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