Cyclophosphamide induced nail pigmentation

Disorders of hyperpigmentation. Part I. Pathogenesis and clinical features of common pigmentary disorders

Disorders of hyperpigmentation are common and, depending on the extent and location of involvement, can affect the quality of life and pose a significant psychologic burden for patients. Given the similarities in presentation of the various causes of hyperpigmentation, it is often difficult to elucidate the etiology of these conditions, which is important to guide management. Furthermore, certain disorders, such as lichen planus pigmentosus and ashy dermatosis, have similar clinical and/or histologic presentations, and their classification as distinct entities has been debated upon, leading to additional confusion. In this review, the authors selected commonly encountered disorders of hyperpigmentation of the skin, subdivided into epidermal, dermal, or mixed epidermal-dermal disorders based on the location of pigment deposition, along with disorders of hyperpigmentation of the mucosa and nails. Melanocytic nevi, genetic disorders, and systemic causes of hyperpigmentation were largely excluded and considered to be outside the scope of this review. We discussed the pathogenesis of hyperpigmentation as well as the clinical and histologic features of these conditions, along with challenges encountered in their diagnosis and classification. The second article in this 2-part continuing medical education series focuses on the medical and procedural treatments of hyperpigmentation.

In vitro Evaluation of Isatin derivatives as Potent Anti-Breast Cancer Agents against MCF-7, MDA MB 231, MDA-MB 435 and MDA-MB 468 Breast Cancers cell lines: A Review

INTRODUCTION

Breast cancer (BC) is one of the most frequent malignancy and most common reasons of impermanence in women. The backbone of therapy for BC is principally chemotherapy, but due to its non-specific nature between normal cells and cancer cells and severe side effects are the main barriers in its therapy. So, there is an intense requirement for the enlargement of more efficacious, more specific and safer anti-BC agents.

OBJECTIVE

Isatin (IST) is an endogenous molecule which is a principal class of heterocyclic compounds and exhibits a wide range of therapeutic activities which can be used as a starting material for the synthesis of several drug molecules. Many literatures were reported previously on different pharmacological activities of IST derivatives and particularly on anticancer activity but this review mainly focus on anti-BC activities of IST derivatives through MCF-7, MDA MB 231, MDA-MB 435 and MDA-MB 468 cell lines. Here in we mentioned, a total 33 IST derivatives (compound 24- 56) which shown good anti-BC activity. IST derived compounds are also available in market and are used for various cancer types like sunitinib for renal cell carcinoma (RCC) and Nintedanib used for the cryptogenic fibrosing alveolitis treatment but when evaluated for BC did not get much success.

CONCLUSION

This review mainly highlights anti-BC activities of various IST analogues using MCF-7, MDA MB 231, MDA-MB 435 and MDA-MB 468 cell lines, display the potent compound of the series and structure-activity relationships of compounds with molecular docking also. So, this study mainly shows the importance of IST as major sources for drug design and development of newer anti-BC drugs.

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.

Nail toxicities induced by systemic anticancer treatments

Patients treated with systemic anticancer drugs often show changes to their nails, which are usually well tolerated and disappear on cessation of treatment. However, some nail toxicities can cause pain and functional impairment and thus substantially affect a patient's quality of life, especially if they are given taxanes or EGFR inhibitors. These nail toxicities can affect both the nail plate and bed, and might present as melanonychia, leukonychia, onycholysis, onychomadesis, Beau's lines, or onychorrhexis, as frequently noted with conventional chemotherapies. Additionally, the periungual area (perionychium) of the nail might be affected by paronychia or pyogenic granuloma, especially in patients treated with drugs targeting EGFR or MEK. We review the nail changes induced by conventional chemotherapies and those associated with the use of targeted anticancer drugs and discuss preventive or curative options.

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 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.

Mucocutaneous adverse effects of hydroxyurea: a prospective study of 30 psoriasis patients

Hydroxyurea is an anti-tumour agent most commonly used to treat chronic myeloproliferative disorders in doses up to 4 g per day. Dermatological adverse effects reported so far have been observed predominantly in these patients. As we are treating selected psoriasis patients with low dose hydroxyurea we attempted to define the spectrum and chronology of dermatological adverse effects in this group of patients prospectively. Of the 29 evaluable patients, 19 (65.5%) developed a mucocutaneous adverse reaction after a mean duration of 6.4 weeks of treatment. Pigmentation of nails, skin or mucosa was the most common observation and was seen in 17 (58.6%) patients. Other less common findings were xerosis, diffuse alopecia, oedema of the legs, oral ulcers and actinic psoriasis. Adverse effects subsided in 11 (57.9%) patients during a mean follow up of 18 weeks. Three hitherto unreported side-effects - scleral pigmentation, acquired ichthyosis and pigmentation of lunula of the nails - were noted. This first study of dermatological adverse effects of hydroxyurea therapy on Asian psoriatic patients reveals several new findings. Pigmentation of skin, nails and mucosa appears to be very common and occurs early. Serious dermatological side-effects probably do not occur with low dose (up to 1.5 g per day) hydroxyurea in patients with psoriasis.

Mucocutaneous reactions to chemotherapy

Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

Mucocutaneous manifestations of lymphomas and leukemias in black Kenyan children

BACKGROUND

Childhood leukemia and lymphoma are common problems in Tropical Africa, including Kenya. Studies done in Western populations indicate that 25-50% of patients with leukemia and lymphoma have specific or nonspecific cutaneous signs. In dark-skinned patients, reports of such mucocutaneous manifestations are scarce. The lesions in these patients may easily be missed, if not specifically looked for.

