Chemotherapy-induced acral erythema

Chemotherapy-induced acral erythema

Pictures of hands on capecitabine
Classification and external resources
ICD-10 Y43.1-Y43.3
ICD-9 693.0, E933.1
DiseasesDB 34044

Chemotherapy-induced acral erythema (also known as palmar-plantar erythrodysesthesia, palmoplantar erythrodysesthesia, or hand-foot syndrome) is reddening, swelling, numbness and desquamation (skin sloughing or peeling) on palms of the hands and soles of the feet (and, occasionally, on the knees, elbows, and elsewhere) that can occur after chemotherapy in patients with cancer. Hand-foot syndrome is also rarely seen in sickle-cell disease. These skin changes usually are well demarcated. Acral erythema typically disappears within a few weeks after discontinuation of the offending drug.[1][2]

Synonyms

Synonyms for acral erythema (AE) include: hand-foot syndrome, palmar-plantar erythrodysesthesia, peculiar AE, chemotherapy-induced AE, toxic erythema of the palms and soles, palmar-plantar erythema, and Burgdorf’s reaction.

Signs and symptoms

The symptoms can occur anywhere between days to months after administration of the offending medication, depending on the dose and speed of administration (Baack and Burgdorf, 1991; Demirçay, 1997;). The patient first experiences tingling and/or numbness of the palms and soles that evolves into painful, symmetric, and well-demarcated swelling and red plaques. This is followed by peeling of the skin and resolution of the symptoms (Apisarnthanarax and Duvic 2003).

Causes

Acral erythema is a common adverse reaction to cytotoxic chemotherapy drugs, particularly Cabozantinib, cytarabine, doxorubicin, and fluorouracil and its prodrug capecitabine.[3]

Targeted cancer therapies, especially the tyrosine kinase inhibitors sorafenib and sunitinib, have also been associated with a high incidence of acral erythema. However, acral erythema due to tyrosine kinase inhibitors seems to differ somewhat from acral erythema due to classic chemotherapy drugs.[4]

Pathogenesis

The cause of PPE is unknown. Existing theories are based on the fact that only the hands and feet are involved and posit the role of temperature differences, vascular anatomy, differences in the types of cells (rapidly dividing epidermal cells and eccrine glands).

Diagnosis

Painful red swelling of the hands and feet in a patient receiving chemotherapy is usually enough to make the diagnosis. The problem can also arise in patients after bone marrow transplants, as the clinical and histologic features of PPE can be similar to cutaneous manifestations of acute (first 3 weeks) graft-versus-host disease. It is important to differentiate PPE, which is benign, from the more dangerous graft-versus-host disease. As time progresses, patients with graft-versus-host disease progress to have other body parts affected, while PPE is limited to hands and feet. Serial biopsies every 3 to 5 days can also be helpful in differentiating the two disorders (Crider et al., 1986).

Prevention

The cooling of hands and feet during chemotherapy may help prevent PPE (Baack and Burgdorf, 1991; Zimmerman et al., 1995). Support for this and a variety of other approaches to treat or prevent acral erythema comes from small clinical studies, although none has been proven in a randomised controlled clinical trial of sufficient size.

Treatment

The main treatment for acral erythema is discontinuation of the offending drug, and symptomatic treatment to provide analgesia, lessen edema, and prevent superinfection. However, the treatment for the underlying cancer of the patient must not be neglected. Often, the discontinued drug can be substituted with another cancer drug or cancer treatment.[5][6]

Symptomatic treatment can include wound care, elevation, and pain medication. Corticosteroids and pyridoxine have also been used to relieve symptoms.[7]

Prognosis

PPE invariably recurs with resumption of chemotherapy. Long-term chemotherapy may also result in reversible palmoplantar keratoderma. Symptoms resolve 1–2 weeks after cessation of chemotherapy (Apisarnthanarax and Duvic 2003).

History

Hand-foot syndrome was first reported in association with chemotherapy by Zuehlke in 1974.[8]

In Popular Culture

In season three, episode 8, titled "Sins of the Father," in the American television medical drama Private Practice, hand-foot syndrome is depicted, possibly inaccurately, in a patient. This episode first aired on November 19, 2009.

References

  1. ↑ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.:132
  2. ↑ Palmar-plantar rash with cytarabine therapy. Rosenbeck L, Kiel PJ. N Engl J Med. 2011 Jan 20;364(3):e5.
  3. ↑ Baack BR, Burgdorf WH (Mar 1991). "Chemotherapy-induced acral erythema". J Am Acad Dermatol 24 (3): 457–61.
  4. ↑ Lacouture ME, Reilly LM, Gerami P, Guitart (2008). "Hand foot skin reaction in cancer patients treated with the multikinase inhibitors sorafenib and sunitinib". J. Ann Oncol 19 (11): 1955–61.
  5. ↑ Cutaneous complications of conventional chemotherapy agents. Payne AS, Savarese DMF. In: UpToDate [Textbook of Medicine]. Massachusetts Medical Society, and Wolters Kluwer publishers. 2010.
  6. ↑ Gressett SM, Stanford BL, Hardwicke F (Sep 2006). "Management of hand-foot syndrome induced by capecitabine". J Oncol Pharm Pract 12 (3): 131–41.
  7. ↑ Vukelja SJ, Baker WJ, Burris HA 3rd, Keeling JH, Von Hoff D. "Pyridoxine therapy for palmar-plantar erythrodysesthesia associated with taxotere. J Natl Cancer Inst. 1993 Sep 1;85(17):1432-3.
  8. ↑ Zuehlke RL (1974). "Erythematous eruption of the palms and soles associated with mitotane therapy". Dermatologica 148 (2): 90–2.
Bibliography

Further reading