1. Hand-Foot Syndrome
3. Toe nails
1. Hand-Foot Syndrome (Palmar-Plantar Erythrodysesthesia)
Hand-foot syndrome is a side effect of some types of chemotherapy. In mild to moderate hand-foot syndrome, the following symptoms may occur on the palms of the hands and/or the soles of the feet, although less common, hand-foot syndrome sometimes occurs on other areas of the skin, such as the knees and the elbows:
- Redness (similar to a sunburn)
- A sensation of tingling or burning
- Tenderness (sensitive to touch)
- Tightness of the skin
- Thick calluses and blisters on the palms and soles
Symptoms of severe hand-foot syndrome include:
- Cracked, flaking, or peeling skin
- Blisters, ulcers, or sores on the skin
- Severe pain
- Difficulty walking or using the hands
Following administration of chemotherapy, small amounts of drug leak out of very small blood vessels called capillaries in the palms of the hands and soles of the feet. Exposure of your hands and feet to heat as well as friction on your palms and soles increases the amount of drug in the capillaries and increases the amount of drug leakage. This leakage of drug results in redness, tenderness, and possibly peeling of the palms and soles. The redness, also known as palmar-plantar erythema, looks like sunburn. The areas affected can become dry and peel, with numbness or tingling developing. Hand-foot syndrome can be uncomfortable and can interfere with your ability to carry out normal activities.
Some therapies are more likely to cause hand-foot syndrome than others. The drugs that may cause hand-foot syndrome include:
Axitinib (Inlyta), Cabozantinib (Cometriq), Capecitabine (Xeloda), Cytarabine (Cytosar-U, Docetaxel (Docefrez, Taxotere , Floxuridine (FUDF), Fluorouracil (5-FU, Adrucil), Idarubicin (Idamycin), Liposomal doxorubicin (Doxil), Doxorubicin (Adriamycin), Sunitinib (Sutent), Sorafenib (Nexavar), Pazopanib (Votrient), Paclitaxel (Taxol), Vemurafenib (Zelboraf) and Regorafenib (Stivarga).
Not everyone who is treated with these medications develops hand-food syndrome. The severity of hand-foot syndrome can vary from person to person, even among people taking the same medication for the same form of cancer.
Management and Prevention
Hand-foot syndrome is usually worse during the first six weeks of treatment with targeted therapies, such as axitinib, cabozantinib, regorafenib, sorafenib, sunitinib, and pazopanib. With chemotherapies, it usually appears after two to three months. If you have symptoms of hand-foot syndrome, talk with your doctor or another member of your health care team. There are ways to manage symptoms of hand-foot syndrome and prevent it from worsening. The following tips may help:
- Limit exposure of hands and feet to hot water when washing dishes or bathing.
- Take cool showers or baths. Carefully pat your skin dry after washing or bathing.
- Cool your hands and feet with ice packs or cool running water or compresses (such as a wet towel) for 15 to 20 minutes at a time (avoid applying ice directly to the skin).
- Avoid exposure to sources of heat, including saunas, sitting in the sun, or sitting in front of a sunny window.
- Avoid activities that cause unnecessary force or friction (rubbing) on the hands or feet during the first six weeks of treatment, such as jogging, aerobics, and racquet sports.
- Avoid contact with harsh chemicals used in laundry detergents or household cleaning products.
- Avoid the use of rubber/vinyl gloves without a liner, when cleaning with hot water, as rubber traps heat and sweat against your skin. Use white cotton gloves underneath rubber/vinyl gloves.
- Avoid using tools or household items that require you to press your hand against a hard surface, such as garden tools, knives, and screwdrivers.
- Gently apply skin care creams to keep your hands moist. Avoid rubbing or massaging lotion into your hands and feet; this can cause creates friction.
- Wear loose fitting, well-ventilated shoes and clothes.
- Try not to walk barefoot and use soft slippers and thick socks to reduce friction in your feet.
- Consider visiting a podiatrist to remove any thick calluses and thick nails. They can also recommend products that reduce friction and pressure on the feet.
