What is hand-foot syndrome?
Hand-foot syndrome, also known as Palmar-Plantar Erythrodysesthesia or PPE, is a common side effect of some cancer treatments.
Hand-foot syndrome causes redness, swelling and pain on the palms of the hands and/or the soles of the feet. Sometimes blisters appear. It usually affects the palms of the hands and soles of the feet, but it may also affect other areas such as the skin on the knees or elbows.
What are the symptoms of hand-foot syndrome?
Common symptoms of mild or moderate hand-foot syndrome include:
Redness similar to a sunburn
Swelling
Numbness
A feeling of tingling or burning on the palms and soles
Discomfort / tenderness or sensitivity to touch
Tightness or a feeling of stiffness in the skin
Thick calluses and blisters on the palms of your hands and soles of your feet
Itching
Rash
Symptoms of more severe hand-foot syndrome can include:
Cracked, flaking, or peeling skin
Blisters, ulcers, or sores on the skin
Severe pain
Difficulty walking or using your hands
Nails lifting from the nail bed
Slow-healing wounds
What causes hand-foot syndrome?
The exact way that hand-foot syndrome develops isn’t well understood, but the skin on the palms of the hands and soles of the feet contain small blood vessels (capillaries) which deliver blood to the skin. Hand-foot syndrome happens when small amounts of chemotherapy drugs leak out of these capillaries affecting the skin on the hands and feet. Once a drug is out of the blood vessels, it damages the surrounding tissues. This causes the symptoms of hand-foot syndrome.
Skin cells in the palms and soles tend to divide more quickly than other parts of the skin, which makes them particularly prone to damage from chemotherapy drugs.
Feet also have a high concentration of eccrine sweat glands and some chemotherapy drugs may accumulate in these glands.
What chemotherapy drugs can cause hand-foot syndrome?
Some drugs are more likely to cause hand-foot syndrome than others. The chemotherapy drugs most likely to cause hand-foot syndrome are:
Capecitabine (Xeloda)
Cytarabine (available as a generic drug)
Docetaxel (Taxotere)
Doxorubicin (available as a generic drug)
Fluorouracil (5-FU)
Floxuridine (available as a generic drug)
Idarubicin (Idamycin)
Liposomal doxorubicin (Doxil)
Paclitaxel (Taxol)
Vemurafenib (Zelboraf)
The targeted therapies that are more likely to cause hand-foot syndrome include:
Axitinib (Inlyta)
Cabozantinib (Cabometyx, Cometriq)
Regorafenib (Stivarga)
Sorafenib (Nexavar)
Sunitinib (Sutent)
Pazopanib (Votrient)
When does hand-foot syndrome occur?
Hand-foot syndrome may appear within days of commencing chemotherapy, although it can take several months and a number of chemotherapy cycles. It most commonly develops after six weeks of treatment. The first symptom is tingling, numbness, a feeling of tightness/stiffness or pain in the palms/fingers and sometimes a little later also the soles of feet/toes. This is followed 2-4 days later by bright redness of the palms and soles, which is symmetrical and sharply defined. Burning pain and swelling can develop. If severe it may blister and rarely ulcerate.
The palms are always involved and less consistently the soles, fingers, toes, tops of feet and backs of hands. Uncommon sites include the face, genital area, and sites affected by pressure or friction such as folds of skin and under tight clothing.
With each subsequent cycle of chemotherapy, the reaction will appear more quickly, be more severe and will take longer to heal.
Are some people more likely than others to develop hand-foot syndrome?
It's important to remember that not everyone who takes these medications develops hand-food syndrome. The severity of hand-foot syndrome can be different for everyone - even people taking the same drug for the same form of cancer may not have the same symptoms.
However, hand-foot syndrome tends to occur more often in patients who are taking capecitabine, commonly called 'cape'. It's also more common in patients who receive 5-FU through a pump over time, as opposed to all at once, in what's called a 'bolus' dose.
The occurrence of hand-foot syndrome tends to relate to the dose of chemotherapy drug — both the peak blood level and the cumulative dose appear to be important, with a higher cumulative dose being associated with a higher likelihood of developing hand-foot syndrome.
In addition it's thought that when your hands and feet are exposed to heat or friction, the amount of drug present in the capillaries increases – which in turn can increase the amount of drug leakage.
What is the treatment for hand-foot syndrome?
Until recently, the only treatment shown to be of any benefit for hand-foot syndrome was stopping chemotherapy treatment, waiting until the reaction has improved and recommencing therapy at a lower dose and/or frequency or switching to a different type of chemotherapy drug. However, many patients worry that taking a treatment break or changing treatment, can make the cancer treatment less effective, and so many patients prefer to adopt a strategy based on symptom control.
If there’s swelling or inflammation, topical steroid creams may be prescribed. Moisturisers are recommended for dryness and creams containing urea can help get rid of rough skin. Pain medications may also be prescribed to treat the pain.
It's important to let your medical team know if you’re experiencing skin changes during chemotherapy treatment. Recognising symptoms early and setting up good skin care routines are key to prevent worsening of hand-foot syndrome.
Tips and remedies for coping with hand-foot syndrome
Hand-foot syndrome can be uncomfortable, but there are ways to help manage your symptoms at home.
1. Take care of your skin
Moisturise: Try to apply moisturising cream at least three times per day and always after washing hands or feet. Creams that contain 10% urea may help reduce hand-foot syndrome symptoms if they are applied regularly every day.
