What is the best course of action for a female patient in her 30s with a history of ovarian cancer and recent chemotherapy, experiencing nightly redness to her knees and feet?

Palmar-Plantar Erythrodysesthesia (Hand-Foot Syndrome)

This patient is experiencing palmar-plantar erythrodysesthesia (hand-foot syndrome), a well-recognized chemotherapy toxicity that requires immediate symptomatic management and potential chemotherapy dose modification. 1

Diagnosis and Clinical Features

The nightly redness affecting the knees and feet in this post-chemotherapy ovarian cancer patient is characteristic of hand-foot syndrome, particularly given:

• Symmetric distribution on pressure-bearing areas (soles of feet, knees) is the hallmark distinguishing feature 1
• Timing of 2-6 weeks post-chemotherapy aligns with typical onset patterns 1
• Common causative agents in ovarian cancer include liposomal doxorubicin (preferred for recurrent disease), paclitaxel, and docetaxel—all standard agents for this patient population 1, 2

Associated symptoms to assess include tingling, burning, or numbness suggesting concurrent peripheral neuropathy, which frequently coexists with hand-foot syndrome 1.

Immediate Management Strategies

Non-Pharmacologic Interventions (First-Line)

• Reduce pressure and friction on affected areas by avoiding tight footwear and minimizing walking/standing 1
• Apply cool compresses to affected areas for symptomatic relief 1
• Use topical emollients and moisturizers liberally to maintain skin integrity 1
• Elevate extremities when resting to reduce dependent edema 1

Pharmacologic Management

For neuropathic pain component (if present):

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily has demonstrated 30-50% reduction in neuropathic pain in randomized controlled trials 1
• Physical activity programs have shown improvement in neuropathy symptoms 1

Chemotherapy Modification Protocol

Grade 3 hand-foot syndrome requires immediate chemotherapy adjustment: 1

1. Hold chemotherapy until symptoms improve to Grade 1 or less 1
2. Reduce dose by 25% upon rechallenge 1
3. Switch to alternative agent if symptoms recur despite dose reduction 1

Critical Monitoring Requirements

• Assess for infection in any areas of skin breakdown, as these patients are at high risk for secondary bacterial infections 1
• Monitor renal function, electrolytes, and myelosuppression particularly if the patient received intraperitoneal chemotherapy 1
• Screen for other chemotherapy toxicities including hepatic damage, metabolic abnormalities, and dehydration 1

Important Clinical Pitfalls

The chronic pain and fatigue experienced by one-third of ovarian cancer survivors can be multifactorial 3. While addressing the hand-foot syndrome, also evaluate for:

• Depression, anemia, and infection as differential diagnoses for fatigue 3
• Post-chemotherapy cognitive impairment which affects many patients and may require neurologist referral if severe 3
• Sleep disturbance and psychological distress which commonly coexist with physical symptoms in long-term survivors 3

Do not dismiss these symptoms as minor cosmetic issues—hand-foot syndrome significantly impacts quality of life and can progress to severe debilitating pain with skin breakdown if not managed aggressively 1.