Supravenous hyperpigmentation, transverse leuconychia and transverse melanonychia after chemotherapy for Hodgkin's disease

Serpentine supravenous hyperpigmentation induced by chemotherapy: a systematic review

Serpentine supravenous hyperpigmentation (SSH) describes increased skin pigmentation that develops in the area immediately overlying the vessels through which chemotherapeutic drugs are administered. While SSH can be cosmetically distressing and there are no definitive management options, the literature is severely limited and the variations in clinical presentation, risk factors, and histopathology of SSH across patients are not well understood. We aimed to systematically summarize characteristics from current available data, and thus improve SSH awareness and management. A literature search was conducted in PubMed using specific eligibility criteria through the end of December 2022. Included articles focused on patients who experienced SSH after chemotherapy infusion. Study quality was assessed using a modified Oxford Centre for Evidence-Based Medicine quality rating scheme. Of the 41 articles identified by literature search, 24 met eligibility criteria. Two additional articles were identified through the reference sections of retrieved articles, for 26 articles total. All articles were case reports, representing 28 patients total. Locations of SSH were mostly in the forearm near the site of injection (85%), and the most common associated symptom was erythema. Histopathologic analysis was available for half of cases, the majority of which were inflammatory in nature. The most common inflammatory pattern observed was a vacuolar/lichenoid interface dermatitis. Duration of SSH ranged from days to > 1 year after the chemotherapy was stopped. Six (21%) patients were managed with topical steroids and oral vasodilators, six (21%) patients switched to central venous infusion rather than peripheral infusion, five (18%) patients received only supportive care, three (11%) patients received venous washing with chemotherapy, three (11%) patients stopped chemotherapy, and one (4%) patient reduced the chemotherapy dosage. Ten (36%) patients attained complete resolution, seven (25%) had SSH that was near resolution/fading, and three (11%) had persistent hyperpigmentation. Although SSH often spontaneously resolves once the chemotherapeutic agent is stopped, it can persist in some patients and cause significant distress. As the literature is severely limited and there are no definitive treatments, additional research using more standardized definitions and methods of assessments is necessary to improve characterization of SSH and evaluate potential interventions.

Dasatinib-Induced Transverse Melanonychia

Introduction

Transverse melanonychia, characterized by grey to black pigmented bands traversing the nail plate, can occur as a side-effect of certain medications. While no documented reports specifically associate dasatinib, a tyrosine kinase inhibitor used in the treatment of chronic myeloid leukaemia (CML) and acute lymphoblastic leukaemia, with nail changes, we present a case of transverse melanonychia possibly related to dasatinib therapy.

Case Report

A 54-year-old male with CML, receiving dasatinib for 1.5 years, presented with transverse pigmented lines involving all fingernails and toenails. Clinical examination revealed discrete bands of transverse melanonychia in the nails. Onychoscopy of all finger- and toenails revealed multiple longitudinal grey lines within transverse grey bands of homogeneous chromonychia. Based on clinical presentation, onychoscopic features, and temporal association with dasatinib therapy, a provisional diagnosis of dasatinib-induced transverse melanonychia was made.

Discussion

The exact mechanisms underlying melanonychia are not fully understood but may involve nail matrix or toxicity, stimulation of nail-matrix melanocytes, or drug deposition within the nail plate. This case highlights the possibility of dasatinib-induced transverse melanonychia and underscores the importance of monitoring and evaluating nail changes in patients undergoing dasatinib treatment.

Dose-dependent melanonychia by mitoxantrone

We report an unusual case of a 43-year old female patient suffering from multiple sclerosis, who was treated with mitoxantrone. Few weeks after treatment initiation a hyperpigmentation of the patient’s left thumb and index was noted. Following dose-reduction (from 12 to 10 mg/m2) and over the further course of mitoxantrone treatment the discoloration slightly faded. Although mitoxantrone is known to cause hyperpigmentation of various tissues this is the first report of melanonychia without hyperpigmentation of other tissue. Albeit speculative, pathogenesis of selective melanonychia by mitoxantrone could involve selective activation of nail matrix melanocytes or endocrine disturbances involving melanocyte stimulating hormone.

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.

A complex pattern of melanonychia and onycholysis after treatment with pemetrexed for lung cancer

A 53-year-old black man was diagnosed with poorly differentiated adenocarcinoma of the lung and treated initially with 4 cycles of paclitaxel in combination with carboplatin and external-beam radiation therapy with a good clinicoradiologic response. The patient tolerated the chemotherapy well and did not develop any skin or nail changes during that period of time. His lung cancer recurred 10 months later, when he was found to have bone metastases. Second-line chemotherapy with pemetrexed 500 mg/m2 intravenously every 3 weeks was commenced. A week prior, the patient was started on folic acid 1 mg orally daily and given an injection of vitamin B12 1000 microg intramuscularly that was continued every 3 cycles thereafter. Dexamethasone 4 mg orally twice daily was given around the time of chemotherapy administration to prevent the dermatitis associated with the drug. The patient denied taking other drugs. Two months into his second-line chemotherapy, he developed multiple, concomitant, transverse and longitudinal black lines in all of his fingernails and toenails. After an interval of 3 months, he presented a complex pattern of nail hyperpigmentation, from combined dense horizontal and longitudinal streaks in some nails to diffuse black discoloration in others (Figure). Other associated changes included koilonychia, dystrophy, and friability of nail plates. Along with normal results of a hepatorenal panel and normal serum vitamin B12 and folate levels, no metabolic or endocrinologic alterations were present to explain the nail pigmentation and dystrophic changes. Results of his mycologic examination and cultures came back negative. When questioned, he denied taking any other drugs including other alternative medicine approaches or vitamin supplements, particularly retinoids, well known for causing severe nail dystrophy.

Dermatologic toxicity of chemotherapeutic agents

Due to its high metabolic rate, skin represents one of the major target organs of chemotherapy-associated toxicity. Reactions range from common, nonspecific exanthematous eruptions to rare but distinctive cutaneous lesions that may not become apparent until a drug transitions from clinical trials to widespread oncologic use. The challenge of the physician is to recognize reaction patterns that reflect a drug reaction, identify a likely causative drug, and determine whether the reaction is a dose-limiting toxicity. This review will focus on the cutaneous side effects of the newer classes of chemotherapy drugs, including targeted monoclonal antibody therapy and small molecule inhibitors.