Hand-foot syndrome: Treating this chemotherapy side effect

By Jules Murtha | Medically reviewed by Kristen Fuller, MD
Published August 2, 2022

Key Takeaways

  • Hand-foot syndrome (HFS)—also known as palmar-plantar erythrodysesthesia syndrome and Burgdorf’s syndrome—is a common skin reaction to some chemotherapy treatments including pegylated liposomal doxorubicin, docetaxel, and fluoropyrimidines.

  • HFS causes pruritus (itchiness) and hyperemia (redness due to vascular congestion) of the palms and the plantar skin, pain, numbness, swelling—and in severe cases, blisters and desquamation (skin peeling).

  • Doctors can help patients prevent and manage HFS through the use of topical treatments, chemotherapy dose reductions, and other chemo medications that are less likely to cause HFS.

After living with an ovarian cancer diagnosis for 2 years, a 64-year-old patient turned to the chemotherapy drugs liposomal doxorubicin and carboplatin in hopes of slowing the cancer’s progression. Less than 2 months later, she reported the appearance of erythema (redness), ulceration, and exudation (fluid oozing from the skin) on her back, hands, and feet.

This patient ultimately learned she had hand-foot syndrome (HFS)—a side effect of some chemotherapy treatments.

Clinicians can help patients prevent and manage HFS with the help of alternative drugs, dosage reductions, and topical treatments.

Chemotherapy side effect

HFS, which is also called palmar-plantar erythrodysesthesia and Burgdorf’s syndrome, is a side effect of certain chemotherapy drugs.

According to an article published by Oncology Reviews, HFS symptoms kick off with palmoplantar (palms and soles) numbness, burning pain, or tingling.[]

HFS targets the hands and feet—which is likely how the syndrome earned its name. These symptoms occur alongside well-defined redness that may or may not include edema, desquamation, or cracking.

As HFS progresses, patients who have it can experience ulceration and blistering. Patients of color may notice macular hyperpigmentation in place of erythema.

HFS has a side range of symptoms from redness, swelling and itching to pain, ulceration, blistering and severe loss of fingerprint quality.

Which drugs induce HFS?

Research has shown that pegylated liposomal doxorubicin (PLD), which is used to treat breast and ovarian cancers, docetaxel (used to treat breast, gastric, prostate, non-small cell lung, and head and neck cancer), and fluoropyrimidines (used to treat solid tumor types) including intravenous 5-fluorouracil (5-FU), capecitabine, and S-1 are often to blame.

Patients are more likely to develop HFS if they take these treatments on a continuous dosing schedule, or if their medication (such as capecitabine) has high blood serum levels.

Little is known about the pathogenesis of HFS, but its side effects may differ based on the medication that triggers it. Symptoms usually show up with repeated use of the above-named drugs, and decrease once the treatments are discontinued.

Ultimately, HFS is not life-threatening—but it can severely impact a patient’s quality of life.

HFS prevalence and diagnostics

HFS is relatively common. Oncology Reviews states that different drugs have varying rates of incidence. For example, between 2.6% and 18% of patients who take intravenous 5-FU in phase three trials report the development of HFS symptoms.

Capecitabine, on the other hand, shows up in 22% to 77% of patients in the same trial phase. When taken in combination with pegylated liposomal doxorubicin, that incidence rate coasts at 39%. PLD alone tends to cause HFS in as much as 48% of patients with metastatic breast cancer.

While further research is needed to confirm rates of HFS among patients who take Docetaxel, some evidence shows that any grade of HFS may surface in about 40% to 53% of patients who take generic Docetaxel products.

Diagnosing HFS can be tricky, since the identifiable characteristics can look similar to other skin conditions such as contact dermatitis and eczema, or vasculitis.

The 64-year-old patient with ovarian cancer, for example, was initially diagnosed with Tinea corporis, commonly referred to as ringworm infection and prescribed calamine lotion and terbinafine cream. Only when that treatment failed did her doctors consider HFS a possibility, according to a case report published by the Journal of International Medical Research.[]

Clinicians should therefore keep in mind each potential diagnosis that may apply when a patient starts showing symptoms of HFS and take into consideration the patient’s cancer history and medication history.

How to manage HFS

As far as prevention and treatment options go for HFS, there are several promising courses of action to keep in mind.

An article published by Breastcancer.org offers the following prevention tips:[]

  • Limit heat exposure on hands and feet

  • Relieve your hands and feet of pressure

  • Take breaks from exercise

  • Avoid use of knives, screwdrivers, hammers, and gardening tools

By implementing these tips, patients reduce the risk of chemotherapy leakage through their skin and the subsequent development of HFS.

If HFS is already present, the Oncology Reviews article suggested that clinicians consider lowering the medication dose—although this may lead to other undesirable effects—or switch to a similar medication that has a lesser association with HFS.

Finally, topical treatments, including prophylactic use of urea-based cream, may help soothe patients’ symptoms.

What this means for you

Patients may develop HFS from certain chemotherapy treatments. Patients who have it report numbness, redness, swelling, blisters, and desquamation of the soles of the feet and palms of the hands. Pegylated liposomal doxorubicin, docetaxel, and fluoropyrimidines typically cause HFS. You can improve patients’ quality of life by reducing their chemo medication dose, prescribing topical treatments, or switching to a different chemo medication in the same class.

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