How to manage 5-fluorouracil (5-FU) extravasation in a male?

Management of 5-Fluorouracil Extravasation After Several Days

For 5-fluorouracil (5-FU) extravasation that is discovered after several days, the recommended approach is to apply topical dimethyl sulfoxide (DMSO) 99% (four drops per 10 cm² of skin surface) to the affected area every 8 hours for 1 week, along with dry cold compresses for 20 minutes several times daily for 1-2 days. 1, 2

Initial Assessment

• Evaluate the extent of tissue damage
• Document the extravasation area with photographs if possible
• Assess for signs of:
  • Pain
  • Erythema
  • Swelling
  • Tissue necrosis
  • Functional impairment

Treatment Protocol

Immediate Interventions

1. Elevate the affected limb to reduce swelling 1
2. Apply dry cold compresses for 20 minutes several times daily for 1-2 days 1
3. Administer analgesia as needed 1

Specific Antidote Application

• Apply DMSO 99% topically:
  • Four drops per 10 cm² of skin surface
  • Cover twice the affected area
  • Apply every 8 hours
  • Continue for 7 days 1, 3
• Note: If 99% DMSO is not available, 50% concentration may be used, though it may be less effective 1

Monitoring and Follow-up

• Evaluate the site daily for:
  • Changes in erythema
  • Pain levels
  • Signs of tissue necrosis
  • Progression of symptoms
• Schedule follow-up within 7 days for reassessment 2
• Continue monitoring for 3-4 weeks as 5-FU is classified as an irritant with potential for delayed tissue damage 2, 4

Special Considerations

Potential Complications

• Although 5-FU is classified as an irritant rather than a vesicant, it can still cause significant tissue damage in some cases 4
• A case report has documented grade III extravasation injury from 5-FU 4
• Be alert for potential vascular complications, as 5-FU has been associated with endothelial damage 5

When to Consider Surgical Referral

• Unresolved tissue necrosis
• Pain lasting more than 10 days despite conservative management
• Progressive tissue damage
• Signs of compartment syndrome 1, 2

Surgical Management (if required)

• Wide three-dimensional excision of all involved tissue
• Temporary coverage with biologic dressing
• Delayed application of split-thickness skin graft (usually at 2-3 days) 1

Documentation Requirements

• Patient name and identification
• Date and time of extravasation discovery
• Name of drug extravasated (5-FU) and diluent used
• Signs and symptoms reported by patient
• Description of the IV access used
• Estimated extravasation area and amount
• Management steps with time and date
• Photographic documentation if possible 1, 2

While DMSO has shown efficacy in preventing tissue damage from 5-FU extravasation 3, early recognition and treatment are key factors in successful management. The delayed presentation in this case may affect outcomes, but the DMSO protocol has been shown to be effective even when not initiated immediately 1.