Management of Hand-Foot Syndrome in Athletes

Introduction:

Hand-foot syndrome (HFS) is a significant skin condition that is rarely life-threatening. It can substantially affect the quality of life and cause considerable pain and functional impairment, especially in elderly people often treated by chemotherapies like Pegylated liposomal doxorubicin, Docetaxel, and Fluoropyrimidines. Clinical symptoms worsen after the medicine has stopped working and recur with repeated exposure. There is a higher risk of HFS when some medications are continuously dosed, such as continuous infusion of 5-FU (5 Fluorouracil), or when certain medications maintain high serum levels, including Capecitabine (an oral 5-FU prodrug). Systemic and topical therapies, dosage reductions, and switching to alternate medications in the same class decrease the effect of HFS. The type and duration of the treatment play a major role in the HFS.

What Is Hand-Foot Syndrome?

Hand-foot syndrome (HFS) is a significant skin condition, rarely life-threatening, due to the side effects of chemotherapy medications. It manifests as redness, swelling, blister, and pain in the palms and soles. The hand-foot syndrome can decrease the quality of life and affect day-to-day activities. It is also known as Palmar-Plantar Erythrodysesthesia or PPE.

What Is the Cause of Hand-Foot Syndrome?

When the patient is under chemotherapy or cancer treatment, small quantities of chemotherapy medications leak out of the capillaries of the hand and sole, causing the hand-foot syndrome, which affects the hands and feet's skin. The dosage and length of therapy may affect the severity of hand-foot syndrome. The common chemotherapy medications that cause hand-foot syndrome are:

• Capecitabine or Xeloda.

• Cyclophosphamide.

• Docetaxel or Taxotere.

• Doxorubicin or Adriamycin.

• Liposomal doxorubicin

• Paclitaxel or Taxol.

• Vinorelbine or Navelbine.

• 5 Fluorouracil, also known as 5FU.

Other targeted therapies which can also cause hand-foot syndrome include:

• Axitinib.

• Cabozantinib.

• Regorafenib.

• Sorafenib.

• Sunitinib.

• Pazopanib.

What Are the Signs and Symptoms of Hand-Foot Syndrome?

After a few days or weeks of treatment, symptoms might begin to manifest. Sometimes, symptoms appear months or even years after using a medicine. The most common symptoms are:

• Burning or tingling sensation in the soles and palms of the feet.

• Redness.

• Skin rigidity (like sunburn).

• Swelling or numbness.

• Blisters on the palms and soles.

• Tenderness.

• Itching sensation or rash.

• Flaking, peeling or cracking of the skin.

• Skin sore and ulcer.

• Restricted joint movement.

How to Diagnose Hand-Foot Syndrome?

The presenting symptoms and previous treatments are used to make a diagnosis. Early detection and treatment decrease the intensity of the symptoms. The symptoms are evaluated according to grading listed by the national cancer institute's common toxicity criteria, to identify the patients who are at an increased risk of developing HFS.

How to Manage and Prevent Hand-Foot Syndrome?

In most cases, the hand-foot syndrome worsens in the first six weeks of receiving targeted therapy. However, it often develops after 2 to 3 months of chemotherapy. The following strategy helps to manage the condition:

• When cleaning dishes or taking a bath, use a small amount of hot water on the hands and feet.

• Take cold baths or showers. Dry skin gently with a towel after a shower.

• Cool down the feet and hands. For 15 to 20 minutes, use moist towels, ice packs, or cold running water to cool down the feet and hands.

• Avoid prominent skin exposure.

• Avoid exposure to the strong chemicals found in home cleaners or laundry detergents.

• Avoid cleaning with hot water while wearing vinyl or rubber gloves without a lining. Heat and sweat are trapped against the skin by rubber; hence consider wearing white cotton gloves over rubber gloves.

• Avoid activities like running, aerobics, and racquet sports, frequently contacting the palm and sole during the first week of therapy.

• Take caution while using household objects or tools like knives, screwdrivers, and gardening tools that involve pressing the hand against a hard surface.

• Stay in highly ventilated areas that allow air to circulate freely on skin, dress, and wear loose-fitting, well-ventilated clothing.

• Stay cautious in applying or massaging the lotion on hands or feet.

• Avoid walking barefoot to prevent foot friction; use soft slippers and thick socks.

• Consult a podiatrist (medical professional focusing on issues with the foot) before starting cancer therapy.

What Is the Treatment Option for Hand-Foot Syndrome?

The treatment strategy is based on treating symptoms, minimizing consequences, and preventing symptoms from worsening. By altering lifestyle, interventions should focus on avoiding irritation to the hands and feet. The major therapy involves dose alteration, Pyridoxine supplement, regional cooling, Celecoxib (Celebrex), and oral corticosteroids. Topical anti-inflammatory medications reduce pain and inflammation, and 10 % topical urea prevents moisture loss from the skin.

• Dose Modification: The most definitive therapy suggested for the treatment. With dose modification therapy, the symptoms of hand-foot syndrome disappear within 2 to 4 weeks after the drug administration. Drugs like Sorafenib and Sunitinib interrupt therapy for grade 3 and 2 symptoms. When the grade reaches 0 or 1, therapy is resumed at a lower dosage (Sorafenib, 400 mg (milligrams) twice daily, reduced to once daily; Sunitinib, dose decreases to 2.5 mg).

• Pyridoxine: 50 to 300 mg of Pyridoxine daily helps manage hand-foot syndrome reaction. Pyridoxine was used with several chemotherapeutic drugs to postpone the onset and lessen the severity of skin reactions. In contrast, 200 mg of Pyridoxine per day indicates that the more effective preventative treatment involves a greater dosage.

• Cyclo-oxygenase-2 Inhibitors: Patients using Capecitabine experienced a lower incidence of HFS. However, there is little proof that COX-2 drugs are useful for treating TKI (Tyrosine kinase inhibitors) induced hand-foot syndrome reactions.

• Vasoconstriction: Drug delivery to the acral regions may be reduced by techniques such as targeted chilling to cause vasoconstriction.

• Topical Emollients: Topical emollients, particularly those containing lanolin, are useful in treating HFS or HFS-related skin irritation. The capacity of topical emollients to improve moisture retention and preserve hydration reduces additional desquamation and lowers the risk of infection.

Conclusion:

Patients on Capecitabine (cancer treatment) have experienced significant morbidity due to the chronic dose-limiting effect known as hand-foot syndrome (HFS). Eventually, this complicates the ability of cancer patients to manage their physical and psychological levels and impairs their quality of life. Cancer prevention and therapy improvements have been accomplished over the past 20 years. However, therapy-related toxicities have gained more significance as systemic treatment options have become available and more patients survive for extended periods while receiving treatment.