What topical cream is recommended for a grade 2 skin ulceration caused by cabozantinib?

Treatment of Grade 2 Skin Ulcerations from Cabozantinib

For grade 2 skin ulcerations caused by cabozantinib, apply a topical high-potency corticosteroid (such as clobetasol propionate 0.05%) twice daily, combined with antiseptic solutions like silver sulfadiazine 1% cream for the ulcerated areas. 1

Primary Topical Management

Cabozantinib causes hand-foot skin reaction (HFSR), which occurs in 40-60% of patients and can progress to ulcerations. 1 For grade 2 HFSR with ulcerations, the treatment approach includes:

Anti-inflammatory Therapy

• High-potency topical corticosteroids twice daily (e.g., clobetasol propionate 0.05%) to reduce inflammation 1
• Continue cabozantinib at current dose while monitoring for severity changes 1

Wound Care for Ulcerations

• Antiseptic solutions are specifically indicated for erosions and ulcerations:
  • Silver sulfadiazine 1% cream 1
  • Polyhexanide 0.02%-0.04% cream 1
• These prevent secondary infection and promote healing of ulcerated areas 1

Adjunctive Topical Treatments

• Keratolytic agents if hyperkeratosis is present around ulcerated areas:
  • Salicylic acid 5%-10% cream 1
  • Urea 10%-40% cream 1
• Lidocaine 5% patches or cream for pain control on ulcerated areas to maintain activities of daily living 1

Reassessment Protocol

Reassess after 2 weeks - if reactions worsen or show no improvement, dose interruption may be necessary until severity decreases to grade 0-1. 1 Grade 2 reactions with pain that limit instrumental activities of daily living warrant close monitoring, as progression to grade 3 requires treatment interruption. 1

Common Pitfalls to Avoid

• Do not use alcohol-containing solutions on ulcerated skin, as these cause further irritation 1
• Avoid mechanical stress to affected areas (long walks without cushioned shoes, heavy carrying without gloves) 1
• Avoid chemical irritants, solvents, and disinfectants on affected skin 1

Clinical Context

HFSR from cabozantinib typically develops within the first 1-2 months of treatment, with 57% of reactions occurring in the first month and 80% by the second month. 2 The incidence of all-grade HFSR with cabozantinib is 35.3%, with high-grade reactions occurring in 9.5% of patients. 3 Dose reduction is required in approximately 30% of patients for symptom management, with treatment discontinuation needed in 13%. 2