When taking medications known to cause hand-foot syndrome, topical anti-inflammatory medications such as cortisone based cream may help. Also, your doctor may reduce your chemotherapy dose or alter your chemotherapy schedule. If necessary, your doctor may temporarily stop your chemotherapy until symptoms of hand-foot syndrome improve.
The following medications may also be used to treat hand-foot syndrome:
- Topical anesthetics, such as lidocaine, used as a cream or a patch over painful areas in the palms and soles.
- Topical moisturising exfoliant creams are available, either over the counter or through your doctor, such as those containing urea, salicylic acid, or ammonium lactate.
- Pain relievers, such as ibuprofen, naproxen and Celebrex.
- Ice packs under the hands and feet during the infusion of certain chemotherapies (paclitaxel, docetaxel, doxorubicin) to prevent hand-foot syndrome.
Vitamin B6 (pyridxine), may assist in prevention and treatment.
2. CIPN (Chemotherapy Induced Peripheral Neuropathy)
- Peripheral Neuropathy describes damage to the nerves that carry sensations (feeling) to the brain and control the movement of our arms and legs. They also control the bladder and bowel.
- Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect of many anticancer drugs, such as platinum analogs, antitubulins, bortezomib, and thalidomide.
- The symptoms or signs of chemo-induced peripheral neuropathy (CIPN) depend mostly on which nerves are involved.
The most common symptoms are:
- Pain (may be there all the time or come and go, like shooting or stabbing pain)
- Tingling (“pins and needles” feeling) or electric/shock-like pain
- Loss of feeling (which can be numbness or just less ability to sense pressure, touch, heat, or cold)
- Trouble using your fingers to pick up or hold things; dropping things
- Balance problems
- Trouble with tripping or stumbling while walking, when your feet are affected, it can affect your balance and gait, making you more likely to fall
- Being more sensitive to cold or heat
- Being more sensitive to touch or pressure
- Shrinking muscles
- Muscle weakness
- Trouble swallowing
- Trouble passing urine
- Blood pressure changes
- Decreased or no reflexes
CIPN can cause severe pain and can affect your ability to do things like walk, write, button your shirt, or pick up coins. If it gets very bad, it can cause more serious problems like changes in your heart rate and blood pressure, dangerous falls, trouble breathing, paralysis, or organ failure. Talk to your doctor about any symptoms of CIPN that you have.
- This may include medications that help reduce the pain, such as steroids, pain medications, and low doses of antidepressants. Modifications may need to be made to your chemo medications if the CIPN is severe. Physiotherapy and Occupational Therapy may help, as well as using walking assistance if needed, such as installing hand rails at home or using a walker or cane. They may recommend a sensory retraining program or an exercise-based program to help improve these problems. In addition, devices, such as elastic shoe laces, button hooks, or grip build up for writing utensils can be utilised.
- To take care of your feet, you should wear properly fitting, supportive shoes at all times, including when you’re at home. Protect your feet from cold by wearing comfortable socks and boots in the winter, and stay off your feet when you can. While there are no clinical trials showing the effectiveness of these treatments specifically for patients with CIPN, there is evidence that these treatments are effective for patients with similar problems.
- You should also check your feet daily for injuries or sores. In some cases, orthotics may be helpful to provide comfort and protection. A Podiatrist can prescribe the appropriate ones for your feet.
- Make sure you check water temperature carefully in the bath or shower. Feet affected by neuropathy may not detect hot water, and can be burned.
- Clinical trials investigating complementary and alternative medicine in the treatment of CIPN, such as acupuncture and massage therapy is currently underway. A few small trials have investigated the use of Scrambler therapy, a device that provides non-invasive cutaneous electrostimulation, to treat CIPN with some positive results. A trial to evaluate Scrambler therapy is under way now. The use of topical menthol for CIPN is also being investigated in a trial.
Will it last?
- The course of CIPN can be unpredictable, and although some symptoms may improve with time, others may persist or worsen as a result of permanent nerve damage. One of the challenges in managing and preventing CIPN is that the exact cause is not well understood, with different drugs affecting the nerve pathways in different ways.
