An Atypical Dorsal Presentation of Paclitaxel-Induced Acral Erythema Erin Lowe, DO,* Miesha Merati, DO,** Jenifer R. Lloyd, DO***

*Dermatology Resident, PGY-2, Largo Medical Center, Largo, FL **Dermatology Resident, PGY-4, University Hospitals Cleveland Medical Center, Cleveland, OH ***Program Director, Dermatology Residency, University Hospitals Cleveland Medical Center, Cleveland, OH

Disclosures: None Correspondence: Erin Lowe, DO; 201 14th St. SW, Largo, FL 33770; 203-313-0109; [email protected]

Abstract Acral erythema is a relatively common cutaneous reaction to a variety of anti-neoplastic agents, typically involving the palms and soles. The occurrence of paclitaxel-induced acral erythema is rare (1.5%) and affects the dorsal hands and/or feet, sparing palmar/plantar surfaces, for reasons unknown.1 We present a case of paclitaxel-induced acral erythema affecting the dorsal hands and forearms in a 73-year-old female undergoing chemotherapy for ovarian cancer.

Based on past reports of cutaneous reactions to involvement tends to occur earlier and with greater Introduction 8 Acral erythema, also known as palmoplantar paclitaxel presenting atypically on dorsal hands and/ severity than foot involvement. erythrodysesthesia or hand-foot syndrome, is or feet, the absence of any reports of acral erythema The exact pathogenic mechanisms of chemotherapy- a cutaneous side effect of many conventional caused by carboplatin, and the fact that she did induced acral erythema remains undetermined. Acral chemotherapies, most commonly doxorubicin, not experience acral erythema with repeat dose of 1 erythema may be confined to the hands and feet 5-fluorouracil, cytarabine, and docetaxel. Patients carboplatin monotherapy, the patient was diagnosed due to certain physical factors such as temperature present with painful, burning erythema of the palms with paclitaxel-induced dorsal acral erythema. According to the National Cancer Institute criteria gradient and vascular anatomy, rapid cell turnover, and/or soles associated with swelling, paresthesias, 8 and thick stratum corneum. In addition, one study and desquamation. Rarely, the chemotherapeutic for classification of hand-foot syndrome, our patient 9 discovered anomalous expression of intracellular agent paclitaxel causes acral erythema, and it had Grade 2 disease (Table 1). She was instructed to adhesion molecule-1 in eccrine ducts in patients presents atypically, on the dorsal hands and/or use cold compresses and triamcinolone 0.5% cream. 2-8 with acral erythema, suggesting that keratinocytes dorsal feet without palmar/plantar involvement. She was educated that the symptoms should resolve in two to four weeks and that re-administration in the eccrine apparatus may favor natural killer 11 We report the case of a 73-year-old female with of paclitaxel would likely cause recurrence of acral cells, leading to direct cytotoxicity. Hypotheses of erythema in this distinct pattern. She was advised to graft-versus-host disease have also been proposed ovarian cancer receiving combination treatment 1,12 with paclitaxel and carboplatin who developed elevate arms and apply cool compresses to decrease based on histological findings. The relationship paclitaxel-induced acral erythema. A thorough the amount of drug delivered to the hands during between chemotherapy dose and lesion severity, literature review found only six case reports and subsequent paclitaxel administration. as well as the fact that symptom resolution always one prospective study discussing this atypical occurs after drug withdrawal, seem to support presentation of acral erythema that is specific Discussion the direct cytotoxicity hypothesis. If the drug is to paclitaxel.2-8 Clinicians informed of this Since its first use as a chemotherapeutic agent in not discontinued, the eruption often progresses 1957, paclitaxel has been associated with a wide either to intense edema and blisters or to fissured phenomenon will be better able to advise their 8 patients undergoing treatment with paclitaxel, array of dermatologic side effects, including alopecia palmoplantar keratoderma. Total resolution of acral totalis, mucositis, onycholysis, hypersensitivity lesions is usually seen within two months of stopping a chemotherapy agent commonly used to treat 8 ovarian, breast, lung, and head and neck squamous reactions (with erythema and urticaria), radiation the offending chemotherapy. cell cancer. recall dermatitis, erythema multiforme, bullous fixed drug eruption, pustular eruption, and scleroderma- 10 Conclusion Case Report like cutaneous lesions. Acral erythema is a rare Although the definite mechanism behind paclitaxel- A 73-year-old female with ovarian serous cutaneous reaction of paclitaxel administration. induced acral erythema remains unknown, carcinoma was undergoing treatment with In one prospective study, two out of 127 patients knowledge of the atypical dorsal presentation will receiving paclitaxel developed acral erythema, help clinicians recognize this entity sooner, and paclitaxel/carboplatin chemotherapy. During 8 the third cycle (third month of three weekly both cases involving the dorsal hands only. Hand better advise their patients. infusions), she developed a burning sensation that progressed to pain with erythema and edema of bilateral dorsal hands and fingers. The patient was subsequently admitted to the hospital for a small bowel obstruction related to metastases, at which point the rash was assessed by her primary team. An ultrasound of bilateral upper extremities ruled out deep venous thrombosis. Dexamethasone 10 mg and diphenhydramine 25 mg were administered intravenously, which temporarily improved her redness, swelling, and pain.

Physical exam by dermatology revealed non-tender, erythematous, edematous plaques of the bilateral dorsal fingers and hands and extending about a third of the way up the forearms (Figure 1). There were a Figure 1 Figure 2 few areas of desquamation but no blisters, erosions, or ulcerations. Palmar hands were spared (Figure 9 2). Nails could not be assessed due to acrylic overlay. Table 1. National Cancer Institute criteria for classification of hand-foot syndrome Feet were largely uninvolved with the exception of Grade Characteristics one small erythematous patch with central crust 1 Minimal skin changes or dermatitis, without pain overlying the dorsal aspect of the left hallux. There was no tenderness on palpation or restriction of 2 Skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis), with pain that limits movement. She admitted to mild constant pain of instrumental activities of daily life the hands but denied pruritus, numbness, tingling, 3 Severe skin changes, with pain that limits self-care activities of daily life and muscle weakness.

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LOWE, MERATI, LLOYD