Palmar plantar erythrodysesthesia pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Chitsazan, M.D.
Overview
Pathophysiology
The exact pathogenesis of palmar plantar dysesthesia is not completely understood. Suggested explanations include:
- Direct toxic effect of the chemotherapeutic drug against epidermal cells (keratinocytes)[1]
- Concentration and excretion of cytotoxic drug in eccrine sweat glands causing damage or alteration in these structures [2] [3]
- A type I (immunoglobulin E [IgE]-mediated) allergic reaction [4], suggested based on the occasional co-occurrence of facial erythema/edema, papular rash, and fever.
Unique characteristics of the palms and the soles which justify their involvement as the preferred sites of involvement include [2] [5] [6]
- High density of eccrine sweat glands [7]
- Absence of folliculosebaceous units (hair follicles and sebaceous glands)[7]
- Thick stratum corneum [7]
- Wide dermal papillae [7]
- High proliferation rate of epidermal basal cells
- The temperature and pressure gradient
- Gravitation forces
- Vascular anatomy peculiar to these areas
- In cases caused by capecitabine, higher expression of the capecitabine-activating enzyme thymidine phosphorylase in the skin of the palms[8]
Microscopic Pathology
- The pathological features of PPE are non-specific.
- However, since PPE involves a cytotoxic reaction primarily affecting keratinocytes the histopathologic findings are similar to histologic manifestation of direct toxic reactions:
- Dominantly an interface dermatitis with a cell-poor infiltrate
- A variable degree of epidermal (keratinocytes) necrosis[9]
- Generally, in mild cytotoxic reactions (PPE WHO grades 1 and 2), necrosis is restricted to basal keratinocytes.
- In severe cytotoxic reactions (WHO grades 3 and 4) destruction of the entire basal layer occurs, and a blister along with complete epidermal necrosis may also be seen.[10]
- Other histologic manifestations in epidermis include:
- Vacuolar degeneration of the basal cell layer of epidermis
- Mild spongiosis
- Hyperkeratosis
- Lymphohistiocytic infiltrates
- Apoptosis of keratinocytes
- Partial separation of the epidermis from the dermis
- Dermal changes include:
- Superficial perivascular infiltration of dermis composed of lymphocytes and eosinophils
- Papillary dermal edema
- Neutrophilic eccrine hidradenitis
- Eccrine squamous syringometaplasia, in severe PPE (WHO grades 3 and 4)
- Histologic evidence of small-fiber neuropathy, as shown by reduced epidermal nerve fiber density, has been suggested to be responsible for occurrence of neuropathic pain, dysesthesias, paresthesias, and temperature intolerance in PPE. [11]
References
- ↑ J. E. Fitzpatrick. "The cutaneous histopathology of chemotherapeutic reactions". Journal of cutaneous pathology. PMID 8468414.
- ↑ 2.0 2.1 Baack BR, Burgdorf WH (1991). "Chemotherapy-induced acral erythema". J Am Acad Dermatol. 24 (3): 457–61. PMID 2061446.
- ↑ Hiromi Tsuboi, Kohzoh Yonemoto & Kensei Katsuoka. "A case of bleomycin-induced acral erythema (AE) with eccrine squamous syringometaplasia (ESS) and summary of reports of AE with ESS in the literature". The Journal of dermatology. PMID 16361756.
- ↑ Perry, Michael (2012). Chemotherapy source book. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781451101454.
- ↑ W. S. Susser, D. L. Whitaker-Worth & J. M. Grant-Kels. "Mucocutaneous reactions to chemotherapy". Journal of the American Academy of Dermatology. PMID 10071309.
- ↑ Yvonne Lassere & Paulo Hoff. "Management of hand-foot syndrome in patients treated with capecitabine (Xeloda)". European journal of oncology nursing : the official journal of European Oncology Nursing Society. doi:10.1016/j.ejon.2004.06.007. PMID 15341880.
- ↑ 7.0 7.1 7.2 7.3 Cox GJ, Robertson DB (1986). "Toxic erythema of palms and soles associated with high-dose mercaptopurine chemotherapy". Arch Dermatol. 122 (12): 1413–4. PMID 2947543.
- ↑ Levine LE, Medenica MM, Lorincz AL, Soltani K, Raab B, Ma A (1985). "Distinctive acral erythema occurring during therapy for severe myelogenous leukemia". Arch Dermatol. 121 (1): 102–4. PMID 3855356.
- ↑ Fitzpatrick JE (1993). "The cutaneous histopathology of chemotherapeutic reactions". J Cutan Pathol. 20 (1): 1–14. PMID 8468414.
- ↑ Calista D, Landi C (1998). "Cytarabine-induced acral erythema: a localized form of toxic epidermal necrolysis?". J Eur Acad Dermatol Venereol. 10 (3): 274–5. PMID 9643337.
- ↑ Stubblefield MD, Custodio CM, Kaufmann P, Dickler MN (2006). "Small-Fiber Neuropathy Associated with Capecitabine (Xeloda)-induced Hand-foot Syndrome: A Case Report". J Clin Neuromuscul Dis. 7 (3): 128–32. doi:10.1097/01.cnd.0000211401.19995.a2. PMID 19078798.