Pazopanib induced hand-foot syndrome

A 55-year-old male was diagnosed as a case of metastatic renal cell carcinoma (clear cell histology) and started on tyrosine kinase inhibitor (TKI) pazopanib. He reported back to us 2 weeks later with painful, erythematous and desquamating lesions of the hands and soles. On examination, erythematous and desquamating lesion involving dorsum of hands and soles consistent with grade 2 hand-foot syndrome were noted (Fig. 1). Pazopanib was stopped temporarily for 1 week and supportive care in the form of analgesics (ibuprofen 400 mg three times a day and pregabalin 150 mg once a day), emollients and application of ice packs provided. Skin lesions regressed; pazopanib was re-introduced after 25% dose reduction and tolerated well. Figure 1: Erythematous and desquamating lesions of hands and sole. Hand-foot syndrome, also known as palmar-plantar erythrodysesthesia, is a frequently seen skin toxicity associated with chemotherapeutic agents like 5-fluorouracil, capecitabine and TKI-like sorafenib, sunitinib; less commonly with pazopanib [1, 2]. It has been reported in 9–62% of patients receiving TKI and develops within the first 2–4 weeks of drug administration [3, 4]. It presents as symmetric erythematous lesions on skin surfaces exposed to repeated pressure or friction. Treatment depends upon the severity of syndrome. Grade 1 disease can be managed by avoiding hot water, wearing gloves and socks and using skin moisturisers. Grade 2 disease requires application of topical or systemic analgesics like pregabalin, codeine or steroid ointments. A reduction in the dose of TKI is often necessary. In addition to above-mentioned measures, grade 3 disease also requires a brief interruption of the treatment [5]. Early recognition and prompt management is therefore necessary for early re-introduction of targeted therapy.