Nail Changes in a Patient With Cancer

A man in his 30s with adenoid cystic carcinoma of the lung presented with nail changes of several months’ duration. Chemotherapy with docetaxel and cisplatin was initiated for tumor recurrence, and nail changes developed 5 months later. Skin examination revealed onycholysis, splinter hemorrhage, and subungual hyperkeratosis on the fingernails with Beau lines and melanonychia on the toenails (Figure). There were no symptoms of peripheral neuropathy. Fungal culture yielded negative results. Chemotherapy-associated nail changes were diagnosed and the patient was treated with topical emollients. Nail changes are among chemotherapy-associated dermatologic toxicities in which onycholysis is exclusively associated with taxanes and anthracyclines.1Mittal S. Khunger N. Kataria S.P. Nail changes with chemotherapeutic agents and targeted therapies.Indian Dermatol Online J. 2022; 13: 13-22Crossref PubMed Scopus (5) Google Scholar,2Hussain S. Anderson D.N. Salvatti M.E. Adamson B. McManus M. Braverman A.S. Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature.Cancer. 2000; 88: 2367-2371Crossref PubMed Scopus (0) Google Scholar Onycholysis is dose related, often starting from the distal nail bed, progressing proximally, and finally causing nail detachment.3Lacouture M.E. Sibaud V. Gerber P.A. et al.ESMO Guidelines CommitteePrevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines.Ann Oncol. 2021; 32: 157-170Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Patients with onycholysis often deliberately clip distal nails (Figure B) because the distal parts of the nails are nearly perpendicular to the hyponychium, resulting in nail bed exposure. In this case, onycholysis and splinter hemorrhage were induced by docetaxel, while melanonychia (matrix melanocyte stimulation) and Beau lines (cessation of nail growth) may be associated with docetaxel and cisplatin.1Mittal S. Khunger N. Kataria S.P. Nail changes with chemotherapeutic agents and targeted therapies.Indian Dermatol Online J. 2022; 13: 13-22Crossref PubMed Scopus (5) Google Scholar,3Lacouture M.E. Sibaud V. Gerber P.A. et al.ESMO Guidelines CommitteePrevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines.Ann Oncol. 2021; 32: 157-170Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Preventive measures are crucial for chemotherapy-induced nail toxicities, including keeping nails clean and properly trimmed, wearing protective gloves, and applying fragrance-free moisturizing creams or ointments.1Mittal S. Khunger N. Kataria S.P. Nail changes with chemotherapeutic agents and targeted therapies.Indian Dermatol Online J. 2022; 13: 13-22Crossref PubMed Scopus (5) Google Scholar, 2Hussain S. Anderson D.N. Salvatti M.E. Adamson B. McManus M. Braverman A.S. Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature.Cancer. 2000; 88: 2367-2371Crossref PubMed Scopus (0) Google Scholar, 3Lacouture M.E. Sibaud V. Gerber P.A. et al.ESMO Guidelines CommitteePrevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines.Ann Oncol. 2021; 32: 157-170Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Cold therapy with frozen gloves for a duration of 15 minutes before, during, and after chemotherapy infusion can reduce the risk of chemotherapy-associated onycholysis.3Lacouture M.E. Sibaud V. Gerber P.A. et al.ESMO Guidelines CommitteePrevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines.Ann Oncol. 2021; 32: 157-170Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,4Kadakia K.C. Rozell S.A. Butala A.A. Loprinzi C.L. Supportive cryotherapy: a review from head to toe.J Pain Symptom Manage. 2014; 47: 1100-1115Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Early recognition and treatment of nail toxicities are paramount to maintain patients’ health-related quality of life. The authors report no competing interests. Author Contributions: Drs P.-C. Wu, J. Wu, and Y.-T. Hung—Conception and design of the study, analysis and interpretation of data, literature search, drafting the article and manuscript revision, and final approval of the version to be submitted.