What is the best course of action for a patient with itching of hands and feet for 1 week?

Itching of Hands and Feet for 1 Week

Initial Diagnostic Approach

Begin by performing a thorough skin examination to distinguish primary skin lesions (indicating diseased skin) from secondary lesions caused by scratching, as this distinction is critical for determining whether the pruritus is dermatologic, neuropathic, or systemic in origin. 1

Key History Elements to Obtain

• Exposure history: Ask specifically about new medications, chemotherapy agents, contact with infected individuals, use of communal showers, athletic activities (especially wrestling, swimming, or marathon running), and occupational exposures to chemicals or irritants 2, 1
• Timing and pattern: Document when itching began, diurnal variation, and factors that worsen or improve symptoms 3
• Associated symptoms: Inquire about fever, weight loss, fatigue, or other systemic symptoms that might suggest underlying disease 4

Physical Examination Priorities

Examine the following areas carefully:

• Palms and soles: Look for erythema, scaling, blistering, or callus-like hyperkeratosis at pressure-bearing areas (heels, joints) which suggests hand-foot syndrome from chemotherapy 2
• Interdigital spaces: Check for scaly, pruritic eruptions suggesting tinea pedis/manuum 2
• Groin and feet: Assess for scaly plaques indicating dermatophyte infection 2
• Finger webs, anogenital region, nails, and scalp: Essential for comprehensive evaluation 1

Most Likely Diagnoses and Management

If Primary Skin Lesions Are Present

Tinea Pedis/Manuum (Fungal Infection)

For scaly, itchy eruptions on hands and feet, treat with topical antifungals as first-line therapy:

• 0.77% ciclopirox cream or gel twice daily for 4 weeks, OR 2
• 1% terbinafine gel once daily for 1 week, OR 2
• Naftifine ointment twice daily for 4 weeks 2

Important caveat: Itching may persist for weeks after treatment due to hypersensitivity reaction and does not indicate treatment failure 2

Prevention measures include:

• Daily sock changes and careful drying between toes after showers 2
• Wearing rubber-soled flip-flops in communal showers 2
• Applying foot powder after bathing 2

Chemotherapy-Induced Hand-Foot Syndrome

If the patient is receiving capecitabine, doxorubicin, taxanes, or MEK inhibitors:

For Grade 1-2 (minimal skin changes with pain):

• Continue current medication dose 2
• Apply topical high-potency steroid twice daily 2
• Reassess after 2 weeks; escalate if no improvement 2

For Grade 3 or intolerable Grade 2:

• Interrupt treatment until severity decreases to Grade 0-1 2
• Continue topical high-potency steroid twice daily 2
• Consider adding lidocaine 5% patches or cream for pain relief 2

If No Primary Skin Lesions Are Present

Initial Laboratory Workup

Order the following tests to evaluate for systemic causes:

• Complete blood count with differential 1, 5, 4
• Comprehensive metabolic panel (creatinine, blood urea nitrogen, liver function tests) 1, 5, 4
• Fasting glucose or A1C 1, 5
• Thyroid-stimulating hormone 1, 5, 4
• Iron studies 1

Additional testing if history suggests:

• HIV screening, hepatitis serologies, chest radiography 1
• Heightened concern for malignancy in patients >60 years with chronic generalized pruritus lasting <12 months 1, 4

Empiric Treatment While Awaiting Results

For likely neuropathic or mixed etiology pruritus:

Apply topical neuropathic agents:

• Menthol, pramoxine, or lidocaine to affected areas 5
• Can combine with hydrocortisone 2.5% or triamcinolone 0.1% if inflammatory component suspected 5

General supportive measures:

• Apply 10% urea cream at least twice daily, ideally after bathing when skin is slightly damp 6
• Avoid hot water, frequent washing, and skin irritants 2
• Use alcohol-free moisturizers liberally 2
• Limit water exposure 1

Oral antihistamines may provide symptomatic relief 1

Common Pitfalls to Avoid

• Do not apply urea ≥10% to inflamed skin, open fissures, or facial flexures, as this causes irritation and burning 6
• Do not dismiss persistent itching after antifungal treatment as treatment failure—hypersensitivity reactions can persist for weeks 2
• Do not overlook systemic causes in patients >60 years with generalized pruritus of recent onset (<1 year), as this may indicate underlying malignancy 1, 4
• Avoid using pyridoxine for prevention of chemotherapy-induced hand-foot syndrome, as randomized studies show no benefit 2

When to Refer

Refer to dermatology if:

• No response to topical therapies after 2-4 weeks 5
• Systemic treatments (dupilumab, methotrexate, gabapentin) are being considered 5
• Diagnosis remains unclear after initial workup 1