Is it safe to use steroids on skin cancer?

Steroid Use on Skin Cancer

Steroids are safe and recommended for managing dermatological toxicities in patients receiving anticancer therapy, but oral corticosteroids may increase the risk of developing new skin cancers, particularly squamous cell carcinoma.

Context Clarification

The question requires distinguishing between two distinct clinical scenarios:

Using Steroids to Treat Skin Reactions in Cancer Patients

Topical corticosteroids are explicitly recommended and safe for managing chemotherapy-induced skin toxicities. 1

• High-potency topical steroids (e.g., clobetasol propionate 0.05%) twice daily are the standard treatment for palmar-plantar erythrodysesthesia syndrome (PPES) and hand-foot skin reactions in patients receiving chemotherapy agents like capecitabine, doxorubicin, and taxanes 1

• For Grade 1-2 skin reactions from anticancer agents, topical high-potency steroids should be applied twice daily while continuing cancer treatment 1

• For Grade 2 PPES from doxorubicin/taxanes, oral dexamethasone (8 mg twice daily for 5 days beginning the day before infusion) is recommended in addition to topical steroids 1

• For papulopustular rashes from EGFR inhibitors, topical low/moderate-potency steroids are recommended alongside oral antibiotics 1

• For immune checkpoint inhibitor-related rashes, systemic corticosteroids (prednisone 0.5-1 mg/kg/day) are indicated for Grade 3 reactions covering >30% body surface area 1

Risk of Developing Skin Cancer from Steroid Use

Oral corticosteroids increase the risk of developing non-melanoma skin cancers, particularly squamous cell carcinoma, but topical steroids have not been shown to increase this risk. 2, 3, 4

• Oral glucocorticoid use is associated with a 2.31-fold increased risk of squamous cell carcinoma (95% CI: 1.27-4.18) and a modest 1.49-fold increased risk of basal cell carcinoma 4

• A gene-drug interaction at the glucocorticoid receptor increases squamous cell carcinoma risk nearly 6-fold in individuals with specific genetic variants 3

• A systematic review found no studies establishing an association between long-term topical corticosteroid use and skin cancer risk 2

• Inhaled steroids showed no relationship with skin cancer risk 4

Important Caveats

The FDA label for topical corticosteroids warns about systemic absorption when applied to large surface areas, under occlusive dressings, or for prolonged periods, which could theoretically increase immunosuppression 5

• Pediatric patients absorb proportionally larger amounts and are more susceptible to systemic toxicity 5

• Patients should avoid using topical steroids under occlusive dressings unless specifically directed 5

In cancer patients receiving systemic steroids for supportive care, survival may be reduced (HR = 1.18,95% CI: 1.1-1.26), particularly in lung cancer and palliative settings 6

Clinical Algorithm

For dermatological toxicities from anticancer therapy:

• Use topical high-potency steroids twice daily without concern for increasing skin cancer risk 1
• Add oral dexamethasone for severe reactions (Grade 2-3) as per protocol 1
• Continue cancer treatment while managing skin reactions 1

For patients requiring chronic oral corticosteroids:

• Consider the 2-fold increased squamous cell carcinoma risk when prescribing 4
• Implement enhanced skin cancer screening protocols 7
• Minimize duration and dose when possible 7