Dermatological toxicity from chemotherapy containing 5-fluorouracil

Cancer Treatment Related Pain

When discussing cancer treatment, it is important to be aware of the potential toxicities and side effects associated with these treatments.

Unilateral hand-foot syndrome: an extraordinary side effect of capecitabine

BACKGROUND

Hand-foot syndrome (HFS), the most common toxicity of capecitabine, is characterized by tingling, numbness, pain, erythema, dryness, rash, swelling, increased pigmentation, and/or pruritus of the palmar and/or plantar surfaces of the hands and/or feet. HFS is usually seen in both the hands and the feet, with varying severity. We have previously published a case report of dihydropyrimidine dehydrogenase (DPD) deficiency that manifested a variant of HFS.

CASE REPORT

We report the case of a 65-year-old Turkish Cypriot male patient with advanced gastric cancer who developed pain, numbness, and reddening in his left palm and left sole 10 days after the fourth cycle of capecitabine at a dose of 1,000 mg/m(2)/day twice daily (BID) on days 1 to 14 every 21 days. On physical examination, he had unilaterally erythematous changes and skin scaling on his left sole and palm consistent with grade II HFS. After stopping administration of capecitabine and supportive management, the HFS resolved in a week's time.

CONCLUSIONS

To the best of our knowledge, this is the first case of capecitabine-induced unilateral HFS. Further investigation related to this toxicity associated with capecitabine is warranted.

Focal acral hyperpigmentation in a patient undergoing chemotherapy with capecitabine

Capecitabine is a prodrug of fluorouracil. Systemic immunosuppression has been reported as a cause of eruptive pigmented lesions, although the mechanisms causing this eruption are not known. A 58-year-old woman undergoing chemotherapy with capecitabine presented with multiple pigmented macules on the skin and tongue, and generalized hyperpigmentation, which finally faded after the drug was discontinued. Capecitabine may induce the growth of normal and dysplastic melanocytic nevi, and lentiginous melanocytic hyperplasia. Careful follow-up is mandatory, since the risk of developing melanoma in these cases remains uncertain.

Candidate mechanisms for capecitabine-related hand-foot syndrome

AIMS

The oral fluoropyrimidine prodrug capecitabine is widely used in oncology. Capecitabine was designed to generate 5FU via the thymidine phosphorylase (TP) enzyme, preferentially expressed in tumoral tissues. Hand-foot syndrome (HFS) is a limiting toxicity of capecitabine. A pilot study on healthy volunteers was conducted in order to test the hypothesis that the occurrence of HFS could be related to tissue-specific expression of drug-metabolizing enzymes in the skin of the palm and sole. To this end, the expression of TP (activating pathway), dihydropyrimidine dehydrogenase (DPD, catabolic pathway) and cell proliferation (Ki67) were measured in the skin of the palm (target tissue for HFS) and of the lower back (control area).

METHODS

Two paired 4-mm diameter punch biopsy specimens (palm and back) were taken in 12 healthy volunteers. Immunohistochemical analyses were performed on frozen tissues.

RESULTS

Proliferation rate (Ki67 staining) was significantly higher in epidermal basal cells of the palm compared with the back (P = 0.008). Also, TP and DPD expression were significantly greater in the palm relative to the back (P = 0.039 and 0.012, respectively). TP and Ki67 expression were positively and significantly correlated in the palm.

CONCLUSIONS

The high proliferation rate of epidermal basal cells in the palm could make them more sensitive to the local action of cytotoxic drugs. TP-facilitated local production of 5FU in the palm during capecitabine treatment could explain the occurrence of HFS. This observation may support future strategies to limit the occurrence of HFS during capecitabine therapy.

Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre

Palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome (HFS) is a relatively common side effect of cytotoxic chemotherapy. Many cytotoxic drugs have been reported to cause the condition but it is more frequently associated with 5 fluorouracil (5FU), liposomal doxorubicin and cytarabine. The oral 5FU precursor, capecitabine is frequently associated with PPE and with the recent extension of its use to adjuvant treatment, the incidence of PPE is likely to increase. The initial symptoms are dysesthesia and tingling in the palms, fingers and soles of feet and erythema, which may progress to burning pain with dryness, cracking, desquamation, ulceration and oedema. Palms of the hands are more frequently affected than soles of the feet. This condition is painful and distressing to patients and in some incidences it results in patients not being able to work or perform normal daily activities. It can also result in treatment interruptions which impact on the efficacy of the treatment regimen. Effective and appropriate patient education from a specialist nurse prior to treatment is an essential part of patient management which will facilitate early identification of the symptoms and therefore prevent treatment delays and PPE progression. This article reviews current knowledge of the condition, including classification, and discussion of the findings of a clinical audit in a cancer centre. It includes the incidence, grading, management and impact of PPE on normal daily activities.

Chemotherapy and Cutaneous Toxicities: Implications for Oncology Nurses

OBJECTIVE

To review common cutaneous effects and dermatologic or cutaneous toxicities related to the administration of chemotherapy. These range from mostly cosmetic, such as hyperpigmentation or alopecia, to dose-limiting toxicities such as palmar-plantar erythrodysesthesia or hand-foot syndrome.

DATA SOURCES

Current research, published literature, and internet resources.

CONCLUSION

Assessment and grading of associated toxicities of therapy is an integral part of caring for this patient population. Early intervention may reduce toxicities associated with therapies for this patient population

IMPLICATIONS FOR NURSING PRACTICE

As more patients receive chemotherapy, dermatologic effects are becoming more common. Oncology nurses must be skilled in managing these side effects.

Palmar–plantar erythrodysesthesia due to docetaxel–capecitabine therapy is treated with vitamin E without dose reduction

Palmar-plantar erythrodysesthesia (PPE) is a distinctive and relatively frequent toxic reaction related to some chemotherapeutic agents. Doxorubicin, cytarabine, docetaxel, fluorouracil, and capecitabine are the most frequently implicated agents. Recently, taxanes, especially docetaxel, have been widely used in combination with capecitabine in patients with metastatic breast cancer (MBC). A high percentage of PPE has been seen in patients undergoing this combination therapy. PPE seems to be dose dependent and both peak drug concentration and total cumulative dose determine its occurrence. Withdrawal or dose reduction of the implicated drug usually gives rise to amelioration of the symptoms. Supportive treatments such as topical wound care, elevation, and cold compresses may help to relieve the pain. Use of systemic corticosteroids, pyridoxine (vitamin B6), blood flow reduction, and, recently, topical 99% dimethyl-sulfoxide have been used with variable outcomes. Vitamin E treatment has not been published before, especially without dose reduction of docetaxel-capecitabine therapy. Here we present five MBC patients treated with docetaxel-capecitabine combination therapy in whom PPE was observed during the clinical follow-up period. In all patients grade 2-3 PPE was observed. Vitamin E therapy was started at 300 mg/day p.o. without dose reduction of therapy and after 1 week of treatment PPE began to disappear. We suggest that it could be of interest to consider vitamin E as a preventive drug when drugs with a strong association with PPE are going to be administered.

Management of hand-foot syndrome in patients treated with capecitabine (Xeloda)

Comparative trials of capecitabine (Xeloda) versus 5-FU/LV in metastatic colorectal cancer have shown that hand-foot syndrome (HFS) was the only clinical adverse event occurring more frequently with capecitabine. Most patients with HFS present with dysesthesia, usually with a tingling sensation in the palms and soles of the hands and feet. This can progress in 3-4 days to burning pain plus well-defined symmetric swelling and erythema. The hands tend to be more commonly affected than the feet, and might even be the only area affected in some patients. HFS can interfere with the general activities of daily living, especially when blistering, moist desquamation, severe pain or ulceration occurs. While HFS is manageable, if ignored it can progress rapidly. However, dose interruption and reduction of capecitabine usually leads to a rapid reversal of signs and symptoms without long-term consequences. Nurses play a key role in educating patients how to recognise HFS, when to interrupt treatment and how to adjust the dose to maintain effective therapy with capecitabine over the long term. It is particularly important that patients and nurses are aware that dose interruption/reduction does not affect the overall antitumour efficacy of capecitabine.