Glove-Like Distribution of Burning Pain in Chemotherapy-Induced Peripheral Neuropathy
A "glove-like" or "stocking-glove" distribution of burning pain refers to chemotherapy-induced peripheral neuropathy (CIPN) that affects the distal extremities (hands and feet) in a symmetrical, bilateral pattern, starting in the fingers and toes and potentially progressing proximally if the condition worsens. 1
Clinical Pattern and Characteristics
The glove-like distribution describes a length-dependent axonal neuropathy where symptoms follow a predictable anatomic pattern:
- Distal-to-proximal progression: Symptoms begin in the fingertips and toes (the most distal parts of the extremities) and advance toward the body if severity increases 1, 2
- Bilateral and symmetrical presentation: Both hands and/or both feet are affected equally, distinguishing this from focal nerve injuries 3, 1
- Sensory predominance: The primary manifestations include numbness, tingling, burning pain, and impaired perception of light touch, vibration sense, and proprioception 4, 3
Symptom Onset and Evolution in Your Patient
For this 31-year-old woman receiving chemotherapy for breast cancer:
- Symptoms typically emerge within the first 2 months of treatment with neurotoxic chemotherapy agents (taxanes, platinum-based drugs, or vinca alkaloids) 1
- Numbness and tingling appear first, followed by burning pain as the condition progresses 1
- Motor symptoms are uncommon but may include weakness or tremor in advanced cases 1
Mechanism and Risk Factors
The exact pathophysiology remains incompletely understood, but CIPN represents damage to peripheral sensory nerves caused by chemotherapy agents, particularly taxanes (like paclitaxel) and platinum compounds (like cisplatin or oxaliplatin), which are commonly used in breast cancer treatment 4, 5
Co-existing conditions amplify risk, including:
- Concurrent alcohol use
- Renal insufficiency
- Hypothyroidism
- Vitamin B12 deficiency
- HIV infection
- Autoimmune conditions 3
Immediate Management Priorities
Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily, is the only medication with Level 1 evidence showing 30-50% relative risk reduction in neuropathic pain, numbness, and tingling 4, 1, 6
Physical activity has Level IA evidence for improving neuropathy symptoms and should be offered immediately 4, 1
Assess severity at every encounter using a simple pain scale to determine impact on quality of life and functional status 4, 1
Prognosis Considerations
The clinical course depends on the specific chemotherapy agent:
- For taxane-based regimens (common in breast cancer): Symptoms typically improve over several months after chemotherapy completion 1
- For platinum-based regimens: Expect a "coasting phenomenon" where symptoms paradoxically worsen for 2-3 months AFTER stopping chemotherapy before stabilizing 1
- Long-term outcomes: 15-40% of patients experience persistent symptoms despite treatment cessation, though most improve gradually with time and rehabilitation 6
Critical Pitfall to Avoid
Do not delay duloxetine initiation while waiting for "natural improvement"—early pharmacologic intervention provides the best opportunity for symptom control and quality of life preservation 4, 1, 6