Changes in the nail unit are common during treatment with anti-cancer drugs. Most changes are generally well-tolerated, cosmetic, and reversible on cessation of treatment. However, some nail toxicities (e.g. paronychia) have high morbidity, causing pain and functional impairment, affecting a patient's quality of life.r
Nail toxicities can affect both the nail plate, folds and bed. Fingernails are more commonly affected than toenails. However, for example, epidermal growth factor receptor (EGFR)-induced paronychia affects the nails of both the fingers and toes. Some nail changes are more common with conventional cytotoxic chemotherapies (e.g. hyperpigmentation, Beau's lines and onycholysis). In contrast, other changes (e.g. paronychia) are more common with targeted agents such as EGFR and Mitogen-activated Protein/Extracellular Signal-regulated Kinase (MEK) inhibitors. Severe nail toxicity may lead to dose modifications of treatment or treatment discontinuation.
The onset and resolution of nail changes are often delayed, usually occurring 1-2 months after the initiation or interruption of treatment due to the kinetics of nail formation and growth.
Nail toxicities |
Drugs associated with nail changesr |
Changes in pigmentation
a change in colour of the nail plate
|
(a) Melanonychia
A brown or black pigmentation of the nail plate
© Lancet Oncol 2015r
|
Bleomycin
Busulfan
Capecitabine
Cisplatin
Cyclophosphamide
Doxorubicin
Hydroxyurea
Taxanes (orange discolouration due to haemorrhagic suffusions)
Imatinib |
(b) Leukonychia
A white colouration of the nail plate
© Lancet Oncol 2015r
|
Antimetabolites (e.g. doxorubicin, cyclophosphamide, and vincristine) |
Beau's lines
transverse linear depressions in the dorsum of the nail plate
|
© Lancet Oncol 2015r
|
Antimitotic drugs (e.g. taxanes, vinca alkaloids) |
Onychoschizia and onychorrhexis
brittle nails and nail splitting
|
(a) onychoschizia (b) onychorrhexis
© Lancet Oncol 2015r
|
Many anti-cancer drugs including both cytotoxic and targeted therapies |
Onycholysis
separation of the nail plate from the nail bed
|
© Lancet Oncol 2015r
|
Capecitabine
Doxorubicin
Etoposide
Mitozantrone
Taxanes |
Paronychia
An inflammatory reaction involving the nail folds.
The presence of pus may be an indication of bacterial infection.
|
© J Am Acad Dermatol 2012r
|
Less frequent with cytotoxic chemotherapies (except taxanes) than with targeted therapies
EGFR inhibitors
MEK inhibitors
mTOR inhibitors
Taxanes
|