Hand-foot syndrome (palmar-plantar erythrodysesthesia)

Hand-foot syndrome, also known as palmar-plantar erythrodysesthesia (PPE), is a common side effect of some chemotherapy and targeted therapy drugs used to treat breast cancer.

It usually affects the palms of the hands and soles of the feet, causing redness, pain or discomfort in these areas. In severe cases the skin on the hands and feet can blister or peel.  

Hand-foot syndrome can affect daily activities such as walking or grasping objects (for example, doing up buttons). This can affect your quality of life.

Supportive treatments are available to help manage the symptoms of hand-foot syndrome.

There are also things you can do that may reduce the possibility of developing hand-foot syndrome.

Although it’s unclear why hand-foot syndrome happens, we know some chemotherapy and targeted therapy drugs can cause it.

This could be because small amounts of drug may leak out of the small blood vessels in the palms of the hands and soles of the feet. This can affect the skin in these areas.

Individual chemotherapy and targeted therapy drugs may cause hand-foot syndrome in different ways. Whether you develop hand-foot syndrome, and how severe it is, can depend on the type of drug, the dose and the duration of the treatment.

The chemotherapy drugs most likely to cause hand-foot syndrome are:  

• Capecitabine (Xeloda)
• Cyclophosphamide
• Docetaxel (Taxotere)
• Doxorubicin (Adriamycin)
• Epirubicin
• Liposomal doxorubicin

The following chemotherapy drugs may also cause hand-foot syndrome, but this is much less common:

• Paclitaxel (Taxol)
• Vinorelbine (Navelbine)

The targeted therapy drugs that can cause hand-foot syndrome are:

• Trastuzumab emtansine (Kadcyla)
• Tucatinib (Tukysa)
• Alpelisib (Piqray)
• Everolimus (Afinitor)
• Lapatinib (Tyverb)
• Bevacizumab (Avastin)

You may develop hand-foot syndrome if you’re having any of the chemotherapy or targeted therapy drugs listed above. However, this depends on the dose of the treatment and if you’re having a combination of drugs.

Being older, female and having diabetes, peripheral neuropathy or circulation problems can increase your risk of developing hand-foot syndrome.

Heat, friction and pressure on your hands and feet, even from normal daily activities, can also make hand-foot syndrome more likely or its symptoms more severe.

Symptoms and their severity vary from person to person.

Symptoms may appear within a short time of starting treatment or weeks or months afterwards.

Tell your treatment team as soon as you notice symptoms or if your symptoms get worse. 

Common symptoms

Common symptoms of hand-foot syndrome include the skin on your hands and feet:

• Tingling or burning
• Feeling tight or stiff
• Becoming red (similar to sunburn) or getting darker
• Swelling
• Feeling numb
• Feeling uncomfortable or tender
• Itching
• Developing a rash

You may also have thickened skin (calluses) and blisters on your palms and soles, or calluses and hardened skin on your heels, the pads of your toes and your fingertips.

More severe symptoms

More severe symptoms include:

• Cracked, flaking or peeling skin on your hands and feet
• Ulcers or sores on your hands and feet
• Severe pain in your hands and feet
• Difficulty walking
• Difficulty using your hands
• Nails lifting from the nail bed
• Wounds that heal slowly

If you’re taking capecitabine and develop severe and ongoing hand-foot syndrome, you may lose your fingerprints. This is a rare symptom, but it may be permanent.

If you develop a high temperature (over 37.5°C), contact your treatment team immediately.

Treatment for hand-foot syndrome aims to reduce symptoms and stop them getting worse.

It’s important to let your treatment team know if you have any symptoms.

They may prescribe emollients or creams for you to apply to the affected areas. These could be:

• Moisturisers
• Steroids
• Anti-inflammatories
• Numbing creams
• Pain relief

Your doctor may also recommend you use creams containing urea to help prevent your skin becoming dry.

If your symptoms are severe, your treatment team may recommend delaying treatment, reducing the dose, or stopping treatment. Symptoms usually get better once treatment is reduced or stopped. Your skin should start to improve within a few weeks.

The following suggestions may help reduce your chances of developing hand-foot syndrome.

They can also make the symptoms of hand-foot syndrome less severe if it does develop.

Things to do

• Regularly apply hand and foot creams or lotions containing urea to keep the skin well moisturised before starting treatment
• Continue to regularly apply creams or lotions throughout your treatment
• Wear loose-fitting, comfortable clothing and footwear to avoid rubbing
• Take lukewarm or cool baths and showers
• Pat skin dry rather than rubbing it
• Use rubber gloves that have a liner when washing up
• Cool your hands and feet with cold running water, ice packs or cool compresses for short bursts of time (no longer than 15 minutes). Do not apply ice directly to your skin

Things to avoid

• Avoid having your hands or feet in hot water
• Avoid using saunas or steam rooms
• Avoid harsh chemicals like the ones used in some laundry detergents or cleaning products, or chlorine in swimming pools
• Avoid being out in the sun
• Avoid taking part in sporting or everyday activities that cause rubbing or friction on the hands or feet
• Avoid using tools or household items that require you to apply pressure with your hands or feet onto a hard surface (for example, garden tools or screwdrivers)
• Try not to walk barefoot. Instead, wear soft slippers or socks

If hand-foot syndrome is affecting your everyday life, you do not have to cope alone. Our expert helpline team can offer support. Find out more below. 

On our forum you can talk to people dealing with the side effects of chemotherapy.  

You can also speak to someone who has had chemotherapy through our Someone Like Me service. Find out more below.