Alleviation of EGFR tyrosine kinase inhibitor-induced skin toxicity by modified Huang-Lian-Jie-Du Decoction cream in cancer patients

Background: The EGFRIs and TKIs are effective for cancer target therapy, but the acneiform rashes or called inflammatory papulopustular exanthemas are common (50% to 100%). The conventional therapy for EGFRIs/TKIs-induced skin toxicity is steroids and antibiotics, but their effect is still limited. In this study, a modified Chinese herbal medicine Huang Lian Jie Du decoction cream with Yin-Cold ( YC ) medicine characteristic was investigated for the effect on patients suffering EGFRIs/TKIs-induced skin toxicity. Methods: The modified Huang Lian Jie Du (mHLJD) decoction cream was made from 10 herbal medicines including 4 major medicines ( Huanglian , Huangqin , Huangbo , and Zhizi ) in traditional HLJD decoction. Patients with EGFRIs/TKIs-induced skin toxicity were enrolled. Patients were excluded if they also used other cream for the skin toxicity. Skin conditions were follow up every 2 weeks. The patients’ characteristics, the skin toxicities and treatment response were recorded and analyzed after using mHLJD decoction cream for 1~2 months. Results: The mHLJD decoction cream and its subpackages were stored at 4℃ before use. Thirty-four patients who had grade 1-3 skin toxicities after receiving EGFRIs or TKIs were enrolled. Five patients were withdrawal or excluded, 2 patients with paronychia syndrome had no improvement and were excluded, too. Finally, data from 27 patients were analyzed. The mean grade of rash acneiform was decreased from 2.23 (ranged 1 to 3) to 0.38 (ranged 0 to 1) after mHLJD decoction cream treatment for 1~2 months. And the mean grade of dry skin was decreased from 1.57 (ranged 1 to 2) to 0.77 (ranged 0 to 1). The changes of skin toxicity were significant and no obvious adverse events. Conclusions: In summary, the mHLJD decoction cream is effective for alleviation of EGFRIs/TKIs-induced skin rash acneiform and dry skin. And mHLJD decoction cream has no effect in patients with paronychia syndrome.

The EGFRIs/TKIs-induced skin reactions including papulopustular rash, pruritus, mucositis, xerosis, fissures and etc. According to the TCM theory and the experiences of Chinese Medicine doctors, skin rashes mostly belong to the Yang-heat (YH) type of TCM syndromes. The YH type disease should be treated with Yin-Cold (YC) medicine to maintain the homeostasis of the whole body [5]. There are some TCMs could be applied as YC herbal medicine because they have been used for clearing heat, removing moisture, purge endogenous fire, toxin excretion, for example, Gan  The formula of HLJDT (also called HLJD decoction) was first recorded in the book "Wai-Tai-Mi-Yao" in the Chinese Tang dynasty (618-907 A.D.). It consists of four traditional herbs including Huanglian (Coptidis Rhizoma), Huangqin (Scutellariae Radix), Huangbo (Phellodendri Cortex), and Zhizi (Gardeniae Fructus) in a dry weight ratio of 3:2:2:3 (2013-150-1137_JE). HLJD decoction has been widely used in the treatment of inflammation. For example, it ameliorates type II collagen-induced rat arthritis by oral [7], reduces vascular cell adhesion molecule 1 protein expression and leukocyte-endothelial adhesion in rat lung venules after lipopolysaccharide (LPS) stimulation [8]. In spontaneous hypertensive rats, HLJD decoction also has antihypertensive effect and alters gene expression profile including the genes with immune function [9]. In dextran sulphate sodium-induced mice ulcerative colitis (UC), HLJD decoction alleviates the UC symptoms and decreases inflammatory cytokines in colons [10]. HLJD decoction mitigates mice atopic dermatitis induced by 2,4-dinitrochlorobenzene [11], and decreases nitric oxide and various cytokines release in LPS-stimulated RAW264.7 cells [12]. Taken together, HLJD decoction shows its effects in various inflammatory conditions.
In this study, we planned to treat EGFRIs-induced skin adverse effect by HLJD decoction but we didn't want to produce systemic action because it might interfere the anti-cancer effect of EGFRIs. Therefore, we processed the HLJD decoction as cream formulation for a tropic YC medicine. In addition to the 4 herbal medicines in original HLJD decoction, other 6 herbal medicines were also involved to make the modified For decoction preparation, we weighed Huanglian (168.75 g), Huangqin (112.5 g), Huangbo (112.5 g), and Zhizi (168.75 g), Sangbaipi (75 g), Longdan (37.5 g), Kushen (112.5 g), Tofulin (112.5 g), Lianqiao (75 g) and Shigao (187.5 g), mixed and put into a refined cotton bag. All the powder was socked in 4.5 L water for 20 min, then decocted by boiling water for 90 min. After taking out the cotton bag with medicines, the remaining decoction was about 3000 ml. The mHLJD decoction was stored at 4℃.

Process of modified HLJD (mHLJD) decoction cream for skin use
There were 26 kinds of chemical (Table 1) in the cream preparation including the concentrated mHLJD decoction. Figure 1 shows the procedure for making mHLJD decoction cream. The mHLJD decoction cream was stored at 4℃.

