Symptom: Peeling skin

Initial Grading Reminder

CTCAE grading of blisters/peeling:

Grade 2 (Moderate): Skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis) with pain; limiting instrumental ADLs
Grade 3 (Severe): Severe skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis) with pain; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Is this a new or worsening symptom? When did it start or get worse? Have you had any excessive sun exposure? Has it developed gradually or suddenly? What body areas are affected? Have you had any issues with peeling skin in the past?

Grade the symptom

Ask the patient:

Please send a photo, if possible. Please describe your skin. How much of your body is covered by blisters or is peeling? Are they limiting your ability to take care of yourself or do your normal daily activities?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any blisters that are peeling in or around the mouth or in or around the rectum?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with any unexplained peeling skin should be evaluated.

    Patients with any of the red-flag symptoms should be evaluated immediately.

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    Nursing Assessment of Potential Causes

    Skin Toxicities - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is there an obvious rash?
    • Is the patient scratching during the visit?
    • Is skin integrity intact?
    • Are there skin changes?
      • Xerosis
      • Changes in skin pigment or color
    • Is there oral involvement of the rash?
    • Does the patient have pruritus with or without rash? Is there a rash with or without pruritus?
    • Are symptoms interfering with ADLs?
    • With sleep?
    • Have symptoms worsened?
    • Is there a history of dermatitis, pre-existing skin issues (psoriasis, wounds, etc.)?
    • Laboratory abnormalities consistent with other etiologies (e.g., eosinophils on complete blood count, liver function abnormalities)

    Differential Diagnosis

    What do you suspect is the cause of the blisters?