- The onset and resolution of symptoms varies from person to person. Some drugs may cause symptoms during or immediately after the first dose. The platinum compounds have been reported to have a delayed onset of symptoms, up to several weeks after the last dose. The severity of symptoms is related to the cumulative dose of the drug received. Patients with pre-existing peripheral neuropathy may be at risk for a more severe and long-lasting neuropathy. Other factors that may increase the risk include: the presence of diabetes, smoking history, and decreased creatinine clearance. Also, there is interest in identifying genes that may play a role in the development of CIPN.
- It is unclear what proportions of patients has a complete resolution of symptoms or how long it takes for symptoms to resolve because there are no published studies that have examined these questions. However, many patients report to their health care providers that their symptoms improve or totally resolve over time.
- At this time, there are no effective treatments to reverse or prevent CIPN symptoms such as numbness, tingling, or diminished reflexes. Fortunately, peripheral nerves are able to repair themselves and therefore many people’s symptoms disappear over time. However, if the damage is too severe, symptoms may persist. The factors that predict who most is at risk for CIPN are unclear at this time.
During chemotherapy, you may notice some changes in the colour or thickness of your fingernails or toenails or changes around the nail bed.
- Your nails may look bruised – turning black, brown, blue, or green. People with darker complexions notice the colour change more.
- You may develop blemishes on your nails – such as a horizontal or vertical lines, or small indentations. These marks reflect the timing of chemotherapy. You may have multiple lines or indentations that mark the different cycles of chemotherapy. These spots are not permanent, and will grow out with the nail.
- Your nails may become thin or brittle – Your nails probably won’t grow as long as they used to and may tend to break more easily.
- The nail can lift completely off the nail bed or fall off in some cases. If the nail is not tightly bound to the nail bed, it can be a site for bacteria or fungi to enter and cause infection. A suppressed immune system, will also contribute to this.
- The nail bed may become dry and you may have frayed cuticles.
- You may develop ingrown nails on your fingers or toes.
Nail Care during Chemotherapy
Toenails grow half as fast as fingernails, or about half a centimetre every three months. Like fingernails, toenails can develop disorders, lines, ridges, discolorations, and even come loose during chemotherapy. To keep your toenails healthy during treatment and recovery, try these tips:
- During a chemo infusion, try soaking your fingers and toenails in ice water or use cooling gloves, this can help prevent nail problems.
- Researchers have shown a benefit in reducing nails to exposure of UV light. The use of gloves, opaque tape, artificial nails or reflective sunscreens to avoid exposure, may be of assistance.
- Cut toenails straight across, keeping them short. This helps prevent breakage and splitting, as well as ingrown toenail. Try soaking your toes in warm water for a short while before clipping the nails, as this will soften them, and may prevent splitting or cracking as you cut your nails.
- Gently cut away any loose cuticles, do not pick or pull at them. This can cause bleeding which can easily lead to an infection.
- Keep your toenails clean and moisturised. See a Podiatrist to take care of your toe nails during this time
- Fragile nails may be strengthened with biotin, a water-soluble B-complex vitamin, at
5 mg per day. Tea tree oilcan be used for fungal infections in toenails, if those occur. clear nail polish may also help protect toenails during treatment. For home care, patients with signs of infection in separated nails can soak their fingers or toes in a solution of white vinegar and water for 15 minutes every night, it kills the bacteria and dries the areas out.
- If your nails become infected, inflamed or painful you need to see a podiatrist. An infection around the nail can become quite painful very quickly. There are some over the counter treatments that may be fine for your type of infection or you may need a prescription medication to help combat the problem. Fungal infections can spread, so seek treatment promptly. Treatment options include: topical treatments, oral medication and laser or light therapy for fungal toenails. Visit your podiatrist for more answers to toenail conditions.
