Early Identification and Management of Patients with Rash on Apalutamide

Authored by Alison Birtle, published on 2026-05-28 05:03:16.0

  1. Patient on apalutamide presents with rash
    • Determine cause of rash
      e.g., infectious disease, inflammatory skin disorder, drug interaction, infection or allergy. Ask about concomitant medications, especially antibiotics.
      • If other cause identified, treat according to aetiology (if cause unclear, refer to dermatology)* If other causes excluded, manage as ADR and grade rash using NCI-CTCAE.
        *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
        • Grade 1
          • Continue apalutamide at the same dose
            AND Moderate/high strength topical corticosteroid cream/lotion e.g., prednicarbate 0.1%, mometasone furoate 0.1%, methylprednisolone aceponate 0.1%, or hydrocortisone butyrate 0.1% AND Oral antihistamine BID* For relief of itch, consider topical polidocanol 2–10% in a moisturiser. *Prescribe non-sedating antihistamines for daytime but consider sedating antihistamines at night to help make the patient more comfortable when the itch can be particularly troublesome.
            • Monitor for change in severity every 5–7 days
              • If rash is stable or improving, continue current treatment until rash resolves
              • If rash worsens or does not improve, follow guidance for Grade 3 and refer to a dermatologist*
                *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                • Pause apalutamide until rash is Grade ≤1
                  AND Oral prednisone 0.5–1 mg/kg/day for 20 days (or equivalent); max. dose 100 mg/day AND Ultra-high potency topical steroid cream/lotion/solution BID e.g., triamcinolone acetonide 0.1% or clobetasol propionate 0.1% AND Oral antihistamine BID* *Prescribe non-sedating antihistamines for daytime but consider sedating antihistamines at night to help make the patient more comfortable when the itch can be particularly troublesome.
                  • Monitor for change in severity every 5–7 days
                    • If rash improves to Grade 2, continue current management
                      • Monitor at least once per week
                        • If rash improves to Grade ≤1
                          Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
                        • If rash is the same or has worsened, refer to a dermatologist*
                          *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                    • If rash is the same or has worsened, refer to a dermatologist*
                      *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                    • If rash improves to Grade ≤1
                      Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
        • Grade 2
          • Continue apalutamide at the same dose
            AND Moderate/high strength topical corticosteroid cream/lotion e.g., prednicarbate 0.1%, mometasone furoate 0.1%, methylprednisolone aceponate 0.1%, or hydrocortisone butyrate 0.1% AND Oral antihistamine BID* For relief of itch, consider topical polidocanol 2–10% in a moisturiser. *Prescribe non-sedating antihistamines for daytime but consider sedating antihistamines at night to help make the patient more comfortable when the itch can be particularly troublesome.
            • Monitor for change in severity every 5–7 days
              • If rash is stable or improving, continue current treatment until rash resolves
              • If rash worsens or does not improve, follow guidance for Grade 3 and refer to a dermatologist*
                *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                • Pause apalutamide until rash is Grade ≤1
                  AND Oral prednisone 0.5–1 mg/kg/day for 20 days (or equivalent); max. dose 100 mg/day AND Ultra-high potency topical steroid cream/lotion/solution BID e.g., triamcinolone acetonide 0.1% or clobetasol propionate 0.1% AND Oral antihistamine BID* *Prescribe non-sedating antihistamines for daytime but consider sedating antihistamines at night to help make the patient more comfortable when the itch can be particularly troublesome.
                  • Monitor for change in severity every 5–7 days
                    • If rash improves to Grade 2, continue current management
                      • Monitor at least once per week
                        • If rash improves to Grade ≤1
                          Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
                        • If rash is the same or has worsened, refer to a dermatologist*
                          *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                    • If rash is the same or has worsened, refer to a dermatologist*
                      *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
                    • If rash improves to Grade ≤1
                      Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
        • Grade 3 (If signs of DRESS/SJS/TEN, refer to dermatology)*
          *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
          • Pause apalutamide until rash is Grade ≤1
            AND Oral prednisone 0.5–1 mg/kg/day for 20 days (or equivalent); max. dose 100 mg/day AND Ultra-high potency topical steroid cream/lotion/solution BID e.g., triamcinolone acetonide 0.1% or clobetasol propionate 0.1% AND Oral antihistamine BID* *Prescribe non-sedating antihistamines for daytime but consider sedating antihistamines at night to help make the patient more comfortable when the itch can be particularly troublesome.
            • Monitor for change in severity every 5–7 days
              • If rash improves to Grade 2, continue current management
                • Monitor at least once per week
                  • If rash improves to Grade ≤1
                    Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
                  • If rash is the same or has worsened, refer to a dermatologist*
                    *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
              • If rash is the same or has worsened, refer to a dermatologist*
                *Consider blood tests to check for abnormal leukocyte count (atypical lymphocytes and/or eosinophilia).
              • If rash improves to Grade ≤1
                Reinitiate apalutamide at half dose (120 mg) for 2 weeks; Start tapering oral steroids; Continue oral antihistamines‡ & topical treatment until rash resolves; After 2 weeks of half-dose apalutamide and if rash remains ≤1, return to full dose
  2. Information for patients starting apalutamide
    Patients should be advised to contact their oncology team at the first sign of rash so it can be managed early. From the start of treatment with apalutamide, patients should be advised to: USE: Light emollients (lotion) daily; Soap substitute or mild pH-neutral soap; Sunblock (SPF 50) when outdoors; For patients with pre-existing eczema, intensify usual skin care routine. AVOID: Harsh soaps; Strong sun and weather extremes; Long, hot baths, showers and saunas (use tepid water for bathing); Alcohol-based and fragranced skin-care products.
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