Drug-induced Nail Diseases

Nails in older adults

As the world's population of adults greater than 60 years old continues to increase, it is important to manage nail disorders that may impact their daily lives. Nail disorders may have significant impact on quality of life due to decreased functionality, extreme pain, or social embarrassment. In this review, we discuss nail disorders affecting older patients, including physiologic, traumatic, drug-induced, infectious, environmental, inflammatory, and neoplastic conditions. Diagnosis of these conditions involves a detailed history, physical examination of all 20 nails, and depending on the condition, a nail clipping or biopsy and/or diagnostic imaging. Nails grow even more slowly in older adults compared to younger individuals, and therefore it is important for accurate diagnosis, and avoidance of inappropriate management and delay of treatment. Increased awareness of nail pathologies may help recognition and management of nail conditions in older adults.

Optimal diagnosis and management of common nail disorders

Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.

Nail changes with chemotherapeutic agents and targeted therapies

Patients on Cancer chemotherapeutic agents often develop nail changes most of which are only cosmetic concern and disappear on drug withdrawal. But some nail changes can be painful and disabling thereby affecting quality of life substantially. Different components of the nail unit include the nail matrix, nail bed, nail plate, the hyponychium, lunula, the proximal and lateral nail folds. In this article we review the nail changes induced by chemotherapeutics and targeted anticancer drugs, preventive measures and treatment options available.

Effects of ısotretinoin on the growth rate and thickness of the nail plate

BACKGROUND

Isotretinoin has various effects on nails. However, the mechanism of how isotretinoin affects the nail plate is unknown. We aimed to investigate the effects of isotretinoin on morphology, growth rate, and thickness of the nail plate.

METHODS

A total of 70 acne vulgaris patients treated with isotretinoin and a control group consisting of 68 healthy volunteers were included in the study. Isotretinoin treatment was started at a dose of 0.5 mg/kg per day. Nail changes were noted; length and thickness of the nail plate were measured in all participants every month.

RESULTS

The medians of nail growth rates in the isotretinoin and control groups were 3.16 (2.87-3.57) mm/month and 2.89 (2.56-3.19) mm/month, respectively. The medians of nail thickness in the isotretinoin and control groups were 0.47 (0.38-0.53) mm and 0.50 (0.40-0.65) mm, respectively. Statistically significant differences were observed between the groups in terms of nail growth rate and thickness (P < 0.01, P = 0.02, respectively). Nail findings were observed in nine out of 70 patients (12.8%), mostly onychoschizia.

CONCLUSION

Isotretinoin gradually increases the nail growth rate and thins the nail plate over time during the course of isotretinoin treatment. Dermatologists prescribing isotretinoin should also consider the nail changes, which may impact the life quality of patients.

Diagnosis of Melanonychia

Melanonychia has many causes and can involve one or several fingernails or toenails, and may occur at any age. Dermoscopy is used routinely in the evaluation of a pigmented nail. If pigmentation is caused by melanin produced by nail matrix, identify whether the pigmentation is caused by an activation or proliferation of nail melanocytes. When melanocytic proliferation is suspected, biopsy with histopathologic examination is the gold standard for diagnosis and is recommended when a longitudinal melanonychia occurs in an adult and is localized in a single digit, in the absence of local or systemic causes that may explain its onset.

Nail Changes Induced by Chemotherapeutic Agents

Introduction:

Nail toxicity is a relatively uncommon cutaneous adverse effect of chemotherapeutic agents. Rapidly dividing cells of the nail matrix are perturbed by the antimitotic activity of these agents. Although most of these changes are cosmetic and regress once the therapy is completed, a few of these adverse effects are challenging to manage and require temporary or permanent suspension of chemotherapeutic agents.

Materials and Methods:

A total of 205 patients with various malignancies and under chemotherapy in oncology ward of the hospital over a period of 3 months were screened for nail involvement postchemotherapy. Relevant details, protocol of chemotherapeutic agents were assessed. Nail examination was carried out in daylight and the changes were analyzed.

Results:

A total of 124 (60.4%) patients had nail changes due to chemotherapeutic agents. The most common change was diffuse hyperpigmentation in 101 (81.4%) patients commonly due to a combination of cyclophosphamide and adriamycin in 43 (42.5%) patients. Longitudinal melanonychia was seen in 36 (29%), Beau's lines in 31 (25%), onychomadesis in 17 (13.7%), Mees' lines in 15 (12%), paronychia in 12 (9.6%), subungual hyperkeratosis in 10 (8%), and Muehrcke's lines in 4 (3.2%) patients. All the patients who developed Muehrcke's lines were on a combination of cyclophosphamide/doxorubicin/5 FU. Exudative onycholysis was observed in 2 (1.6%) patients; both these patients were on paclitaxel therapy. A total 2 (1.6%) patients who developed exudative onycholysis were advised discontinuation and another substitute chemotherapy was advised. Therapy for 2 (1.6%) patients who developed acute paronychia due to gefitinib was temporarily suspended. Unfortunately, most of the patients were on multiple chemotherapeutic agents hence, we could not pinpoint one drug as a cause. Therefore, a combination of agents was implicated in most cases.

