Table 1.

Adverse event management strategies—palmar–plantar erythrodysesthesia (PPE)

PPE
Prophylaxis
Provide education on prophylactic skin care before starting treatment [58]
Advise manicure and pedicure before and during treatment to remove hyperkeratotic areas [57, 61]
Protect sensitive areas: recommend sunscreen with SPF protection ≥ 30, thick cotton gloves and socks, padded insoles, and well-fitting shoes; avoid heat sources and use cooling aids, and avoid activities that may cause force or rubbing on the hands and feet (e.g., heavy lifting, dish washing) [57, 58, 108]; delegate such tasks to caregivers
Advise on optimal hand cleaning: avoid fragranced/foaming soaps and hand sanitizers containing alcohol; ensure hands are dried thoroughly after cleaning [63]
Prophylactically administer keratolytic cream (e.g., 10% urea) [63, 109]
Monitor regularly in order to proactively manage skin toxicities: evaluate at baseline, monitor up to weekly for the first 2–4 months and monthly thereafter [63, 64]
Supportive care
Continue prophylactic measures [63]
Maintain moisture of skin using emollients [57, 61, 110]
Consider topical treatment with salicylic acid, urea 20–40% cream either alone or with tazarotene cream or 5% fluorouracil cream, and/or clobetasol 0.05% cream; topical analgesics may be added for pain control [57, 61, 63]
Topical cortisone and clobetasol 0.05% may also be used; consider oral analgesics (e.g., NSAIDs, pregabalin, cautious use of opioids) [57, 61, 63]
Consult with a dermatologist to drain blisters and remove hyperkeratotic areas [63]
To prevent infection of cracked skin, soak in equal parts vinegar and water for 10 min per day [63]
Antibiotics should be prescribed only if there is evidence of infection [62]
There is limited evidence for the use of pyridoxine (vitamin B6) [111]

NSAID nonsteroidal anti-inflammatory drug, SPF sun protection factor