and it presents a DVT/Blood Clot risk, and this should be considered a potential medical emergency. In addition to no circulatory massage applications on the arm, eliminate circulatory-type applications on the décolleté area – which would restrict the facial to the clavicle and above.

Q. Regarding LED and skin cancer: because the red wavelength in LED therapy has been known to facilitate the healing process by stimulating the growth of new tissues, collagen productivity, etc., are there any effects on the growth of abnormal cells? Cancer seems so autonomous, and with a mind of its own, I am curious if those cells would respond to the light in a way that could promote any growth to reoccur during the treatment phases.

A: While LED red/orange light has shown to help stimulate and regenerate the skin in some instances with clients who have had cancer, especially skin cancer, I would avoid it as you could be increasing cell replication. Only use LED if the client’s oncology team has approved the therapy.

Q: Does treating the skin topically during active radiation have any negating effects on the treatment of cancer?

A: Skin side effects experienced with radiation are localized, i.e. experienced only at the site of radiation. Working guidelines for skin therapists are to not treat the skin in the immediate area of radiation during active treatment. It's not that our treatment would negate the effects of the radiation treatment, but rather may intensify the effects, and these treatments are very carefully modulated. Additionally, it may interfere with the ability of the skin to heal during radiation. The radiation oncology team are the BEST people to make a recommendation on what should be used topically on the area of radiation, during the weeks of radiation treatment. Many radiology teams will also recommend the use of a cream on the area a few weeks prior to starting treatment. The clinical team is the best suited to make this type of recommendation. The products they use are specific to type of skin, type and dosage strength of radiation, and most importantly, the response of patients’ skin to the radiation treatment.

Q: Are there certain protocols for skin care treatments if a client has skin cancer? Or if they are undergoing chemotherapy?

A: Many skin cancer clients have had sentinel lymph nodes compromised during diagnostic procedures, so that would be a starting point on your protocol modification. Also, their cancer treatment dependent, there will also be modifications in the localized area. Regarding chemotherapy, as a starting point it must be said that although many people think chemotherapy is most all of what there is to know about cancer treatment, nothing could be further from the truth. There is much more to cancer treatment than chemotherapy. Therapist needs to understand the disease, the medical treatments, the side effects related to medical treatment, and disease progression, and an oncology trained person is able to recognize and safely work within this framework of clinical considerations. During chemotherapy treatment primary clinical consideration for the client will include, but not be limited to, compromised blood cell count, blood clots or risk thereof, medical devices, and the clients’ experience of pain, nausea and neuropathy.

Q: Because many topicals contain essential oils, are there any specific ones that should be avoided on compromised skin versus any that would be more beneficial? Especially since they go to the blood stream, are there any contraindications for active cancers?

A: For a long time essential oils were thought of as a contraindication with this clientele. In fact, essential oils can be very beneficial but you need to have advanced training as an aromatherapist if you are desiring to create your own. Having said that you, can utilize pre-blended combinations with great effect. NOTE: Oncology clients may be overly sensitive to their aromas. If you do introduce aromatherapy to your service use blended formulations, and check in with client at the start of service as their sensitivity to fragrance can easily change day to day.

Q: My client has just had a double mastectomy and is now in her second round of chemo. Her facial skin has become sensitized, irritated, and is showing red spots. What are the first steps toward getting her on a good routine throughout this process?

A: The side effects you are witnessing are common. Chemotherapy targets and kills all fast growing cells, including both cancer cells and healthy cells. The fastest growing healthy cells, those most affected by chemotherapy, are the skin cells, blood cells and gastrointestinal cells. Most common skin side effects with chemotherapy are sensitivity, dryness and dehydration, and chemotherapy agents dependent, can also cause mild, moderate or severe hives, blistering and acne-type lesions. First and foremost address her sensitivity issues. After that work to replenish the barrier function.

Q: After radiation therapy I started developing raised areas of skin in the area of the armpit where I had experienced radiation burn. I thought it was just my wound healing at first, but then I started getting what appeared to be bites down my arm from armpit to elbow. When I went to see my radiation oncologist for a follow up she immediately said that I have shingles! Apparently she wasn't surprised and went on to explain how it happens to a lot of cancer patients since the chicken pox virus stays dormant in your body if you've had them and can come out if the immune system is suppressed. I read that shingles treatment is best to treat within 72 hours of the breakout, but I was several days beyond that when I was diagnosed. Are there any ways to help relieve symptoms, especially the itching?

