Transverse leukonychia in patients receiving cancer chemotherapy

Leukonychia: What Can White Nails Tell Us?

Changes in nail color can provide important clues of underlying systemic and skin disease. In particular, white discoloration (leukonychia) has a high prevalence with a wide array of potential relevant causes, from simple manicure habits to life-threatening liver or kidney failure. Therefore, a reliable assessment of the patient with leukonychia is essential. In the past, two classifications for leukonychia have been presented. The morphological classifies the nail according to the distribution of the white lines: total, partial, transversal, and longitudinal leukonychia. Mees’ and Muehrcke’s lines are examples of transversal leukonychia, while Terry’s and Lindsay’s nails are examples of total and partial leukonychia. The anatomical classifies according to the structure responsible for the white color: the nail plate in true leukonychia, the nail bed in apparent leukonychia, and the surface only in pseudoleukonychia. In this review, both morphological and anatomical features have been combined in an algorithm that enables clinicians to approach leukonychia efficiently and effectively.

Management and Outcome of Taxane-Induced Nail Side Effects: Experience of 79 Patients from a Single Centre

Background

Nail changes are a common side effect of taxane chemotherapy, although their correct management is poorly standardized.

Objective

To evaluate incidence, clinical aspects, and response to treatment of taxane-induced nail side effects in patients treated with taxanes for malignancies.

Patients and Methods

We performed a retrospective clinical study of 79 patients with taxane-induced nail changes from January 2015 to July 2018.

Results

Paclitaxel was the most responsible drug and both hands and feet were often affected (46.8%). Grade 2 nail toxicity was seen in 63.3% of the patients, including painful subungual hematoma, hemorrhagic onycholysis, and paronychia. Grade 3 nail toxicity was seen only in 2.5% of the patients, including hemorrhagic onycholysis and pyogenic granuloma. Removal of the detached nail plate with application of topical antibiotics and steroids induced regression of symptoms within 2 weeks.

Conclusions

Nail toxicity develops mostly at the end of therapy, and total drug dosage is the only known factor that predisposes to these side effects. Trauma possibly plays a role as the most severe signs are located on the great toenails. Although it is impossible to prevent taxane-induced nail side effects, a careful patient monitoring permits to immediately recognize and manage the symptoms in order to induce their remission and improvement of the patient's quality of life.

An Update on Drug-Induced Pigmentation

Drug-induced pigmentation accounts for up to 20% of all cases of acquired pigmentation. A thorough review of medical history and previous and ongoing medications as well as a complete skin examination can guide diagnosis. Implicated agents include alkylating/cytotoxic agents, analgesics, antiarrhythmics, anticoagulants, antiepileptics, antimalarials, antimicrobials, antiretrovirals, metals, prostaglandin analogs, and psychotropic agents, among others. Confirming true drug associations can be challenging, especially in the setting of delayed onset of pigmentation and coexisting polypharmacy.

Nail abnormalities associated with systemic pathologies

Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.

Reações tegumentares adversas relacionadas aos agentes antineoplásicos: parte I

O tratamento local e sistêmico das neoplasias pode causar alterações na pele, membranas mucosas, cabelos e unhas. O diagnóstico preciso e o tratamento adequado destes efeitos colaterais requerem conhecimento dos padrões das reações adversas mais comuns para as medicações que o paciente está utilizando. O dermatologista deve estar familiarizado com as manifestações tegumentares das neoplasias, bem como com os efeitos adversos mucocutâneos dos tratamentos antineoplásicos.

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.

Drug reactions affecting the nail unit: diagnosis and management

Several drugs may be responsible for the development of nail abnormalities, but only a few classes are consistently associated with nail symptoms. Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues, or the digit blood vessels. Pharmacologic agents that most frequently produce nail abnormalities include retinoids, indinavir, and cancer chemotherapeutic agents.

Drug-induced nail abnormalities

A large number of drugs may be responsible for the development of nail changes, including cancer chemotherapeutic agents and retinoids, however, only a few classes of drugs are consistently associated with nail symptoms. Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues or the digit blood vessels. The most common symptoms include Beau's lines, onychomadesis, melanonychia, onycholysis and periungual pyogenic granulomas. Drug-induced nail changes usually involve several or all of the nails. In most cases, nail abnormalities are asymptomatic, but can sometimes cause pain and impair manual activities.

Chemotherapy induced transverse leukonychia in children

Transverse white nail banding can be inherited or caused by various diseases and medications, including cancer chemotherapeutic agents, retinoids, tetracyclines, antimalarials, sulfonamides, pilocarpine, cortisone and zidovudine. Neither a specific drug nor classes of cancer chemotherapeutics were associated more frequently than the other with acquired transverse leukonychia in patients with cancer. Here we report transverse leukonychia in four children with cancer receiving different chemotherapeutic agents.

The physical basis of cosmetic defects of the nail plate

Cosmetic defects of the nail cover a range of changes. Some are variants of normal which are considered unattractive, others are part of the normal ageing process and some changes are manifestations of local or systemic disease. Interpretation of these changes relies on recognition of the specific characteristics in question and an understanding of the anatomy and biology of nails. In many instances, therapies are limited and explanation of the changes represents one of the most useful contributions the professional can make to the affected individual. This article covers some of the most common cosmetic defects of nail involving colour, surface, brittleness and behaviour of surrounding tissues. Understanding of the physical basis of these defects is limited in many cases, but current thinking is recorded.