What is the recommended treatment for bullae (blisters) in cancer patients?

Management of Bullae in Cancer Patients

The recommended treatment for bullae (blisters) in cancer patients includes gentle cleansing, application of topical emollients, non-adherent dressings, and appropriate pain management, with more intensive interventions required for severe cases involving large body surface areas or mucous membrane involvement. 1

Assessment and Classification

When managing bullae in cancer patients, first determine the severity and etiology:

• Causes of bullae in cancer patients:

  • Immune checkpoint inhibitor (ICI) therapy complications
  • Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN)
  • Bullous pemphigoid
  • Infection-related bullae
  • Pressure or friction-related bullae

• Severity assessment:

  • Body surface area (BSA) involved
  • Presence of mucous membrane involvement
  • Signs of infection
  • Associated systemic symptoms

Treatment Algorithm

Mild to Moderate Bullae (Limited BSA, No Mucosal Involvement)

1. Wound care:

   • Gently cleanse wounds with warmed sterile water, saline, or dilute antimicrobial solution (e.g., chlorhexidine 1/5000) 1
   • Decompress intact blisters by piercing and expressing fluid while leaving the roof intact as a biological dressing 1
   • Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire affected area 1

2. Dressings:

   • Apply non-adherent dressings to denuded areas (e.g., Mepitel™ or Telfa™) 1
   • Use secondary foam dressings to collect exudate 1
   • Consider silver-containing products for sloughy areas 1

3. Infection prevention:

   • Take swabs from lesional skin for bacterial and candidal culture 1
   • Monitor for signs of infection (increasing redness, warmth, pain) 1
   • Administer systemic antibiotics only if clinical signs of infection develop 1

4. Pain management:

   • Provide appropriate analgesia before wound care procedures 1
   • Use opioid analgesics as needed for background and procedural pain 1
   • Consider topical morphine in hydrogel for painful malignant wounds 1

Severe Bullae (Extensive BSA or Mucosal Involvement)

1. Immediate measures:

   • Admit patient to a burn unit or ICU with experience in treating extensive skin loss 1
   • Consult dermatology and wound care services 1
   • Employ strict barrier nursing to reduce nosocomial infections 1

2. Medical management:

   • For immune-related bullous conditions (e.g., from ICIs):
     • Administer IV methylprednisolone 1-2 mg/kg and convert to oral steroids when appropriate, tapering over at least 4 weeks 1
     • Consider IVIG or rituximab for bullous pemphigoid 1
     • Permanently discontinue the causative ICI therapy 1

3. Supportive care:

   • Maintain ambient temperature between 25-28°C 1
   • Use pressure-relieving mattresses 1
   • Monitor fluid balance carefully and establish adequate IV fluid replacement 1
   • Provide continuous enteral nutrition (20-25 kcal/kg daily during acute phase) 1

4. Specialized interventions:

   • For SJS/TEN cases, consider transfer to a burn center 1
   • For infected bullae, consider percutaneous drainage with a small caliber tube and washing with cytocidal agents 2

Special Considerations for Cancer Patients

1. Immunocompromised status:

   • More vigilant monitoring for infection is required 3
   • Lower threshold for initiating systemic antibiotics 3
   • Consider prophylactic antimicrobials in severely immunocompromised patients 3

2. Cancer treatment modifications:

   • For ICI-induced bullous reactions, permanently discontinue the ICI therapy 1
   • For mild reactions from other cancer therapies, consider dose reduction rather than discontinuation 4
   • Balance the need for cancer treatment against the severity of skin reactions

3. Psychological support:

   • Provide psychological support to patients and families, particularly vital after diagnosis of skin complications 1
   • Continue support throughout treatment and consider bereavement support for families if needed 1

Monitoring and Follow-up

• Regular clinical evaluation of wound healing
• Surveillance for signs of infection
• Assessment of pain control
• Monitoring of fluid and nutritional status
• Regular photography to document progress

Pitfalls and Caveats

1. Delayed recognition of severe reactions:

   • Even limited BSA involvement with bullae or erosions should raise concern for potential progression to more severe reactions 1
   • Early consultation with dermatology is essential for any mucous membrane involvement 1

2. Infection risk:

   • Cancer patients are at higher risk for infection due to immunosuppression 3
   • Bullae provide an entry point for pathogens, requiring vigilant monitoring 3

3. Medication considerations:

   • Avoid adhesive tapes or dressings that may cause further skin damage 1
   • When using opioids for pain management, be mindful that larger doses may make patients less alert and responsive 1

4. Surveillance for malignancy:

   • In patients with chronic bullous disease, particularly in smokers over 50 years old, consider regular screening for potential malignancy developing within bullae 5

By following this comprehensive approach to managing bullae in cancer patients, clinicians can minimize complications, reduce morbidity and mortality, and improve quality of life for these vulnerable patients.