Pulsed Azithromycin for the Treatment of Dacomitinib Induced Skin Toxicity in Patient with Tetracycline Intolerance – A Case Report

Abstract Background Skin toxicities such as paronychia and acneiform rash are common side-effects of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) and significantly altered the quality of life of patients. Consensus guidelines recommended tetracycline antibiotics as the first line choices for both prophylaxis and treatment for grade II-III acneiform rash and paronychia. While generally well-tolerated, a subset of patients experiences adverse effects such as nausea, vomiting, diarrhea, headache, and photosensitivity, leading to antibiotics intolerance and leaving EGFR TKI-induced skin toxicities unmanaged. Therefore, an alternative treatment is needed.Methods We present a case of stage IV EGFR-mutated non-small cell lung cancer (NSCLC) treated with the second-generation EGFR TKI, dacomitinib. The patient developed grade 3 skin toxicities and was subsequently treated with azithromycin after demonstrating intolerance to tetracycline antibiotics.Results Azithromycin was administered using various dosing strategies, and our findings indicated that 500 mg every other day might be the most effective regimen for treating EGFR-TKI-induced acneiform rash. However, this approach appeared to be less effective in managing paronychia.Conclusion This case highlights the potential efficacy of azithromycin 500mg once another day as an alternative to tetracycline antibiotics for managing EGFR TKI-related skin toxicities in NSCLC patients.