Docetaxel-induced onycholysis: the role of subungual hemorrhage and suppuration

Candida guilliermondii Onychomycosis Involving Fingernails in a Breast Cancer Patient under Docetaxel Chemotherapy

Onychomycosis has been shown to have a higher incidence in cancer patients. Nail toxicity is a quite common side effect of anticancer agents. Taxotere© is a chemotherapeutic known to cause great incidence of nail change and has a role in subungual suppuration. We report on a 52-year-old woman with breast cancer admitted in our institution for onycholysis. Because of the stage and histology of breast cancer, neoadjuvant chemotherapy was initiated. The patient received 8 cycles of Taxotere and Adriamycin (AT), and she underwent a modified radical mastectomy. Three months later, the patient developed evidence of onycholysis, involving all the fingernails. We observed the following changes in nails of all the digits in both hands: onycholysis, dystrophy, oedema, and exudate. Nail scraping and purulent discharge were collected and cultured on Sabouraud medium. Physical features of the colonies and biochemical tests (Auxacolor©) revealed Candida guilliermondii as the sole etiologic agent of onychomycosis. This case details an onycholysis in a breast cancer case successfully managed solely with amorolfine lacquer. This clinical and mycological presentation should alert the clinician to the possibility of onychomycosis induced by docetaxel chemotherapy.

The Effect of Nail Lacquer on Taxane-Induced Nail Changes in Women With Breast Cancer

Objective

Taxane-induced nail changes are considered as an important cosmetic manifestation with an incidence that reaches up to 44% of patients treated with taxane-included therapeutic regimens. In this article, we represent a clinical observational study to evaluate the effect of cosmetic nail lacquer on taxane-induced nail changes in female patients diagnosed with breast cancer.

Methods

Prospectively, we identified those women who were diagnosed with breast cancer, scheduled to have AC-Taxol protocol. Any female with previous dermatological or systemic disorders that affect nails was excluded from the study. Patients were categorized into 2 groups based on the utilization of nail lacquer. The first group includes women who started to use the nail lacquer after development of nail changes. The second group comprises those women who did not use the nail lacquer at any occasion.

Results

A total of 59 female patients were included in the study; 46 (78%) of them developed nail changes and the main change was nail discoloration. The first group which has used nail lacquer (17, 28.8%) showed an improvement among 15 (78.9%) patients, whereas 2 (7.4%) of them continued to have worsening symptoms. On the contrary, most of the second group (25, 92.9%) did not show any improvement in nail changes. A statistical significance between the tested groups was observed (P = .000). There is no statistical association between the progression of nail changes and the age of patients.

Conclusions

Taxane-induced nail changes are considered as an important clinical, cosmetic, and psychological complication, especially for female patients with cancer. This article suggests that nail lacquer may have an effect in the improvement of nail changes, especially nail discoloration. Further investigations are recommended to prove the efficacy of nail lacquer.

Adverse reactions to docetaxel: an active survey

The rates of breast cancer mortality remain high in Brazil. Docetaxel is a semi-synthetic taxane used to treat various tumors, particularly tumors of the breast, lung and prostate. In this study ADR that occurred in 45 docetaxel users with breast cancer were surveyed. They were identified by type, causality (Naranjo algorithm and World Health Organization categories) and, if considered probable or defined, rated for severity according to SOBRAFO proposal (2007). A total of 325 ADR were observed: 165 in the first, 137 in the second and 23 in the third cycle. Fifty seven ADR were immediate and the others, late. Fatigue and exhaustion for more than five days, classified as Grade 3 by SOBRAFO (2007), were reported as the primary late RAM. There was no significant difference in the occurrence of immediate and late ADR between cycles (p=1 and p=0.3577, respectively). The presence of a pharmacist gave the patients a better understanding of the occurrence of RAM, especially those that occur outside the hospital, between chemotherapy cycles and are often not reported to the healthcare team, creating institutional demands and reaching the goal to track, observe and correlate the RAM for each user.

Nail alterations as a surrogate marker for the efficacy of low-dose metronomic chemotherapy

Docetaxel is a well-known causative agent of nail alterations. The aim of this study was to reveal the impact of nail alterations associated with low-dose metronomic (LDM) docetaxel chemotherapy on the survival of non-small cell lung cancer (NSCLC) patients. Clinical information, survival data and nail alterations in patients treated with LDM docetaxel chemotherapy (docetaxel 15 mg/m² per week) were retrospectively reviewed. Forty-nine patients were included in this study. Various nail alterations were observed in 17 of the 49 patients (34.7%). Onycholysis and subungual hyperkeratosis were observed in 22.4% and 10.2% of patients, respectively. The number of docetaxel administration cycles was correlated with the incidence and severity of nail alterations. Univariate and multivariate analysis clearly demonstrated that the occurrence of nail alterations was an independent favorable prognostic factor for overall survival. Nail alterations associated with treatment may act as a surrogate marker for the efficacy of low-dose metronomic docetaxel chemotherapy.

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.