Dermatologic toxicity is a well-known adverse effect of different cytotoxic chemotherapy drugs [1]. Palmar–plantar erythrodysesthesia, also known as Hand–Foot Syndrome (HFS), is a dermatologic condition which often presents as painful erythemas involving the palms and soles of the feet [2]. Conventional chemotherapeutic agents most frequently associated with HFS include capecitabine, cytarabine, fluorouracil, liposomal doxorubicin and taxanes. Common theory linked to histological findings is a direct cytotoxic effect exerted on the basal keratinocytes by the chemotherapeutic agent [2]. We observed a series of patients experiencing dermatologic reactions after administration of docetaxel in combination with cyclophosphamide, Adriamycin, cisplatin, 5FU for the treatment of breast cancer and head and neck cancers.

Case 1

A 35-year-old female with T2N0MO, Triple Negative Breast Cancer (TIBC) was started on TAC (docetaxel, Adriamycin, cyclophosphamide) based chemotherapy. After receiving 3 cycles she developed itchy rash on her hands, feet neck and face. It was painful with erythema, hyperpigmentation and desquamation of the dorsal aspects of the hands and feet. Docetaxel was thought to be the most likely offending agent; a 20% dose reduction of docetaxel was done for the remaining cycles. The rash continued to persist, but decreased in severity after dose reduction. Following the completion her therapy, the rash did not recur and she is currently on follow up without any dermatologic issues (Figure 1).

Case 2

A 65-year-old female T3NIMO ER+ PR+ HER2NEU- ca breast received 4 cycles of epirubicin and cyclophosphamide followed by 2 cycles od docetaxel-based chemotherapy. After receiving 2 cycles, she presented with erythematous rashes on the dorsal and palmer aspect of both hands with small red papules and some desquamation. Her chemotherapy was continued without any delay or dose adjustments. The rash appeared after each subsequent cycle and resolved spontaneously after 1 week with the use of emollient creams. Following the completion of chemotherapy, the rash did not recur and she is currently undergoing local radiotherapy without any dermatologic issues (Figure 2).

Case 3

A 53-year-old male patient with T1N0MO ER+ PR+ HER2NEU-ca breast received 4 cycles of epirubicin and cyclophosphamide-based chemotherapy   followed by 1 cycle of  docetaxel-based   chemotherapy. 

Figure 1:

Figure 2: 

Figure 3: 

He developed erythematous rashes with desquamation on the dorsal and palmer surface of his hands. He also complained of a painful burning sensation on the affected area. Docetaxel was continued at full dose till cycle 4. He is currently on follow up with no dermatologic issues (Figure 3,4).

Our case series provides an atypical presentation of docetaxel induced toxicity. Considering the atypical nature of this adverse event occurring in several patients, we investigated if there was any issue with the particular batch of docetaxel that was being administered. 

Figure 4: 

However, each patient received docetaxel from different batch and other patients with different primary malignancy also received the same drug without developing this particular side effect. Treatment depends on the severity of HFS and includes supportive management using emollients and creams for palliation of the symptoms. In severe cases dose reductions can also be done [3,4]. In our case series, only one patient required dose reduction in addition to use of topical therapy. In conclusion, docetaxel-induced HFS can be a challenging side effect of taxanes for both patients and clinicians and can present in a unique and atypical manner.

1. A.S. Payne et al. "Dermatologic toxicity of chemotherapeutic agents." Semin Oncol, vol. 33, no. 1, 2006, pp. 86–97.

2. M. Janusch et al. "The hand foot syndrome: a frequent secondary manifestation in antineoplastic chemotherapy." Eur J Dermatol, vol. 16, no. 5, 2006, pp. 494–499.

3. S.M. Gressett et al. "Management of hand-foot syndrome induced by capecitabine." J Oncol Pharm Pract, vol. 12, no. 3, 2006, pp. 131–141.

4. R. Von Moos et al. "Pegylated liposomal doxorubicin-associated hand-foot syndrome: recommendations of an international panel of experts." Eur J Cancer, vol. 44, no. 6, 2008, pp. 781–790.