Conclusion:

Nail toxicities are common with chemotherapeutic agents, however less importance is given to nail involvement. Apart from being cosmetically significant, a few adverse effects may warrant modification of the chemotherapy.

Longitudinal melanonychia and subungual hemorrhage in a patient with systemic lupus erythematosus treated with hydroxychloroquine

Hydroxychloroquine is an antimalarial agent, most commonly prescribed in the treatment of several rheumatic diseases. Although generally well tolerated, a variety of mucocutaneous adverse effects have been reported. Besides the familiar adverse effects, longitudinal melanonychia is rarely seen. Although the incidence is extremely low, systemic lupus erythematosus may also cause nail pigmentation in its own right. We report the case of a 55-year-old woman who was diagnosed with systemic lupus erythematosus and presented with longitudinal melanonychia of all 10 fingernails after 3 years of treatment with hydroxychloroquine, without mucocutaneous hyperpigmentation. The pigment of the nail lasted for more than 15 years. To the best of our knowledge, this is first published report of hydroxychloroquine-induced melanonychia without mucocutaneous hyperpigmentation. This case demonstrates that hydroxychloroquine treatment and the primary disease should be considered in the case of multiple nail changes in patients with systemic lupus erythematosus.

Chemotherapy-associated paronychia treated with 2% povidone-iodine: a series of cases

Background

Nail changes are known to occur during the use of chemotherapy for a variety of malignancies, particularly those treated with taxanes and EGFR inhibitors. There are currently no actively recruiting prospective clinical trials investigating potential treatments. There are also no US Food and Drug Administration-approved medical treatments for chemotherapy-associated paronychia and no consensus on the best way to treat these common chemotherapy-induced events.

Methods

A retrospective review of all cases presenting to a single dermatology private practice from June 2016 to January 2017 identified nine patients with chemotherapy-associated paronychia seeking treatment. Each patient was prescribed a topical solution comprised of 2% povidone–iodine in a dimethylsulfoxide vehicle that was prepared by a licensed compounding pharmacy. Patients were seen at 3 week and 6 week follow-up visits.

Results

All 9/9 patients demonstrated complete or partial resolution. The number of nails involved for each patient ranged from 4–12. There were a total of 58 nails affected in the case series, and 44/58 (76%) resolved overall. The treatment was well tolerated.

Conclusion

The topical povidone–iodine/dimethylsufoxide solution described is very effective in alleviating the signs and symptoms of paronychia associated with chemotherapy. This novel combination warrants further investigation in randomized, controlled trials to further elucidate its clinical utility.

Chemotherapy-associated paronychia treated with a dilute povidone-iodine/dimethylsulfoxide preparation

Background

Nail changes associated with chemotherapy in general, and particularly with taxane and epidermal growth factor receptor inhibitor-based regimens, are common presentations in our clinical population. Currently, there are no consensuses about therapies supported by clinical trials nor are there any US Food and Drug Administration-approved treatments for this indication.

Findings

A 42-year-old woman with stage 2A breast cancer presented to our clinic with chemotherapy-induced paronychia. Symptoms were severe enough that cessation of chemotherapy was being considered. The patient’s chemotherapy regimen included doxorubicin, cyclophosphamide, and docetaxel.

Conclusion

The topical povidone-iodine/dimethylsulfoxide system is very effective in alleviating the signs and symptoms of severe paronychia associated with chemotherapy. This novel combination warrants further investigation in randomized, controlled trials to further elucidate its clinical utility.

Nail findings in hand-foot-and-mouth disease

Hand-foot-and-mouth disease (HFMD) is a common self-limited viral illness seen in the United States and around the world. Its classic features are easily recognizable; however, nail changes are not well known or characterized. This case demonstrates onychomadesis and Beau lines in a child following clinical diagnosis of hand-foot-and-mouth disease. In this setting, nail dystrophies should be reassuring to pediatricians and families.

Tips for diagnosis and treatment of nail pigmentation with practical algorithm

The observation of a black-brown pigmentation of the nail is often alarming for the patient and for the clinician, as they are aware that it can be a possible clinical manifestation of melanoma of the nail apparatus. Luckily, however, nail melanoma is a much less frequent cause of brown-black nail color than other melanocytic and nonmelanocytic pigmentations, which include subungual hematoma, exogenous pigmentations, and melanonychia due to benign conditions. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide the correct management of melanonychia both in children and in adults.