A: The first stages are very bad (and contagious) when the blistering is apparent, so don’t pop the blisters! Cold compresses will help; use a little pure Lavender essential oil on a chilled, wet wash cloth laid over the pattern (follows the nerve path). This will help soothe the itching. Some people apply Zinc Oxide over the actual rash and then put a large band aid over it. This seems to help in calming down the itchiness and drying up the actual rash. Try avoiding fabrics that are synthetic and wear 100% cotton, be sure to regularly apply an after sun lotion or balm, and look for botanicals and extracts like Aloe Vera, Chamomile, Yucca, Licorice, and Cucumber. Also, go for a gel instead of cream – gels are more cooling.

Q: The night I lost my hair my head itched. I noticed when I scratched hair fell out. I took a shower hoping it would help. Well all my hair fell out but my head still itches. I have dry skin all over now and the doctor said it was the chemo. Is there anything I can do to stop the itch?

A: The head feels strange right before hair loss. The only way to adequately explain this feeling is that the “hair hurts”. Others call this sensation itchy. Skin becomes very dry during chemotherapy and it is probably why this person is experiencing the “itchy” sensation post hair loss. Stay away from soap and hot showers. Hot showers or baths can further dehydrate the skin therefore depleting the barrier lipids. Must apply something to seal and protect this sensitive skin.

You could also try washing your hair with baby shampoo, or as recommended by Dr. Dore Gilbert, DHS Zinc shampoo ($14, 8 fl. oz.). The Zinc is calming and less drying than a medicated shampoo with Salicylic Acid.

Q: I have nice skin and I'm about to start chemo, will it age my skin or damage it?

A: Skin treatment objectives during active cancer treatment are to soothe and nourish. If you are heading into active cancer treatment now is the time to simplify your routines. Use a gentle cleanser, a good hydrator, lipid barrier protection and a physical sunblock. After completion of treatment is the right time to focus on strengthening and restoring skin vitality.

Q: Since my radiation therapy ended my skin has been in pain. The blisters that surrounded my wound started to weep and peel, and I ended up at the Wound Institute at my local hospital, applying a debriding cream and then a cream to help heal the area covered with gauze and tape. The largest part has healed and I have just one small part that is still raw. I have white spots around my breast, should I keep rubbing a heavy moisturizer on them?

A: Although not standard, this is the most severe of the reactions. Blistering, like the future possible risk of lymphedema, is not always discussed before treatment because not everyone will experience it. As you’ve now seen, there are creams that can be used before and during radiation that can help prevent or reduce severity of skin reactions. Most clinical teams are specific with what they would like you to use, and we recommend you get your recommendations from your radiation oncologist or your radiation care team.

Our local radiation center recommends patients use Xeroform™ gauze, a petrolatum soaked gauze (like those used on burn patients), to address blistering and infections. A moist healing environment helps skin heal faster than if the area dries out. Often people want to let the area dry out, but this is not conducive to healing; the healing process is better in a moist healing environment.

Q: My body has broken out with red blemishes since starting chemo. My oncologist says it’s from the steroid in my treatment. What can I do to get rid of them? They are on my chest, back, shoulders and neck. They are not healing at all. I feel like I have the chicken pox.

A: The breakouts are because of the drug treatments, so they unfortunately will not go away until drug therapies are ceased. Rashes, hives and breakouts are very common side effects during and after cancer drug treatments and they happen for a number of reasons:

    • They are a side effect of the drug treatment
    • The clients skin is more sensitive and reactive than most
    • Immunity is compromised/impaired due to cancer treatment which makes the skin more reactive
    • Folliculitus, inflammation of the follicle, can also be a side effect of drug treatments

Standard treatment is usually a topical or oral steroid. In the case of topical application, an over-the-counter 1% Hydrocortisone cream might be helpful. Anything higher than that would require a doctor’s prescription. Keeping the skin hydrated, moisturized and occluded is also important.

Greet the Day is an organization that studies massage and skin care for oncology patients. For more information visit: www.greettheday.org

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Oncology Patients and Skin Care