Atypical case of hand foot syndrome due to pegylated liposomal doxorubicin presenting as hyperpigmentation

Hand foot syndrome (HFS) or palmar-plantar erythrodysesthesia (PPE) is a relatively frequent and often a serious side effect of anti-cancer drugs including liposomal doxorubicin. Hyperpigmentation as a part of HFS is infrequently reported. A 51-year-old woman on treatment with pegylated liposomal doxorubicin for recurrence of adenocarcinoma of ovary presented with history of itching and burning sensation in her hand and feet. She also noted hyperpigmentation of palms more than soles and discoloration of finger and toe nails. Physical examination revealed diffuse hyperpigmentation of both the palms and soles. This was accompanied by a bluish discoloration of lunulas of finger and toe nails. She was diagnosed with HFS and started on pyridoxine and emollients. The finding of hyperpigmentation noted in our patient is not commonly seen in HFS and believed by many authors to be an initial manifestation of HFS