What is the management for a patient with pruritic rash and fever undergoing chemotherapy for breast cancer?

Management of Pruritic Rash and Fever During Chemotherapy for Breast Cancer

The immediate priority is to rule out a chemotherapy infusion reaction or infection, particularly if the patient is neutropenic, as both can be life-threatening and require urgent intervention. 1

Initial Assessment and Risk Stratification

Determine Timing and Severity

• If fever and rash occurred during or within hours of chemotherapy infusion: This suggests an infusion reaction (IR), which requires immediate cessation of infusion and symptomatic treatment with antihistamines and corticosteroids 1
• If symptoms developed days after chemotherapy: Consider infection, particularly if neutropenic, or drug-induced dermatologic toxicity 1, 2

Check Neutrophil Count Immediately

• Neutropenic patients (ANC <500 cells/μL) with fever require urgent empirical broad-spectrum intravenous antibiotics within 1 hour, as infection can be rapidly fatal 1, 2
• Blood cultures and complete blood count with differential must be obtained before starting antibiotics 1
• If pruritic rash is present with neutropenic fever, examine carefully for signs of cellulitis, abscess, or fungal infection 1

Differential Diagnosis Based on Clinical Presentation

Chemotherapy Infusion Reaction

• Symptoms: Pruritus, urticaria, flushing, fever, chills, dyspnea, hypotension occurring during or shortly after infusion 1
• Common culprits in breast cancer: Taxanes (paclitaxel, docetaxel), anthracyclines (doxorubicin), platinum agents if used 1
• Management: Stop infusion immediately for Grade 2 or higher reactions; administer antihistamines, corticosteroids, and supportive care 1

Infection with Dermatologic Manifestations

• Look for: Progressive edema, warmth, purulent drainage, lymphangitis, regional adenopathy 3
• Risk factors: Recent surgery with lymph node dissection increases cellulitis risk due to disrupted lymphatic drainage 3
• Obtain wound culture if infection suspected 1, 3
• If sepsis signs present: Blood cultures, check granulocyte count, initiate broad-spectrum IV antibiotics immediately 1

Drug-Induced Pruritus from Targeted Therapies

• If patient is on EGFR inhibitors, VEGFR inhibitors, or immunotherapy: These have high incidence of pruritic rash (13-20% all-grade pruritus) 1
• This typically presents as acne-like rash with pruritus, not usually with fever 1
• Fever suggests superimposed infection or alternative diagnosis 1

Treatment Algorithm

For Infusion Reactions (During/Immediately Post-Chemotherapy)

• Grade 1-2 (mild pruritus, localized rash): Slow or stop infusion, administer antihistamines and monitor 1
• Grade 3-4 (severe symptoms, hypotension, respiratory distress): Stop infusion permanently, aggressive symptomatic therapy with epinephrine if anaphylaxis, corticosteroids, IV fluids 1
• Rechallenge only after complete symptom resolution, with reduced infusion rate and additional premedication 1

For Neutropenic Fever with Rash

• Empirical broad-spectrum IV antibiotics immediately (e.g., ceftazidime, cefepime, or piperacillin-tazobactam) 1, 2
• Add vancomycin if concern for skin/soft tissue infection, catheter-related infection, or MRSA risk 1
• Do NOT delay antibiotics for diagnostic workup 2
• Consider antifungal coverage if prolonged neutropenia (>7 days) or previous fungal infection 1

For Non-Neutropenic Patients with Pruritic Rash and Fever

• Examine for cellulitis or abscess: Erythema, warmth, tenderness, especially in breast/chest wall or surgical sites 3
• If cellulitis suspected: Oral or IV antibiotics covering Staphylococcus and Streptococcus (e.g., cephalexin, clindamycin, or cefazolin) 3
• Culture any drainage or perform skin swab if infection suspected 1, 3

Symptomatic Management of Pruritus

• Topical corticosteroids: Hydrocortisone 1% cream applied 3-4 times daily to affected areas 4
• Oral antihistamines: First-generation (diphenhydramine) for nighttime sedation, second-generation (cetirizine, loratadine) for daytime 1
• Emollients: Fragrance-free moisturizers to maintain skin barrier 1, 3
• Avoid irritants: No perfumes, alcohol-based products, or harsh soaps 3

Special Considerations

If Patient is Receiving Concurrent Radiotherapy

• Radiation dermatitis can coexist with chemotherapy-related rash 1, 3
• Keep irradiated area clean and dry before each radiation treatment 1, 3
• Do not apply topical products immediately before radiation (causes bolus effect) 1, 3
• For Grade 1 radiation dermatitis with pruritus: Optional fragrance-free moisturizer, occasional antibacterial moisturizer (chlorhexidine or triclosan) 1, 3

Red Flags Requiring Urgent Evaluation

• Fever >38.3°C (101°F) with neutropenia: Medical emergency 1
• Hypotension, tachycardia, respiratory distress: Possible anaphylaxis or sepsis 1
• Rapidly spreading erythema with systemic symptoms: Possible necrotizing infection 3
• Mucosal involvement, skin sloughing, or bullae: Consider Stevens-Johnson syndrome/toxic epidermal necrolysis 1

Follow-Up and Monitoring

• Weekly skin assessments during active chemotherapy 1, 3
• Document rash characteristics photographically for objective monitoring 1
• If infection treated, ensure clinical improvement within 48-72 hours or broaden antibiotic coverage 1
• Consider dose reduction or drug substitution if severe drug-induced dermatologic toxicity confirmed 1