Don't pick at dry skin: Urea creams can help with dryness, itching, and scaling.
Do not break open any blisters: Apply a petroleum-based ointment, such as Vaseline, and cover it with a bandage.
Soak your hands and feet at least once a day: Soak them in cool water for 20 - 30 minutes. Then pat them dry and apply a fragrance-free moisturiser.
Pat skin dry: Pat your skin gently when applying lotion or using a towel. Don’t rub your skin.
Avoid harsh chemicals: Avoid contact with harsh chemicals, as these could make irritation worse.
2. Avoid prolonged exposure to heat
Exposure to heat or high temperatures can dry out the skin on hands and feet. Heat also increases the amount of medication in the blood vessels and can increase leakage.
Avoid hot water: Do not soak your hands and feet in hot water. Do not take hot baths try a lukewarm shower instead.
User rubber gloves: It's advisable to wear gloves to wash dishes.
Stay out of direct sunlight: Protect your hands and feet from the sun and apply sunscreen and cover your feet when outside.
Cool your hands and feet: Applying ice packs wrapped in a towel or cold compress, to the hands or feet for up to 15 minutes at a time can offer some relief. Applying ice packs or cold compresses to the wrists and ankles can also help as this will reduce blood flow to the hands and feet.
3. Avoid putting pressure on hands and feet
Reducing exposure of hands and feet to pressure is also suggested.
Avoid rubbing your hands and feet: Do not do anything that would make you rub your palms or soles, except for putting on lotion or cream.
Wear slippers: Wear socks or slippers instead of walking barefoot.
Wear socks: Wear thick, soft cotton socks with all your shoes.
Wear supportive, comfortable shoes: Avoid wearing high heels which may cause more pressure on the forefoot. Try adding foam-type absorbing soles and shock absorbers to your shoes to relieve pressure points.
Protect your hands: Wear thick cotton gloves when doing activities outside or in the house. This includes cleaning the house, gardening, or going food shopping.
Avoid tight fitting gloves, socks or shoes: Reduce stress to your feet by wearing loose-fitting gloves, socks and shoes.
Avoid using tools that require you to squeeze your hand on a hard surface: Tools such as screwdrivers, knives and hammers can put pressure on the palm of your hand.
Avoid activities that cause friction on your palms or soles: Try not to do things that cause friction or make you rub your hands or feet for the first 2 months of treatment. This includes any strenuous exercise where your feet frequently pound the ground (e.g. running, aerobics or jumping) and contact sports (such as rugby or football). It's also advisable to avoid long walks to protect the skin on your feet and even standing in one position for very long.
Rest your feet: Stay off your feet while your feet are irritated.
Elevate: Elevate the hands or feet when sitting or lying down.
4. Medication
Over-the-counter pain medications: It may be possible to take medications to reduce pain and discomfort. Try topical pain relievers or pain relief patches. Check with your medical team first to find out if it is an option.
Steroid medications: People can apply steroid creams topically to the hands or feet, or take them orally, to reduce inflammation and pain. Check with your medical team first to find out if it is an option.
Milk thistle: Some evidence suggests that certain natural extracts may help to ease hand-foot syndrome. A 2017 study found that silymarin, a compound that comes from milk thistle, reduced hand-foot symptoms when people applied it as a 1% strength gel to their feet twice daily for 9 weeks.
What can I do to help prevent hand-foot syndrome?
There are things people can do to reduce their chances of developing hand-foot syndrome while they have chemotherapy. It’s a good idea to ensure that any existing hand or feet skin conditions are treated before starting chemotherapy.
In addition, many of the strategies discussed above that help to manage hand-foot syndrome can also potentially prevent hand-foot syndrome. For example, patients receiving the types of chemotherapy or targeted therapy mentioned above are encouraged to begin regularly applying moisturiser to hands and feet from the first day of treatment. Use thick, unscented creams at least twice a day and avoid using scented lotions because they can contain alcohol, which can be drying.
Try putting ice packs under your hands and feet while receiving chemotherapy especially with paclitaxel, docetaxel or doxorubicin.
Some research suggests that taking vitamin B6 might help prevent hand-foot syndrome, but the data is mixed.
What is the best lotion for hand-foot syndrome?
Use a fragrance-free lotion that doesn’t contain alcohol. Alcohol can dry your skin and worsen your symptoms. Some studies show that applying 10% urea cream on your skin three times a day can help your skin feel better.
What is the outlook for people with hand-foot syndrome?
Hand-foot syndrome isn't a life threatening condition, but it can be very painful and seriously impact on quality of life.
Symptoms tend to go away once chemotherapy treatment is finished, however symptoms may continue for a short time after treatment as your body heals itself. Symptoms usually start to improve between two to five weeks after stopping chemotherapy. Taking care of your skin can prevent long-term effects, like scarring.
Some people temporarily lose their fingerprints with hand-foot syndrome. This can be an inconvenience if you need to be fingerprinted for some reason, like international travel, but fingerprints usually return within a few months after treatment ends.
Above all, keep your medical team informed about the symptoms you’re experiencing during chemotherapy. It’s important they know if you:
Have symptoms that are worsening.
Are bleeding as a result of your skin cracking or peeling.
Have symptoms that are interfering with your everyday life.