Drug induced periarticular thenar erythema with onycholysis related to nano-albumin bound paclitaxel therapy

IntroductionA rather rare hypersensitivity reaction, periarticular thenar erythema with onycholysis (PATEO) syndrome, has been associated with the taxane class. To date, only docetaxel and paclitaxel have been associated with PATEO. This current case is highly suggestive of an association of nab-paclitaxel with PATEO.Presentation of caseA 48 year-old female receiving first-line systemic therapy using nanoparticle albumin-bound paclitaxel (nab-Paclitaxel) for metastatic breast cancer developed a dark erythema on the dorsal surface of both hands and excoriation of the skin of the palmar surfaces of both hands which worsened despite continuing daily topical triamcinolone 0.1% ointment. Skin tightness, along with significant pain, resulted in difficulty ambulating. The rash was diagnosed as PATEO by the Dermatology consult service. Hydrocortisone 2.5% cream applied twice daily and mupirocin 2% cream applied three times daily was prescribed and subsequently nab-paclitaxel was discontinued.DiscussionPATEO is clinically distinct from traditional palmar-plantar erythrodysesthesia (hand foot syndrome) associated with anthracyclines, antimetabolites, or multikinase inhibitors with unique clinical manifestations. The erythema in PATEO appears on the dorsum of the hand as opposed to the palmar surface and around the metacarpal joints. In addition, the thenar eminence and periarticular area of the Achilles tendon are often involved with erythema and violaceous plaques which may blister. Nail changes including discoloration, paronychia, onycholysis and exudation are observed in more severe cases.ConclusionThis case study suggests PATEO may also be induced by the taxane molecule in the protein bound formulation and may be a risk for all patients receiving taxane therapies.