Patients
Adult malignancy patients who received epidermal growth factor receptor inhibitors (EGFRIs), such as monoclonal antibodies cetuximab or panitumumab, or who received tyrosine kinase inhibitors (TKIs), such as gefitinib, erlotinib or afatinb in Ditmanson

Results
From June 2019 to April 2020, 34 adult patients who had skin toxicities after receiving EGFRIs or TKIs were enrolled. The initial characterizes of skin toxicities were included as following: rash acneiform, dry skin, scalp pain, pruritus, pain of skin, palmar-plantar erythrodysesthesia, skin ulcer, and paronychia.
Among the 34 patients, one case withdrew the study 1 week later due to uncomfortable sticky sensation after smearing mHLJD decoction cream. Another one case withdrew the study due to refuse regularly follow up in our out-patient clinic. In addition, there are 3 cases were also excluded in final analysis because two of them used other topical cream by themselves and another one case stopped TKI treatment due to cancer disease progression after enroll the study. Furthermore, two cases had paronychia as initial skin side-effect and did not have any improvement after using mHLJD decoction cream treatment for 1 week. These two cases changed to use other topical medications and withdrew this study. The procedure was summarized in Figure   2. For the fine tuning, we then added paronychia as one of exclusion criteria after group discussion. Therefore, total 27 cases successfully received more than 1 month mHLJD decoction cream treatment can be analyzed about treatment response. During the mHLJD decoction cream treatment, the EGFRIs/TKIs treatment were kept the same dosage except 2 sever cases with intolerance grade 3 skin toxicity. In these 2 cases, the TKI (erlotinib) was paused for one week, but mHLJD decoction cream treatment continued. The basic information and EGFRIs or TKIs receiving of these 27 patients was in Table 2. The incidence percentage and the most severe grade of the skin toxicities about these 27 cases were summarized in Table 3.
After mHLJD decoction cream treatment, the skin toxicities had improvement generally. The most common skin toxicities in our study is rash acneiform (n=26, 96.30%). Calculated the most severe grade of every patient, the mean grade of rash acneiform is 2.23 (ranged 1 to 3). After treatment for a period (1~2 months, depends on cases), the mean grade of rash acneiform is 0.38 (ranged 0 to 1). The improvement is significant (p < 0.001). The grading change of rash acneiform after mHLJD decoction cream treatment is presented as figure 3.
The second common skin toxicities in our study is dry skin (n=7, 25.93%). Record the most severe grade of every patient and calculate the mean grade of dry skin is 1.57 (ranged 1 to 2). After treatment for a period (1~2 months), the mean grade of dry skin is 0.77 (ranged 0 to 1). The improvement is also significant (p = 0.002). The grading change of dry skin after mHLJD decoction cream treatment in each patient is presented as figure 4.

Discussion
In Taiwan, Chinese Medicine clinic is very popular in each city and is essential in a larger hospital. In Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chinese Medicine clinics have their own patients, they also serve consultations for other departments, for example, cancer treatment in hematology oncology. Recently, the cancer patients accepting molecular targeting drug therapy are gradually increase, especially EGFRIs and TKIs. As the skin toxicity induced by EGFRIs and TKIs is getting more serious and limited improvement by steroids and antibiotic treatment, the alternative therapy by Chinese Medicine is introduced and get a significant improvement in this study.
According to the Chinese therapy theory, HLJD decoction might have the ability to relieve the EGFRIs/TKIs-induced skin toxicity. In this study, mHLJD decoction cream really shows a significant effect on relieving EGFRIs/TKIs-induced rash acneiform ( Figure 3) and dry skin (Figure 4). In addition to the Chinese theory, some chemicals in the herbal medicine have been reported to have their biological function related to anti-skin inflammation. The major chemical in Huanglian and Huangbo is berberine. Berberine has been reported to produce anti-inflammatory effect in human keratinocytes, for example, it inhibits 12-O-tetradecanoylphorbol-13-acetate (TPA)induced matrix metalloproteinase-9 activity and interleukin-6 expression which are indicators of aging and inflammation [13]. It also inhibits heatkilled Propionibacterium acnes-induced nitric oxide and proinflammatory cytokine production in HaCaT keratinocytic cells via inhibiting mitogen-activated protein kinase and NF-κB signaling pathways [14].
The major chemicals in Huangqin are baicalin, baicalein and wogonin. In a mice study, it suggests that baicalin can be metabolized to baicalein and oroxylin A by intestinal microflora. All these compounds inhibit lipopolysaccharide (LPS)-stimulated peritoneal cytokine production and NF-kB activation in mice [15]. Baicalein also inhibits TPA-induced skin infiltration of polymorphonuclear leukocytes in mice dermis [16]. Wogonin, a derivative of baicalein, also inhibits IL-1beta or TNF-induced cyclooxygenase-2 expression in skin fibroblast NIH/3T3 cells [17].
The major compound in Zhizi is geniposide. It has been reported that geniposide has anti-inflammation effect in LPS-activated rat fibroblast-like synoviocytes [18]. It also has anti-inflammation effect in LPS-induced mice mastitis [19]. Furthermore, geniposide can be absorbed by skin and accumulated in subcutaneous tissue within 1h in a mice study [20]. In addition to anti-inflammation effect of berberine, baicalin and geniposide, berberine also has anti-bacterial activity [21,22]. Therefore, the potential anti-inflammation and anti-bacterial effects of these compounds in mHLJD decoction cream might constitute of the therapeutic effect in this trial.
In previous studies, the pathophysiology of EGFRIs/TKIs-induced paronychia includes disruption of the protective barrier between the nail and the nail fold, and secondary bacterial and fungal infections [23,24]. The majority compounds of mHLJD decoction cream, such like berberine, have the anti-bacterial effect but focus on Staphylococcus [25]. However, the bacterial specimens of paronychia can be both aerobic bacteria (for example Staphylococcus aureus) and anaerobic bacteria [26,27], thus in our study, it may be the reason that mHLJD decoction cream couldn't have good therapeutic effect for paronychia lesions.

Conclusions
In this study, we conclude that the mHLJD decoction cream is effective for EGFRIs/TKIs-induced skin rash acneiform and dry skin. We hope a better adverse effect control will keep the anti-cancer drug dosage and have a good anti-cancer therapy effect.