Palmar-plantar hyperpigmentation with capecitabine in adjuvant colon cancer

Capecitabine (XELODA) is a chemotherapeutic agent used widely in the treatment of adjuvant/metastatic colon cancer and metastatic breast cancer. It is usually well tolerated; however, one of the major side effects, hand-foot syndrome (HFS), can be quite disabling. Hyperpigmentation is currently not part of the grading system of HFS, but may be a marker of developing toxicity.

Here, we describe three patients treated with adjuvant capecitabine for colon cancer (a 49-year-old East Indian man, a 58-year-old Asian woman, and a 54-year-old Aboriginal man) who developed moderate to severe HFS requiring delay and dose reduction. In every case, toxic side effects were preceded by hyperpigmented macules on the hands and feet.

Hyperpigmentation of the hands and feet is a rare side effect with capecitabine chemotherapy and appeared to predict impending grade 2 HFS in our patients. Clinicians and health care workers in oncology should be aware of this potential side effect; however, further investigation is required to determine whether or not palmar-plantar hyperpigmentation should be included in the spectrum of HFS. Hyperpigmentation may also be more common in the non-Caucasian populations but more research is required to determine the ethnic distribution of this finding.