Palmar-plantar erythrodysesthesia

Abstract

Objective. To provide a comprehensive review of the chemotherapy induced dermatological toxi-city, palmar-plantar erythrodysesthesia (PPE), including clinical presentation, drugs implication in causing the reaction, and approaches for management.

Data sources. A search of MEDLINE (1966-2002), IDIS (1985- 2002) and CANCERLIT (1993-2002) databases was conducted using the terms (and variations of the terms) palmar-plantar erythrodysesthesia, hand-foot syndrome, and acral erythema. Bibliographies from selected articles were also reviewed for appropriate references.

Data extraction. The retrieved literature was reviewed to include all articles pertaining to the incidence, clinical presentation, mechanism, pathology, diagnosis, treatment and prevention of PPE.

Data synthesis. PPE is a distinctive, localized cutaneous reaction to certain antineoplastic agents. A number of drugs have been implicated, including most commonly cytarabine, fluorouracil, doxorubicin, and capecitabine. There appears to be an association with administration schedules that lead to elevated peak plasma concentrations, such as in high-dose therapy, or after prolonged periods of constant exposure, as with continuous infusions, regular oral dosing, or liposomal formulations. The extent and severity of the reaction, time of onset, and duration are variable. Symptoms can occur to both hands and feet, and include dysesthesia, paresthesia, erythema, swelling, pain, blistering, ulceration, and desquamination. Cessation of the offending agent appears to be the most important step in the management of PPE. Dose modification may be necessary for subsequent cycles. As the course of PPE is self-limiting, treatment is commonly supportive and based on the type and severity of symptoms encountered. This can include analgesia, emollient or soothing creams, wound care, and cold compresses. Administration of corticosteroids has produced mixed results. Pyridoxine shows promise as both a treatment and preventative strategy, although confirmation in prospective clinical trials is needed. Advice should be provided to patients to ensure prompt recognition of toxicity and plans for prevention and amelioration of symptoms provided.