How to treat hand foot disease?

Management of Hand-Foot Skin Reaction (HFSR) in Cancer Treatment

Hand-foot skin reaction (HFSR), also known as palmar-plantar erythrodysesthesia syndrome (PPES), is a common dermatological toxicity associated with certain anticancer agents. The most effective approach to managing hand-foot skin reaction includes preventive measures with urea 10% cream applied three times daily, topical high-potency steroids for symptomatic treatment, and temporary dose interruption of the causative medication for severe cases. 1

Types and Causes

HFSR/PPES can be caused by different anticancer medications:

1. Capecitabine-induced PPES: Characterized by erythema, dysesthesia, pain, and desquamation on palms and soles 2
2. MEK inhibitor-induced HFSR: Similar presentation but may have different underlying mechanisms 1
3. Multikinase inhibitor-induced HFSR: Often more localized with hyperkeratotic lesions 1

Prevention Strategies

Prevention is crucial and should be implemented before starting therapy:

• Skin care regimen:

  • Apply urea 10% cream three times daily 1
  • Use alcohol-free moisturizers 1
  • Consider celecoxib 200 mg twice daily for prevention (particularly with capecitabine) 1

• Behavioral modifications:

  • Avoid mechanical stress (long walks, heavy carrying without protective gloves) 1
  • Avoid chemical irritants, solvents, and disinfectants 1
  • Treat predisposing factors like hyperkeratosis before starting anticancer therapy 1

Treatment Based on Severity

Grade 1-2 (Mild to Moderate)

• Continue anticancer drug at current dose while monitoring for changes in severity
• Topical treatments:
  • High-potency topical corticosteroids twice daily 1
  • Lidocaine 5% patches or cream for pain relief 1
• Reassess after 2 weeks - if worsening or no improvement, proceed to next step

Grade 3 or Intolerable Grade 2 (Severe)

• Interrupt anticancer treatment until severity decreases to grade 0-1 1
• Intensive topical therapy:
  • Continue high-potency topical steroids twice daily
  • Apply lidocaine 5% patches or cream
  • Consider topical keratolytics (salicylic acid 5%-10% or urea 10%-40%)
  • Consider antiseptic solutions (silver sulfadiazine 1%, polyhexanide 0.02%-0.04%)
• Reassess after 2 weeks - if no improvement, dose reduction or discontinuation may be necessary 1

Special Considerations

For Capecitabine-Induced PPES

• Celecoxib 200 mg twice daily has shown benefit in prevention 1
• Pyridoxine (vitamin B6) and urea/lactic acid-based topical keratolytic agents have not shown efficacy in preventing PPES 1

For MEK Inhibitor-Induced HFSR

• Similar management approach but may require longer treatment interruptions 1

Common Pitfalls and Caveats

1. Delayed recognition: HFSR can be mistaken for other conditions. Early recognition is essential for effective management.

2. Inadequate prevention: Many clinicians focus only on treatment after symptoms appear rather than implementing preventive measures.

3. Failure to adjust anticancer therapy: Continuing the causative agent at full dose despite severe symptoms can lead to worsening toxicity and potentially unnecessary treatment discontinuation.

4. Overlooking impact on quality of life: HFSR can significantly affect patients' quality of life and treatment adherence, even when graded as "mild" by clinicians 2.

5. Inappropriate use of oral lidocaine: Topical lidocaine is recommended, but oral lidocaine is not advised for pain management in these cases 1.

By implementing these preventive and treatment strategies, clinicians can effectively manage HFSR while maintaining optimal anticancer therapy for patients.