Symptom: Rash

Initial Grading Reminder

CTCAE grading of rash:

Grade 1 (Mild): Macules/papules covering <10% BSA with or without symptoms (e.g., pruritus, burning, tightness)
Grade 2 (Moderate): Macules/papules covering 10-30% BSA with or without symptoms (e.g., pruritus, burning, tightness); limiting instrumental ADLs
Grade 3 (Severe): Macules/papules covering >30% BSA with or without associated symptoms; limiting self-care ADLs; skin sloughing covering <10% BSA
Grade 4 (Potentially Life-Threatening): Papules/pustules covering any % BSA with or without symptoms and associated with superinfection requiring IV antibiotics; skin sloughing covering 10-30% BSA

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Please send a photo, if possible. Have you had issues with rash in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Have you begun any new medications recently? Where is the rash located?  Does the affected area(s) feel hot to touch? (To rule out cellulitis)

Grade the symptom

Ask the patient:

Please describe your skin. How much of your body is affected? What does the rash look like? Is it raised bumps or flat? Is it itchy or painful? Is it interfering with your ability to do your normal daily activities? Do you have an associated itch? Is there an associated itch? Are you sleeping ok?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any rash or blisters that are peeling in the mouth or on or in the rectum? Does any of your skin look like it is infected? Is the rash spreading rapidly?

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 moderate or worse skin rash should be seen.

    Patients with any of the red-flag symptoms should be seen 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 rash?