Hand Foot Syndrome

What is Hand Foot Syndrome?

Cancer chemotherapeutic drugs have several side effects, hand foot syndrome is one of them. The symptoms associated with the hand foot syndrome are dose-limited means a large dose of the chemotherapeutic agent has more risk of severity. In hand foot syndrome, the palm of hand and sole of feet become red. tendered, swelled up. These symptoms often accompanied with pain and rarely blister formation occur.

The hand foot syndrome symptoms appear usually with each subsequent chemotherapy cycles but disappear within 2- 3weeks. In a severe case, the symptoms may not control in between two cycle gap, which worsens the condition and interfere with quality of life of the patients.

Alternatively, Hand foot syndrome is also known as palmar-plantar erythrodysesthesia^1,2,3.

Symptoms

The symptoms related to foot hand syndrome are usually mild to moderate in nature, but in the certain condition, the symptoms may become severe without causing the fetal outcome.

Mild to moderate

• Sunburn-like redness
• Bulginess
• Burning and tingling sensation
• Touching provides sensation of tenderness
• Skin tightness
• Solid lumps and blisters formation on the palms and soles

Severe

• Broken, peeling or cracking skin
• Eruption, soreness or ulcers on the skin
• Unbearable pain
• Restricted walking and difficulty in using of hands
• Nail lifting (Onycholysis)

Hand foot symptoms generally restricted in palm and sole, but in some patients, symptoms can spread to fingers, toes, back of the hand, the upper part of the feet, knees and elbows. Rarely genital parts and the skin which is folded and pressed or get friction with clothes^1,2,3.

Grading

Depending upon the severity Hand Foot syndrome can be graded in four categories. These can be as follows:

Grade 1: Painless redness with a feeling of unpleasant sensation while touching the affected site, which may resultant of peripheral nerve damage (dysaesthesia).

Grade 2: Enhance inflammation and redness with mild pain and dysesthesia

Grade 3: Moderate pain, dysaesthesia, inflammation and redness also increased little difficulty in walking and using hands

Grade 4: Severe pain tenderness interferes daily living activities with compromised quality of life, blister, and soreness, scaling and cracked skin develops^4,5.

Causes

The different chemotherapeutic agent is known as Capecitabine, 5-Flurouracil, doxorubicin (prolong infusion), doxorubicin liposomal, and Interleukin-2 with large dose can cause this skin reaction for some patients.

Some of these drugs reach to palm and sole tissue through blood vessels and some via sweat glands. temperature and pressure factors also influence the drug reach to these sites. The palm and sole skin have numerous blood capillaries and sweat glands. Some chemotherapeutic drugs are excreted through sweat secretion and the cytotoxic reaction occurs with the tissue present in palm and sole.

The increase temperature and pressure causes leakage of drug from blood capillaries present in the palm and sole. This leakage causes drug contact with skin and provides different symptoms of hand and foot syndrome. But these symptoms become worse with large dose exposure and that depends upon temperature and pressure factors and that not same for every individual. Therefore, the severity of the symptoms of hand foot syndrome varies individual to individual^1,4.

Diagnosis

The clinical diagnosis is a usual method to diagnose the hand foot syndrome. The skin biopsy test provides some unique features like scattered, inconsistent skin cell necrosis, swelling at the intersection of the epidermis and dermis and damage of the blood vessels⁴.

Treatment

The treatment for hand and foot syndrome can be done by two ways preventive measure and therapeutic measure.

Preventive Measures

The preventive measure is applied to reduce the occurrence of hand foot syndrome. The preventive measure can assist to the reduction of the severity of the symptoms associated with the hand foot syndrome.

The activities which increase skin friction and heat exposure to hand feet should avoid during and after the intervention of the chemotherapy. This can be possible through following modification:

• Avoid to take long hot shower or tub bath. It is recommended short shower with like warm water beneficial to reduce hot water contact to hand and feet.
• Avoid to wash utensils or cloth with hot water.
• Avoid to wear Dishwashing gloves during washing of the utensils, as the rubber or plastic material of the globes embrace heat against palms.
• Avoid prolonged walking, or activities which increase the pressure of the hand and feet like exercise, aerobics, jumping, jogging and power walking.
• Avoid to handle household tools, like screwdrivers or other related instruments and also garden tools, as these may increase the chance of friction of hand skin.
• The restriction also made in cutting and chopping of fruits and vegetables, as these also increase pressure and friction on hand.

Therapeutic Measures

Cooling effect

Maintaining cooling effect in hand and feet can provide temporary relief from pain and tenderness. The cooling effect can be provided by placing the palm and feet in contact with an ice pack and keep altering this procedure after 15 to 20 minutes periodically.

Lotions

Application of lotion is very important in hand-foot syndrome, as it helps to maintain the moisture content of the skin and preventing dryness and cracking.

Application of emollients available in the pharmaceutical store like Lubriderm^®, Aveeno^®, Bag Balm^{®  and} Udder Cream^® can improve the softness of the skin.

Pain reduction medication

Consult with a doctor for selection of pain reduction medication to control the pain symptom associated with the hand-foot syndrome.

Vitamins

Vitamin B6 has some potential to treat and prevent hand-foot syndrome, but it is suggesting that before administering any vitamin preparation consult with a doctor.

Alternative treatment plan

Discuss in detail the symptomatic features with a consultant, may he recommend or change treatment plan in regards of altering chemotherapeutic agent or treatment cycle. The altered therapy may be beneficial for reduction of the symptoms.

Early intervention

Immediately consult with a doctor at the time of symptoms arise in hand and foot syndrome. Early intervention can relief complications and severity of the symptoms. It is also advisable to take follow-up session to control the symptoms within a mild stage^2,3.

References

1. Hand-Foot Syndrome or Palmar-Plantar Erythrodysesthesia; Cancer.Net; Online available at http://www.cancer.net/navigating-cancer-care/side-effects/hand-foot-syndrome-or-palmar-plantar-erythrodysesthesia
2. Hand-Foot Syndrome; Online available at http://chemocare.com/chemotherapy/side-effects/handfoot-syndrome.aspx
3. Hand-Foot Syndrome (HFS) or Palmar-Plantar Erythrodysesthesia (PPE); BREASTCANCER.ORG; Online available at http://www.breastcancer.org/treatment/side_effects/hand_foot_synd
4. Dr Delwyn Dyall-Smith (2009); DermNet New Zealand; Online available at http://www.dermnetnz.org/topics/hand-foot-syndrome/
5.  Werner Scheithauer; Coming to Grips With Hand-Foot Syndrome; cancerNetwork; Online available at http://www.cancernetwork.com/review-article/coming-grips-hand-foot-syndrome