Introduction

Antineoplastic agent; nitrogen mustard-derivative alkylating agent.

Uses for Mechlorethamine

Mycosis Fungoides-type Cutaneous T-cell Lymphoma (CTCL)

Topical treatment of cutaneous lesions in patients with early (stage IA and IB) mycosis fungoides-type CTCL who have received prior skin-directed therapy. Designated an orphan drug by FDA for use in this condition.

Expert treatment guidelines include topical mechlorethamine as one of several recommended treatment options for patients with early stages of mycosis fungoides-type CTCL.

Mechlorethamine Dosage and Administration

Administration

Topical Administration

Apply to skin as commercially available 0.016% mechlorethamine gel.

Has been applied to skin as aqueous solution or ointment-based preparation compounded extemporaneously using mechlorethamine hydrochloride for injection.

For topical dermatologic use only. Do not use near or in the eyes, nose, or mouth. (See Mucosal or Eye Injury under Cautions.)

Wash hands thoroughly with soap and water after handling or applying the drug. (See Warnings/Precautions under Cautions.)

Application by Caregiver

Manufacturer states caregiver must wear disposable nitrile gloves during application and wash hands thoroughly with soap and water after removing the gloves.

In case of accidental skin exposure, immediately wash exposed areas thoroughly with soap and water for ≥15 minutes and remove contaminated clothing.

In case of accidental exposure to eyes, mouth, or nose, immediately irrigate exposed area for ≥15 minutes with copious amounts of water.

Gel

Apply gel immediately (or within 30 minutes) after removal from refrigerator; return gel to refrigerator immediately after each use.

Apply gel to completely dry skin ≥4 hours before or ≥30 minutes after showering or washing affected areas. After application, allow treated areas to dry for 5–10 minutes before covering with clothing.

May apply emollients (moisturizers) to treated areas 2 hours before or 2 hours after application of the gel.

Do not use occlusive dressings on treated areas.

Avoid fire, flame, and smoking until gel has dried.

Extemporaneously Compounded Ointment

Usually prepared by dissolving mechlorethamine hydrochloride in dehydrated alcohol, filtering the solution to remove insoluble sodium chloride present in the commercial preparation (although filtration may not be necessary), and mixing the drug-alcohol solution into petrolatum or another anhydrous ointment base (e.g., hydrophilic petrolatum). Usual mechlorethamine hydrochloride concentration is 0.01 or 0.02%. Consult specialized references for detailed information on preparation of topical ointments.

Extemporaneously Compounded Solution

Usually prepared by dissolving 10 mg of mechlorethamine hydrochloride in 50–100 mL of water. Consult specialized references for detailed information on preparation of topical solutions.

Because of limited stability, prepare solution immediately before use.

Dosage

Available as mechlorethamine hydrochloride; dosage of gel expressed in terms of mechlorethamine.

Adults

Mycosis Fungoides-type CTCL

Topical

Apply thin film of mechlorethamine 0.016% gel to affected areas once daily.

Interrupt treatment if any skin ulceration or blistering, or moderately severe or severe dermatitis (i.e., marked erythema with edema), occurs.

Upon improvement, may resume with reduced frequency of once every 3 days. If reintroduction tolerated for ≥1 week, may increase application frequency to every other day for ≥1 week and then to once daily if tolerated.

Concentration of mechlorethamine hydrochloride in topical solutions and ointments, frequency of application, and duration of treatment have been based on dermatologic response and tolerance. Usual ointment concentration is 0.01 or 0.02%; may use lower concentrations initially in patients with dermatitis or history of hypersensitivity reactions to the topically applied drug, or use higher concentrations in patients with extensive or resistant lesions.

Topical applications of mechlorethamine preparations generally are repeated once daily until the lesions disappear. Optimal duration of therapy following clinical remission not fully established.

Special Populations

No special population dosage recommendations at this time.

Contraindications

• Known severe hypersensitivity to mechlorethamine.

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity reactions, including anaphylaxis, reported following exposure to topical formulations of mechlorethamine.

Desensitization using topical mechlorethamine has been used with some success to prevent allergic contact dermatitis with additional therapy.

Mucosal or Eye Injury

Eye exposure causes pain, burns, inflammation, photophobia, and blurred vision, and possibly blindness and severe irreversible anterior eye injury.

If eye exposure occurs, immediately irrigate affected eye(s) with copious amounts of water, 0.9% sodium chloride, or balanced salt ophthalmic irrigating solution for ≥15 minutes and obtain immediate medical care, including ophthalmologic consultation.

Mucosal exposure causes pain, erythema, and ulceration, which may be severe.

If mucosal exposure occurs, immediately irrigate affected area with copious amounts of water for ≥15 minutes and seek immediate medical consultation.

Secondary Exposure to Topical Mechlorethamine

Secondary exposure may cause dermatitis, mucosal injury, and secondary cancers.

Avoid direct skin contact with gel by anyone other than patient. Follow application instructions carefully to prevent secondary exposure (see Topical Administration under Dosage and Administration).

Dermatitis

The most common adverse effect of topical mechlorethamine. Reported in 56% of patients receiving the gel; was moderately severe or severe in 23% of patients.

