Palmar-Plantar Erythrodysesthesia
Palmar-Plantar Erythrodysesthesia (PPE) is a dermatologic toxicity associated with a number of chemotherapeutic drugs and some kinase inhibitors. Also known as Hand-Foot Syndrome (HFS), it is characterised by tingling and tenderness developing to symmetrical redness, swelling, and pain primarily on the palm of the hand and sole of the foot.
Palmer Plantar Grading Scale PPE (adapted NCI CTCAE)
Grade 1 (Mild) |
Grade 2 (Moderate) |
Grade 3 (Severe) |
Minimal skin changes or dermatitis (e.g. erythema, oedema, or hyperkeratosis) without pain |
Skin changes (e.g. peeling, blisters, bleeding, oedema, or hyperkeratosis) with pain; limiting self-care activities of daily living (ADLs) |
Severe skin changes (e.g. peeling, blisters, bleeding, oedema, or hyperkeratosis) with pain; limiting self-care ADLs |
Grade 1 (Mild) – Non Urgent |
Patient Management ● Prevention, support, teaching, & follow-up as required ● Skin Care - Before any symptoms develop liberal use of NON-urea based creams regularly to soften the skin. Avoid alcohol-based products. Skin care considerations: - Avoid sun exposure during treatment – use sun block - Avoid contact with harsh chemicals – use non - rubberised protective gloves. - Avoid using hands for activities that might cause abrasion. - Avoid exposure to hot water. Clean hands, feet with lukewarm water and gently pat dry. - Promote adequate hydration/nutrition during treatment to help prevent skin dryness or desquamation. ● Pharmacological Management - Collaborate with clinician / team. - Pharmacological management (e.g. topical application of emollient urea 10%). ● Patient Education and Follow-Up - Encourage daily self-assessment of skin - Early signs of PPE – tingling and numbness, areas of dry furrowed skin with any changes in pigmentation. - When to seek immediate medical attention: - Temperature greater than or equal to 38°C and/or presence of redness, discharge or odour from open areas - When unable to perform ADLs
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Grade 2 (Moderate) - Urgent |
● Requires medical attention within 24 hours ● Collaborate with clinician / team - Treatment delays, reductions or discontinuation of treatment. - Management of skin complications - Pharmacological management (e.g. pain management – topical or oral, antibiotics if infection Identified). - Patient education and follow-up (as previous step) |
Grade 3 (Severe) - Emergency |
● Requires IMMEDIATE medical attention ● Patients will generally require hospital admission ● Notify clinician / team of ABC CNS assessment ● Notify Emergency Department |