METHOD

Eighty-six indigenous Kenyan children with a confirmed diagnosis of leukemia or lymphoma were specifically examined for any mucocutaneous manifestations at presentation, during their treatment, and during subsequent follow-up. Whenever possible, an attempt was made to determine the causes of these lesions. All patients were given standard therapy for the primary hematologic disorder.

RESULTS

Two-thirds of the patients had mucocutaneous symptomatology at presentation: 17.4% had skin infiltration by the malignant cells. During therapy an even larger number developed nonspecific skin manifestations. Most of these were the result of myelosuppression, immunosuppression, or direct cytotoxic effects on tissues.

CONCLUSIONS

Mucocutaneous manifestations in black children with leukemia and lymphoma are very common.

Ifosfamide-induced hyperpigmentation

BACKGROUND

Pigmented banding of the nails and hyperpigmentation of hands and feet may occur during cyclophosphamide therapy. Ifosfamide, an analogue of cyclophosphamide, might be expected to cause similar pigmentary changes, but, to the knowledge of the authors, there are no reports of this.

METHODS

The authors describe skin pigment changes in a 5-year-old patient receiving ifosfamide, MESNA, and etoposide for the treatment of relapsed Wilms tumor.

RESULTS

A review of the literature concerning cyclophosphamide-induced pigmentary changes is presented, along with a discussion of the possible correlation of renal dysfunction with pigmentary changes.

CONCLUSIONS

This case should alert health care providers to this uncommon adverse effect of ifosfamide.

Cutaneous reactions to drugs used for rheumatologic disorders

Cutaneous reactions to medications probably represent the most common manifestation of drug reactions. The diversity of cutaneous eruptions produced by drugs provide a challenge in searching for the mechanisms producing the reaction. Many eruptions are due to a form of allergic hypersensitivity, while others may be idiosyncratic, due to a metabolic abnormality, or represent a cumulative phenomenon. This article discusses the diagnosis of drug-induced cutaneous reactions by reviewing specific drugs commonly used in rheumatologic therapy.

Cutaneous side effects of cancer chemotherapy

Chemotherapeutic agents are used with increasing frequency to treat a wide variety of neoplastic and inflammatory disorders. These drugs may inadvertently affect the skin, mucous membranes, hair, and nails, producing many undesirable reactions including alopecia, stomatitis, hyperpigmentation, hypersensitivity reactions, and photosensitivity. Awareness of these relatively common complications may help physicians caring for patients on these medications.

Drug eruptions

Images

Cutaneous complications of chemotherapeutic agents

Increasing numbers of chemotherapeutic agents are being used to treat patients with cancer and various immunologically mediated and inflammatory disorders. Many of the drugs used have distinctive cutaneous side effects that range from relatively common ones, such as alopecia, stomatitis, and hyperpigmentation, to more unusual ones, such as radiation enhancement and recall phenomena, photosensitivity and hypersensitivity reactions, and phlebitis or chemical cellulitis. In addition, there are some rare complications such as diffuse sclerosis of the hands and feet, Raynaud's phenomenon, sterile folliculitis, and flushing reactions. By being aware of which drug may have caused a particular cutaneous reaction, dermatologists will be able to contribute to the care of patients with complex problems in a meaningful way.

The flag sign of chemotherapy

A case of horizontal pigmented bands developing within the hair of a patient on intermittent high-dose methotrexate chemotherapy is presented.

Melanonychia striata longitudinalis. A case report

Melanonychia strata longitudinalis is a pigmented (dark brown-tan-black) band running in the long axis of the nail. This abnormal color of the nail plate is caused by a focal increase of melanin because of increased number and/or function of normal or abnormal melanocytes in the nail matrix. Pigmented streaks in nails due to melanocytic hyperplasia are said to be so exceedingly common in black persons as to be normal and the phenomenon is benign in the majority of cases. In our white patient reported here the pigmentation is due to epithelial hyperpigmentation without melanocytic hyperplasia or evidence of malignancy, hormonal abnormality, or other adventitious influence.

Drug- and heavy metal--induced hyperpigmentation

Several categories of chemical and pharmacologic agents can cause alterations in cutaneous pigmentation, although the mechanisms differ and in several instances may be unknown. Fixed drug eruptions appear to have alteration of the basement membrane zone with incontinence of epidermal pigment as the mechanism of hyperpigmentation. Heavy metals produce increased pigmentation in part from deposition of metal particles and in part from an increase in epidermal melanin production. The antimalarials may bind to melanin. The phenothiazines and minocycline produce pigmentation from deposition of the drug. The mechanism, site, and nature of the pigment occurring with antineoplastic agents is not well understood, but the location is most likely predominantly epidermal. Clofazimine (Lamprene) alteration in pigmentation appears to result from deposition of the drug in subcutaneous fat.

Nail disorders. A review

The nail is capable of only a limited number of pathologic responses. Some of these alterations, including idiopathic disorders, infections, tumors, and drug-induced reactions, are reviewed in the light of recent observations. Whenever possible, clinicopathologic correlation has been emphasized. Specific suggestions are made for diagnostic technics and treatment modalities.