Monitor patients for erythema, swelling, inflammation, pruritus, blisters, ulceration, and secondary skin infections. Face, genitalia, anus, and intertriginous areas associated with increased risk.

May require treatment interruption or dosage adjustment (see Dosage under Dosage and Administration). Topical emollients, oral antihistamines, and topical corticosteroids have been used to treat dermatitis.

Nonmelanoma Skin Cancer

Nonmelanoma skin cancer reported during clinical trial or one year of posttreatment follow-up in 4% of patients receiving mechlorethamine gel or an extemporaneously compounded ointment (2 or 6% of patients, respectively). Some patients previously had received therapies known to cause such cancers.

May occur on any area of the skin, including untreated areas.

Monitor patients for nonmelanoma skin cancer during and after treatment.

Fetal/Neonatal Morbidity and Mortality

Mechlorethamine can cause fetal harm. If used during pregnancy or if patient becomes pregnant, apprise of potential fetal hazard.

Systemic mechlorethamine associated with malformations in children exposed to the drug in utero; single sub-Q dose in animals associated with growth retardation, teratogenicity, and embryolethality.

Flammable Gel

Gel is alcohol based and flammable. Carefully follow application instructions (see Topical Administration under Dosage and Administration).

Specific Populations

Pregnancy

Category D. (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether mechlorethamine is distributed into human milk. Discontinue nursing or the drug.

Pediatric Use

Safety and efficacy not established.

Geriatric Use

Among patients receiving mechlorethamine gel for mycosis fungoides-type CTCL in a clinical trial, response rate appeared to be lower (44 versus 66%) and rates of adverse cutaneous reactions (70 versus 58%) and discontinuance due to adverse effects (38 versus 14%) higher in patients ≥65 years of age compared with younger patients.

Common Adverse Effects

Dermatitis, pruritus, laboratory abnormalities (anemia, neutropenia, thrombocytopenia), bacterial skin infection, skin ulceration or blistering, skin hyperpigmentation.

Administration

Topical Administration

Apply to skin as commercially available 0.016% mechlorethamine gel.

Has been applied to skin as aqueous solution or ointment-based preparation compounded extemporaneously using mechlorethamine hydrochloride for injection.

For topical dermatologic use only. Do not use near or in the eyes, nose, or mouth. (See Mucosal or Eye Injury under Cautions.)

Wash hands thoroughly with soap and water after handling or applying the drug. (See Warnings/Precautions under Cautions.)

Application by Caregiver

Manufacturer states caregiver must wear disposable nitrile gloves during application and wash hands thoroughly with soap and water after removing the gloves.

In case of accidental skin exposure, immediately wash exposed areas thoroughly with soap and water for ≥15 minutes and remove contaminated clothing.

In case of accidental exposure to eyes, mouth, or nose, immediately irrigate exposed area for ≥15 minutes with copious amounts of water.

Gel

Apply gel immediately (or within 30 minutes) after removal from refrigerator; return gel to refrigerator immediately after each use.

Apply gel to completely dry skin ≥4 hours before or ≥30 minutes after showering or washing affected areas. After application, allow treated areas to dry for 5–10 minutes before covering with clothing.

May apply emollients (moisturizers) to treated areas 2 hours before or 2 hours after application of the gel.

Do not use occlusive dressings on treated areas.

Avoid fire, flame, and smoking until gel has dried.

Extemporaneously Compounded Ointment

Usually prepared by dissolving mechlorethamine hydrochloride in dehydrated alcohol, filtering the solution to remove insoluble sodium chloride present in the commercial preparation (although filtration may not be necessary), and mixing the drug-alcohol solution into petrolatum or another anhydrous ointment base (e.g., hydrophilic petrolatum). Usual mechlorethamine hydrochloride concentration is 0.01 or 0.02%. Consult specialized references for detailed information on preparation of topical ointments.

Extemporaneously Compounded Solution

Usually prepared by dissolving 10 mg of mechlorethamine hydrochloride in 50–100 mL of water. Consult specialized references for detailed information on preparation of topical solutions.

Because of limited stability, prepare solution immediately before use.

Dosage

Available as mechlorethamine hydrochloride; dosage of gel expressed in terms of mechlorethamine.

Adults

Mycosis Fungoides-type CTCL

Topical

Apply thin film of mechlorethamine 0.016% gel to affected areas once daily.

Interrupt treatment if any skin ulceration or blistering, or moderately severe or severe dermatitis (i.e., marked erythema with edema), occurs.

Upon improvement, may resume with reduced frequency of once every 3 days. If reintroduction tolerated for ≥1 week, may increase application frequency to every other day for ≥1 week and then to once daily if tolerated.

Concentration of mechlorethamine hydrochloride in topical solutions and ointments, frequency of application, and duration of treatment have been based on dermatologic response and tolerance. Usual ointment concentration is 0.01 or 0.02%; may use lower concentrations initially in patients with dermatitis or history of hypersensitivity reactions to the topically applied drug, or use higher concentrations in patients with extensive or resistant lesions.

Topical applications of mechlorethamine preparations generally are repeated once daily until the lesions disappear. Optimal duration of therapy following clinical remission not fully established.

Special Populations

No special population dosage recommendations at this time.