A Rare Case of Erythrodysesthesia of Grafted Skin as an Adverse Reaction of Sorafenib

Abstract

Purpose: Hand-foot syndrome (palmer-planter erythrodysesthesia) and other adverse reactions relating to administration of sorafenib lead to discontinuation of medication in one third of patients. We describe a rare case of erythrodysesthesia of grafted skin in hepatocellular cancer (HCC) patient treated with sorafenib. 52 year old male presented with complaints of peeling of the skin of hands and burning of tips of fingers. Patient tried different lotions without benefit. Four weeks prior, patient was initiated sorafenib 400 mg twice a day for multifocal HCC with lymph node metastasis. Past medical history was significant for cirrhosis secondary to HCV diagnosed 25 years ago. Patient was diagnosed with multi-focal HCC one year earlier with portal hepatic lymph node positive for poorly differentiated carcinoma cells on EUS-FNA. Patient was treated with transarterial chemoembolization twice as such transplant is not a possibility. Past surgical history was notable for hand surgery of left fingers for electrocution burn with skin graft. Patient is on alprazolam, Docusate® and morphine. No history of drug allergy or allergy to any substance or material. Patient is 1 pack per day active smoker for 30 years. Physical examination revealed redness, tenderness, swelling of hands, peeling of the grafted skin on the palmer surface of left hand fingers. AFP=154, platelets 66,000/ul, slight elevation of ALT&AST with normal total bilirubin, albumin and INR. Sorafenib was reduced to 200 mg one tablet twice a day. All symptoms resolved after one week. Majority of cases of Hand-foot syndrome, like our patient, presented with skin rash, swelling, redness, pain and/or peeling of the skin on the palms of hands and soles of feet. Symptoms are usually mild and start 5-6 weeks after beginning of chemotherapy. For example, 5-Fluouracil, Doxorubincin, Interleukin-2 and Sorafenib can cause this skin reaction for some patients. There are 3 grades of skin toxicity: Grade 1 = above symptoms which do not disrupt normal activities (requires symptomatic treatment with topical therapy), Grade 2 = above symptoms affecting normal activities (requires dose reduction by one dose level), Grade 3 = ulceration, blistering, or severe pain of the hands or feet or severe discomfort that prevents working or performing daily activities (requires discontinuation of treatment). Symptomatic treatment and dose reduction seems to be effective for majority of patients with Hand-foot syndrome including patient with grafted skin.