Capecitabine-induced diffuse palmoplantar keratoderma: is it a sequential event of hand-foot syndrome?

Drugs Associated With the Development of Palmoplantar Keratoderma: A Systematic Review

BACKGROUND

Palmoplantar keratoderma (PPK) are a heterogenous group of hereditary and acquired disorders that are characterized by excessive epidermal thickening of the palms and/or soles. PPK has been described as a rare adverse event for some medications. The aim of this systematic review was to summarize outcomes in PPK associated with various medications. This data will assist dermatologists and other healthcare providers treating patients with drug-induced PPK.

METHODS

EMBASE and MEDLINE databases were searched in accordance with PRISMA guidelines using the keyword "palmoplantar keratoderma." 40 studies met the inclusion criteria.

RESULTS

A total of 247 patients (mean age: 57.0 years) were included in the analysis. Among patients whose sex was reported, 60.3% (n = 35/58) were male. PPK most frequently developed after treatment with BRAF inhibitors (73.7%, n = 182/247), BRAF inhibitors combined with MEK1/2 inhibitors (15.4%, n = 38/247), tyrosine kinase inhibitors (TKIs) (3.2%, n = 8/247), or chemotherapy (2.4%, n = 6/247). The mean latency period between initiation of the drug and onset of PPK was 7.6 months (range: 0.25-90 months). Improvement of PPK was reported in 24 cases, with 50% (n = 12/24) achieving complete resolution and 50% (n = 12/24) achieving partial resolution. All patients who achieved complete resolution stopped the suspected drug, with a mean resolution period of 2.4 months (range: 2 weeks-6 months). The most common treatments for PPK were keratolytic treatments (n = 10) and topical corticosteroids (n = 4).

CONCLUSIONS

PPK was most frequently associated with targeted kinase inhibitors, specifically BRAF, MEK1/2, and tyrosine kinase inhibitors.

Incidence and implications of chemotherapy related hand-foot syndrome

INTRODUCTION

Hand-foot syndrome (HFS) is a well-established cutaneous adverse event of certain chemotherapeutic agents, mainly capecitabine, continuously infused 5-fluorouracil, docetaxel and pegylated liposomal doxorubicin. Erythema, dysesthesia, pain, cracking and desquamation located on palms and soles are the most characteristic manifestations. Although HFS is a reversible and non-life-threatening clinical condition, it can often affect patient's quality of life significantly, hence necessitating therapeutic modifications or even treatment discontinuation. Areas covered: This is review article on current data regarding the clinical characteristics, grading and management of HFS. Special focus has been given to recent literature studying novel therapeutic strategies. Expert opinion: Early recognition, patient education and supportive measures are considered as the key elements in the management of HFS. Up to date, treatment interruption and dose intensity reduction are the mainstay of HFS management. Many topical formulations and systemic treatment regimens have been proposed, with COX-2 inhibitors being the most promising agents. Nevertheless, large prospective randomized controlled trials are needed in order to agree on solid, evidence-based treatment algorithms.

Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs

Conventional chemotherapy continues to be an important part of cancer management, but may cause various cutaneous reactions because it disturbs specific cell cycle phases. The alkylating agents cyclophosphamide, ifosfamide, and thiotepa can produce hyperpigmentation, while hypersensitivity reactions can be seen with platinum alkylating agents. Antimetabolites vary in reactions from exanthematous to bullous skin lesions. 5-fluorouracil and its derivatives and liposomal doxorubicin and daunorubicin are characteristically known to cause hand-foot syndrome, while bleomycin can cause fibrosis and flagellate dermatitis. Several hypersensitivity reactions may also occur from mitotic inhibitors and topoisomerase inhibitors. These different characteristic presentations are important to dermatologists in identifying the correct diagnosis and management for the cancer patient.

Evolving strategies for the management of hand-foot skin reaction associated with the multitargeted kinase inhibitors sorafenib and sunitinib

The multitargeted kinase inhibitors (MKIs) sorafenib and sunitinib have shown benefit in patients with renal cell carcinoma, hepatocellular carcinoma (sorafenib), and gastrointestinal stromal tumor (sunitinib). Their efficacy in other malignancies is currently being investigated because of their broad range of activity. The effectiveness of these drugs is somewhat diminished by the development of a variety of toxicities, most notably hand-foot skin reaction (HFSR). Although HFSR does not appear to directly affect survival, it can impact quality of life and lead to MKI dose modification or interruption, potentially limiting the antitumor effect. Currently, no standard guidelines exist for the prevention and management of MKI-associated HFSR. To address this issue, an international, interdisciplinary panel of experts gathered in January 2008 to discuss and evaluate the best-practice management of these reactions. Based on these proceedings, recommendations for the management of HFSR have been provided to offer patients the best possible quality of life while taking these drugs and to optimize the patient benefit associated with MKI therapy.

Hand foot skin reaction in cancer patients treated with the multikinase inhibitors sorafenib and sunitinib

BACKGROUND

This study examined clinicopathological findings and management of hand foot skin reaction (HFSR) to sorafenib and sunitinib in a dermatology referral center for cancer-related toxic effects.

PATIENTS AND METHODS

We identified 12 patients who developed HFSR in a 1-year period (2007). Medical records and histological specimens were investigated for clinicopathological data and results on management.

RESULTS

We identified 12 patients developing HFSR on treatment with sorafenib (83%) or sunitinib (17%). Majority presented with grade 3 (75%) HFSR and a median Skindex score of 43. Biopsies in seven patients showed horizontal layers of keratinocyte necrosis, which correlated to time of drug exposure: early (<30 days from initiation) leading to stratum granulosum-spinosum alterations and late (> or =30 days) resulting in stratum corneum pathology. Treatment with topical urea singly (n = 3), plus tazarotene (n = 7), or fluorouracil (n = 2) resulted in > or =2 grade improvement in the majority of patients (58%), with five patients (42%) improving one grade (P = 0.007). Median Skindex score at follow-up was 32 (P = 0.22).

CONCLUSIONS

There are unique clinicopathological characteristics of HFSR due to the multikinase inhibitors that correlate with time of agent initiation. Treatment with topical agents having keratolytic, antiproliferative, and anti-inflammatory properties showed benefit.