[Nail diseases in routine practice]

BACKGROUND

Nail problems are common reasons for patients presenting to dermatological and general practitioners practices.

PROBLEM

Which nail diseases should be known and recognized in routine daily practice?

MATERIAL AND METHODS

This article presents the most common nail alterations experienced by the authors from clinics and routine practices with guidelines on the diagnostics, therapy and additional literature.

RESULTS

Nail alterations can be designated as inflammatory nail dermatoses or neoplasms. Depending on the local nail findings, clinical investigations, patient history, histology if necessary and additional procedures, concrete indications can be derived for the correct diagnosis and therapy.

CONCLUSION

Knowledge of the most commonly occurring nail diseases allows a targeted classification and additional diagnostics which can help to alleviate pain, improve aesthetics and adequately treat malignant alterations.

A hand surgeon's guide to common onychodystrophies

The human fingernail contributes to the precise dexterity of the fingers, enhances sensibility, allows manipulation of fine objects, and shields the fingertip from traumatic injury. Nail abnormalities are a common incidental finding in the course of a hand surgeon's daily practice. These abnormalities may be clues to systemic, dermatologic, traumatic, and infectious processes that would benefit from further evaluation and treatment. The purpose of this review is to discuss common nail dystrophies and their related diagnoses.

Metoprolol-induced psoriatic nail disease

We describe the development of psoriatic nail disease due to metoprolol in a 58-year-old woman who was being treated for cardiac arrhythmias. The nail condition was unresponsive to topical and systemic treatments but resolved completely with the withdrawal of metoprolol. The reaction recurred with drug rechallenge and resolved when the drug was ceased.

Proteomic analysis of human nail plate

Shotgun proteomic analysis of the human nail plate identified 144 proteins in samples from Causcasian volunteers. The 30 identified proteins solubilized by detergent and reducing agent, 90% of the total nail plate mass, were primarily keratins and keratin associated proteins. Keratins comprised a majority of the detergent-insoluble fraction as well, but numerous cytoplasmic, membrane, and junctional proteins and histones were also identified, indicating broad use by transglutaminases of available proteins as substrates for cross-linking. Two novel membrane proteins were identified, also found in the hair shaft, for which mRNAs were detected only at very low levels by real-time polymerase chain reaction in other tissues. Parallel analyses of nail samples from volunteers from Inner Mongolia, China gave essentially the same protein profiles. Comparison of the profiles of nail plate and hair shaft from the latter volunteers revealed extensive overlap of protein constituents. Analyses of samples from an arsenic-exposed population revealed few proteins whose levels were altered substantially but raised the possibility of detecting sensitive individuals in this way.

Nail changes in kidney transplant recipients

BACKGROUND

Nail changes are common complications of end-stage renal disease, and reports of nail changes in kidney transplant recipients (KTR) are rare. Few reports have documented a higher prevalence of onychomycosis in KTR compared with controls, while others found no significant differences. In this study, we investigated the prevalence and nature of nail changes in a large series of KTR.

METHODS

Three hundred and two KTR (216 males and 86 females) were included in this study, and the mean transplant duration was 6.57 years (range 1.5 month-23 years). They were screened for the presence of nail changes. Nail clippings were collected when indicated and cultures were performed for patients with suspected onychomycosis. The patients were compared with 302 age- and sex-matched healthy controls (220 males and 82 females).

RESULTS

One hundred and twenty-one KTR (40.1%) had nail changes compared with 104 (34.4%) in controls. Onychomycosis, Muehrcke's nail and leuconychia were significantly more common in KTR [23 (7.6%), 13.3 (4.3%), 11 (3.6%), respectively] compared with controls [7 (2.3%), 1(0.3%), 2 (0.66%), P = 0.002, 0.001 and 0.02, respectively]. However, the most frequent nail change among KTR and controls was absent lunula, 90 (29.8%) and 80 (26.5%), respectively P = 0.36. Longitudinal ridging was also a frequent nail pathology among KTR and controls, 21 (6.9%) and 19 (6.3%), respectively, P = 0.74.

CONCLUSION

KTR have higher prevalence rates of onychomycosis, Muehrcke's nail and leuconychia than the healthy population. On the other hand, absent lunula could be a normal variation among Egyptian people.

Nail Toxicity Induced by Cancer Chemotherapy

Purpose. To provide a comprehensive literature review of chemotherapy-induced nail toxicity, including clinical presentation, implicated drugs and approaches for prevention and management.

