Toxic Erythema of Chemotherapy: Clinical Presentations, Subtypes, and Management

Conclusions

• Toxic erythema of chemotherapy is a broad, non-allergic, direct cytotoxic skin toxicity rather than a hypersensitivity reaction.
• Chemotherapy-related skin adverse events are common, and chemotherapy remains a major contributor to severe cutaneous reactions despite greater attention to immunotherapy.
• TEC most often affects areas with high eccrine density or friction and commonly involves the hands, feet, flexures, flanks, medial thighs, groin, and axillae.
• Hand-foot syndrome is the best-known TEC subtype and typically progresses from pain or dysesthesia to edema, erythema, and desquamation.
• Drug exposure pattern matters, with continuous infusions and longer drug persistence generally increasing the risk of TEC.
• Certain chemotherapy classes, especially cytarabine, anthracyclines, 5-FU/capecitabine, taxanes, and methotrexate, are repeatedly implicated in TEC.
• Some TEC variants can mimic other diagnoses, including fungal intertrigo and Stevens-Johnson syndrome/toxic epidermal necrolysis, so distribution and clinical context are critical for recognition.
• More severe TEC presentations may include mucositis and widespread exfoliative or bullous changes, but biopsy and history can help distinguish them from true SJS/TEN.
• Biologic and antibody-drug conjugate therapies can also produce TEC-like eruptions when the target or payload affects normal skin structures.
• Recognizing TEC matters clinically because appropriate diagnosis can guide supportive care, chemotherapy modification, and avoidance of unnecessary discontinuation when reactions are manageable.