What is the treatment for a rash on the hands and feet in adults?

Treatment for Rash on Hands and Feet in Adults

For adults presenting with a rash on the hands and feet, the primary treatment approach depends on the underlying cause: if the rash is due to hand-foot-mouth disease (HFMD), management is supportive only as this is a self-limiting viral illness; if related to chemotherapy (hand-foot skin reaction/palmar-plantar erythrodysesthesia), apply urea 10% cream three times daily; and if inflammatory or pruritic without clear etiology, consider topical hydrocortisone applied 3-4 times daily for symptomatic relief. 1, 2, 3, 4

Diagnostic Approach: Key Features to Identify

Viral Etiology (Hand-Foot-Mouth Disease)

• Look for: Fever, sore throat, papulovesicular or maculopapular rash specifically on palms and feet, with or without oral lesions 5, 3, 4
• Important context: HFMD in adults is increasingly recognized and caused by various Coxsackievirus serotypes (not just A16), presenting with atypical features that can mimic chickenpox, impetigo, or vasculitis 5, 3
• Age consideration: While classically a pediatric disease, adult cases are rising with variable clinical presentations 3, 4

Chemotherapy-Related Reactions

• Look for: History of cancer treatment, particularly with doxorubicin, taxanes, or EGFR inhibitors 6, 1
• Presentation: Palmar-plantar erythrodysesthesia syndrome (PPES) or hand-foot skin reactions (HFSR) 1

Inflammatory/Pruritic Causes

• Look for: Intense itching, absence of fever, potential drug exposures, or systemic disease 7
• Red flags: Petechial/purpuric components, systemic illness, or bullous features require urgent evaluation for life-threatening conditions 8

Treatment Algorithm

For Viral HFMD (Most Common in Adults)

• Supportive care only - reassure patient about self-limiting nature 4
• No specific antiviral treatment indicated 5, 3, 4
• Symptomatic relief with analgesics for fever and pain 4
• Expected resolution within 7-10 days 3, 4

For Chemotherapy-Related Hand-Foot Reactions

• Prevention and treatment: Urea 10% cream applied three times daily 6, 1
• For severe hyperkeratosis: Urea 10-40% cream as keratolytic 6
• For doxorubicin/taxane reactions: Apply urea cream at least twice daily 6
• Adjunctive care: Urea-containing lotions to soothe associated pruritus 1

For Inflammatory/Pruritic Rashes Without Clear Cause

• First-line topical therapy: Hydrocortisone cream applied to affected areas 3-4 times daily 2
• For dry skin component: Urea-containing moisturizers applied daily, increased to 2-3 times daily for severe xerosis 1
• Application timing: Apply after bathing when skin is slightly damp for optimal moisture retention 1

For Generalized Pruritus Without Obvious Dermatosis

• Initial workup required: Full blood count, ferritin, urea and electrolytes, liver function tests to exclude systemic causes 7
• Iron deficiency consideration: If ferritin below normal range (15-25 µg/L), trial iron replacement as this can rapidly resolve pruritus 7
• Drug-induced possibility: Consider trial cessation of recent medications if risk-benefit acceptable 7

Critical Pitfalls to Avoid

Misdiagnosis Risks

• Do not dismiss HFMD in adults - the morphology can be highly variable and mimic other conditions including chickenpox or vasculitis 5, 3
• Avoid missing life-threatening causes: If rash has petechial/purpuric features, fever, or systemic signs, consider meningococcemia, Rocky Mountain spotted fever, or other emergent conditions 8
• Drug reactions: Always obtain complete medication history including over-the-counter products, as any ingested chemical can cause cutaneous eruptions 9

Treatment Errors

• Steroid caution: In patients with fever and suspected infection, systemic steroids can mask symptoms and are risky in neutropenic patients 9
• Rechallenge danger: Never rechallenge with drugs that caused urticarial, bullous, or erythema multiforme-like eruptions 9
• Urea cream safety: While generally safe, high concentrations (10-40%) should be used cautiously; no toxicity reports exist in standard use 10

Special Populations

Oncology Patients

• Proactive approach: Urea 10% cream three times daily for prevention of chemotherapy-related skin reactions 6, 1
• Oil-in-water formulations preferred over alcohol-containing products for dry skin 1

Patients with Systemic Disease

• Dermatomyositis consideration: Gottron papules on hands with periungual telangiectasias suggest this diagnosis, requiring immunosuppressive therapy 7
• Enteroviral infections: Lesions on hands, feet, and mouth may indicate Enterovirus 71 or other enteroviruses 7