- Try to avoid injury to your toes, as bruises will heal very slowly. Wear wider shoes that have plenty of room in the toe box. Wider shoes will also allow for improved circulation to the toes and toenails. They will also provide protection for loose or fragile toenails. Also make sure the shoes are long enough, long walks cause swelling so buy your walking shoes a half size larger than normal shoes.
- Wear open-toed or comfortable wide-toed shoes, to improve circulation and speed healing.
Chemotherapy often causes dry, irritated skin. Dry skin is characterized by mild scaling, roughness, feeling of tightness, and possibly itching. Dry skin can get so severely dry that it becomes inflamed and more susceptible to infections.”
Other skin effects include: rashes, hives (with or without swelling and oedema), worsening acne, psoriasis and purpure.
Rather than waiting to deal with symptoms after treatment starts, patients can take steps to minimize skin problems about one week before beginning chemo. This can then be continued during treatment.
- Avoid long, hot showers or baths. Dry yourself by patting your skin with a soft towel, rather than rubbing vigorously.
- Use gentle, fragrance-free soaps (Dove, Basis, Aveeno or Neutrogena). Avoid bubble bath, perfumed soaps and soap-free cleansing bars, these can be drying and potentially irritating.
- Use moisturizers, preferably creams or ointments rather than lotions because the thicker consistency is better at preventing skin dehydration. Apply the cream or ointment within 15 minutes of showering. Reapply moisturizer at night, and moisturize your hands every time after you wash them.
- If your skin is very dry and flaky, ammonium lactate cream can increase moisture. These creams are available by prescription and over-the-counter. Avoid Lanolin-based creams, lotions, ointments etc.
- Some chemotherapy drugs make skin more susceptible tosunburn. Use a sunscreen with at least an SPF 30, and make sure that it protects against both UVA and UVB rays. Protection against UVA requires ingredients such as zinc oxide, titanium dioxide, or avobenzone.
- Avoid anything that you think you might be allergic to (common allergy-causing agents; detergents, plants, pets, harsh chemicals in household cleaning products, rubber gloves, jewellery, feathers, grass and pollen, artificial fingernails and adhesive).
- For rashes and other skin reactions you may require: Corticosteroid creams, Calamine lotion for itching, Antihistamines to treat an allergic response and Analgesics (pain medications) if a painful rash is present.
When to call your doctor/ health care professional about skin reactions:
- Swelling, chest pain or difficulty breathing (signs of an allergic reaction). Seek help immediately and notify your doctor.
- Fever of 100.5° F (38° C) or higher, chills (possible signs of infection).
- Unexplained or worsening skin rash.
- Wear cotton clothes next to your skin, trying to avoid wool, synthetics or rough materials.
- Wash clothes in mild, un-perfumed laundry detergent.
- Keep your feet insulated from the weather (heat, sun, cold and wind), with socks and shoes.
- Avoid sun exposure. Use SPF 30 or above sunscreen.
Drink plenty of fluids to maintain hydration. Approx 2-3 litres of non alcoholic, non-caffeinated drinks a day. If you have fluid restrictions, speak to your doctor about fluid intake.
Photo-sensitivity describes your skins response to sunlight. Following chemotherapy three types of reactions may occur. Photo-toxic, Photo allergic and a UV recall reaction.
- Photo-toxic – with a high enough dose of drug, this usually occur within 5-20 hours of exposure and looks like severe sunburn (redness, blistering, weeping and peeling). The rash only occurs in areas exposed to light.
- Photo allergic- this reaction is less common but similar to a photo-toxic response. It may occur in areas beyond those exposed to light.
- A UV recall reaction causes the sunburn to reappear if chemotherapy drugs are given within 1 eek of the original sunburn reaction. It may be more severe than the original response.
- Use sunscreen or keep your feet covered with shoes and socks, even on a cloudy day.
- Avoid tanning booths
- Even if you have skin that tanned easily without burning in the past, it does not mean that you will respond the same way to Chemotherapy sunburn and may be just as susceptible as a fairer skinned person.
- Reduce inflammation using cool wet dressings and apply cooling lotions as required.
- In severe cases cortisone based creams may be required.