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Palmar-Plantar Erythrodysaesthesia (PPE) or Hand Foot Syndrome

Symptoms include: redness, swelling, tingling or burning sensation, tenderness, sensitivity to touch, tightness of the skin, thick calluses or blisters on the palms of hands and/or soles of feet, cracking, flaking or peeling of the skin, soreness or severe pain.

Questions

  • Has the patient received systemic anticancer therapy?
  • Is the patient receiving any of the following: 5-fluorouracil; capecitabine; Caelyx; sunitinib; doxorubicin, epirubicin?
  • When was the last dose of chemotherapy?
  • Is the patient on a continuous chemotherapy infusion (i.e. 5-fluorouracil)?
  • Is the patient taking oral chemotherapy? Is the patient still taking the tablets?
  • Has the patient any other symptoms such as temperature, mucositis or diarrhoea? If YES refer to specific management guidelines)
  • Did the patient experience the same adverse event during previous treatments?

Grade 1 (Green)

Minimal skin changes

Or dermatitis (e.g. erythema) without pain

Advice

  • Reassure patient this is normal, nothing to worry about and associated with treatment
  • Emphasise the importance of skin care* (moisturising cream, pat hands to dryness and avoid rubbing)
  • Patient to re-contact the service if symptoms worsen

Grade 2 (Amber)

Skin changes (peeling, blister, bleeding, edema)

Or pain, not interfering with function

Advice

  • Stop the treatment until discussed with prescribing team and consider withholding resolved to grade 1 or 0
  • Reassure patient this is associated to treatment, reversible, generally nothing to worry about
  • Emphasise the importance of skin care*
  • Consider pyridoxine

Grade 3 (Red)

Ulcerative dermatitis

Or skin changes with pain, interfering with function

Advice

  • Ensure patient is not neutropenic
  • Stop the medication and inform prescribing team
  • Review current analgesia – consider paracetamol with caution as could mask a temperature
  • Emphasise the importance of continuing skin care*
  • Withhold further treatment until resolved to grade 1 or 0
  • Consultant in charge to consider dose  reduction for further cycles or discontinuation of drug
  • Consider pyridoxine

Grade 4 (Red)

N/A

Advice

N/A

Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding.

Arrange follow up review as necessary.


INITIAL ASSESSMENT- Patient seen in AOCU

  • Read specific drug information sheet in addition to general guidance
  • Interrupt SACT/chemotherapy including oral chemotherapy drugs, if applicable, until discussed with the Acute Oncology Service Team

Initial assessment

  • Observation: temperature, Pulse, Saturation of Oxygen, respiration rate. Early Warning Score (nEWS)
  • Investigations: FBC, U&E, CRP

History to include:

  • What chemotherapy is the patient on and when was the last treatment/tablet?
  • See drug specific information sheet
  • Is the patient on any of the following:5-fluorouracil; capecitabine; caelyx; sunitinib; doxorubicin; epirubicin?
  • Is there any other associated symptoms such as diarrhoea, mucositis, temperature?
  • What part of the body is affected? Solely hands, feet or both?
  • Is the patient able to walk normally? To do his/her buttons up?
  • Any recent new medications?
  • Check bloods (FBC, U&E, CRP, blood cultures if suspecting neutropenic sepsis)
  • Full physical examination

Treatment

  • Emphasise skin care management*
  • Pyrexia (T> 38°C) and grade 3 – initiate neutropenic sepsis protocol – do not wait for FBC
  • Pyridoxine 50 mg TDS

*Skin care advice:

  • moisturising cream,
  • pat hands to dryness and avoid rubbing