Chemotherapy-induced acral erythema

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Chemotherapy-induced acral erythema
Hand-foot Syndrome.jpg
Pictures of hands on capecitabine
Classification and external resources
ICD-10 Y43.1-Y43.3
ICD-9-CM 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 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[edit]

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).


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]


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).


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).


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.


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] Other studies do not support the conclusion. A number of additional remedies are listed in recent medical literature.[8][9][10][11][12][13] Among them henna and uridine cream with or without thymidine.


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).


Hand-foot syndrome was first reported in association with chemotherapy by Zuehlke in 1974.[14]

In Popular Culture[edit]

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.


  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. ^ Juergen Barth (2004-03). "Letter to the editor - 5-FU induced palmar-plantar erythrodyesthesia – a hospital pharmacy developed “antidot”". Journal of Oncology Pharmacy Practice 10 (57).  Check date values in: |date= (help)
  9. ^ Yucel, Idris; Guzin, Gonullu (2008-04). "Topical henna for capecitabine induced hand-foot syndrome". Investigational New Drugs 26 (2): 189–192. doi:10.1007/s10637-007-9082-3. ISSN 0167-6997. PMID 17885735.  Check date values in: |date= (help)
  10. ^ Irena Netikova; Agnes Petska; Juergen Barth (2009). "Recent clinical studies with uridine cream" (PDF). EJOP. Oncology Pharmacy Practice 3 (2): 22–23. 
  11. ^ Hartinger, J.; Veselý, P.; Matoušková, E.; Argalacsová, S.; Petruželka, L.; Netíková, I. (2012). "Local treatment of hand-foot syndrome with uridine/thymidine: in vitro appraisal on a human keratinocyte cell line HaCaT". TheScientificWorldJournal 2012: 421325. doi:10.1100/2012/421325. ISSN 1537-744X. PMC 3417181. PMID 22919318. 
  12. ^ Hand-Foot Syndrome in cancer patients: concepts, assessment and management of symptoms. 2013. 
  13. ^ Ilyas, Saher; Wasif, Komal; Saif, Muhammad Wasif (2014-09). "Topical henna ameliorated capecitabine-induced hand-foot syndrome". Cutaneous and Ocular Toxicology 33 (3): 253–255. doi:10.3109/15569527.2013.832280. ISSN 1556-9535. PMID 24021017.  Check date values in: |date= (help)
  14. ^ Zuehlke RL (1974). "Erythematous eruption of the palms and soles associated with mitotane therapy". Dermatologica 148 (2): 90–2. 

Further reading[edit]