Data sources. A search of MEDLINE and EMBASE (1966—2008) databases was conducted using the terms (and variations of the terms) antineoplastic agents, nails, nail toxicity, onycholysis, and paronychia. Bibliographies from selected articles were reviewed for appropriate references.

Data extraction. The retrieved literature was reviewed to include all articles relevant to the clinical presentation, diagnosis, incidence, prevention, and treatment of chemotherapy-induced nail toxicity.

Data synthesis. Nail toxicity is a relatively uncommon adverse effect linked to a number of chemotherapeutic agents. Clinical presentation varies, depending on which nail structure is affected and the severity of the insult. Nail changes may involve all or some nails. Toxicity may be asymptomatic and limited to cosmetic concerns, however, more severe effects, involving pain and discomfort can occur. Taxanes and anthracyclines are the antineoplastic drug groups most commonly implicated. It is suggested that the administration schedule may influence the incidence of nail abnormalities, for example reported cases linked to the weekly administration of paclitaxel.

Before instituting chemotherapy, patients should be educated regarding potential nail toxicities and strategies for prevention implemented. Management includes appropriate nail cutting, avoiding potential irritants, topical, or oral antimicrobials, and possibly cessation or dose reduction of the offending agent. Cryotherapy, through the application of frozen gloves or socks, has been beneficial in reducing docetaxel-induced nail toxicity and may be effective for other drugs. J Oncol Pharm Practice (2009) 15: 143—155.

Nail changes in chronic renal failure patients under haemodialysis

BACKGROUND

Chronic renal failure is known to cause various nail pathologies. They may be directly related to the renal condition itself or its complications or to the therapy.

OBJECTIVE

To compare nail changes in end-stage renal failure patients under haemodialysis with healthy persons and to study the potential relationship with various parameters in the patients.

PATIENTS AND METHODS

The study comprised 100 patients with chronic renal failure under regular haemodialysis as well as 100 healthy control subjects of matched age and sex. Both groups were subjected to full history taking and thorough general and nail examination. Complete blood picture, liver and kidney function tests and fasting blood glucose level were investigated.

RESULTS

Nail disorders were more prevalent in patients (76%) than in control group (30%). The half and half nail was the most common finding (20%) followed by - in descending manner - absent lunula, onycholysis, brittle nail, Beau's lines, clubbing, longitudinal ridging, onychomycosis, subungual hyperkeratosis, koilonychias, total leukonychia, splinter hemorrhage, pitting and pincer nail deformity. There was non-significant correlation between nail changes and age of the patients or duration of haemodialysis. In addition, no evidence of significant relation was found between nail changes and both haemoglobin and albumin levels.

CONCLUSION

Frequent nail changes are observed on systematic nail examination of uraemic patients undergoing haemodialysis; however, the cause of them remains obscure and could not be traced to a particular abnormality in the renal condition, medication or the procedure itself and it needs further investigations.

Toxicity of dose-dense docetaxel followed by doxorubicin with cyclophosphamide as adjuvant therapy for breast cancer in a phase II study

PURPOSE

In order to evaluate the feasibility of dose-dense docetaxel followed by dose-dense AC (doxorubicin/cyclophosphamide) as adjuvant chemotherapy for operable breast cancer, we conducted a phase II study.

PATIENTS AND METHODS

In cohort 1, 28 patients received docetaxel 100 mg/m2 followed by doxorubicin 60 mg/m2 with cyclophosphamide 600 mg/m2, each every 2 weeks for 4 weeks (total of 8 cycles). Enrollment was discontinued because of stopping criteria based on significant toxicity (grade 4 hematologic toxicity or grade >or= 3 nonhematologic toxicity). In cohort 2, the docetaxel dose was reduced to 75 mg/m2; enrollment was discontinued after 18 patients.

RESULTS

Significant toxicity occurred in 79% and 72% of patients in cohorts 1 and 2, respectively, resulting in treatment delays in 50% and 17% of patients, respectively. The most common grade 4 hematologic toxicity was neutropenia, which occurred in 7% and 42% of cohort 1 patients during docetaxel and AC, respectively, and in none and 19% of cohort 2 patients, respectively. The most common grade >or= 3 nonhematologic toxicity was palmar-plantar erythrodysesthesia, which occurred in 25% and none of cohort 1 patients during docetaxel and AC, respectively. With docetaxel 75 mg/m2 and patient education encouraging routine use of topical strategies, grade 3 palmar-plantar erythrodysesthesia occurred in only 11% of cohort 2 patients. Grade 2 nail changes were also debilitating and occurred in 33% of cohort 1 patients during AC.

CONCLUSION

These phase II findings suggest that dose-dense docetaxel 100 mg/m2 followed by AC is not feasible and, until more studies are conducted, should be restricted to clinical studies.