Our results suggest two novel findings regarding the natural history of PPS and the use of New Skin.
Our patient demonstrated a trend whereby pain was perceived at the site of the fissures before their physical appearance. This has not been described elsewhere. It appears from speaking to other patients that this is a common finding and would be worthy of further investigation.
The patient's pain score decreased to 0 within 4 days of the most severe rating. While previous treatment cycles had resulted in considerable loss of function due to PPS, the application of New Skin coincided with return to normal activities secondary to the relief of pain. Recent studies have reported termination of capecitabine until grade II fissures had healed.1 3 4
Where treatment had continued, fissures progressed resulting in skin breakdown, desquamation, bullous formation and secondary infection.3 5
In severe cases there have even been reports of palmoplantar keratoderma.6
Our patient continued treatment at the same dose without requesting medical advice and suffered none of these sequelae. There is no published evidence to date that suggests that patients are able to continue with capecitabine despite grade II PPS without the mentioned complications. Indeed, all recommendations suggest termination of chemotherapy until the fissures have healed.1
This difference is possibly attributable to the effect of New Skin protecting the wound from mechanical damage and promoting healing.
New Skin is a product of Germolene (Bayer plc, Leverkusen, Germany) and is advertised as providing ‘a waterproof and germproof barrier to protect minor skin wounds’. The observation of pain relief could be considered an unexpected positive outcome of the treatment. There are no apparent contraindications to its use alongside capecitabine. A number of other therapeutic agents have been cited for the relief of PPS of which pyridoxine appears to be the most popular.7
However, the data are far from convincing and show little apparent benefit both in its use prophylactically and for symptomatic relief.8 9
The patient's observations suggest that New Skin may alleviate the pain caused by PPS. We hypothesise that this may result from the provision of a mechanical barrier, which may also promote healing. These findings may warrant further investigation in a RCT. This could determine whether New Skin has a role to play in providing symptomatic relief from PPS. Furthermore, it would address any concerns over potential toxicity that could arise from maintaining capecitabine dose regimen.
- A recent RCT reported that 44% of patients suffered from grade II or III PPS while on oral capecitabine.1 This indicates a requirement for an agent that will effectively address this common side effect.
- The observations regarding New Skin have come to light as a result of a patient's initiative to actively control his symptoms. An exploratory trial among other patients could determine whether these observations are common enough to pursue a RCT. This would also address the potential risks of toxicity associated with continuing treatment.
- The application of robust clinical criteria could determine whether New Skin permits safe continuation of chemotherapy without dose reduction.