Onycholysis associated with weekly administration of paclitaxel

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.

Supportive cryotherapy: a review from head to toe

CONTEXT

Conventional chemotherapy leads to multiple adverse mucocutaneous complications such as oral mucositis, alopecia, ocular toxicity, and onycholysis. Limited pharmacologic interventions are available for preventing these clinical problems.

OBJECTIVES

This study aimed to critically review the role of cryotherapy (regional hypothermia) for alleviating these adverse symptoms.

METHODS

A narrative review was performed, with an emphasis on randomized controlled trials. A comprehensive search using PubMed, Ovid, Embase, and MEDLINE(®) was completed. References of all cited articles also were reviewed. Data from the review were composed of articles published between 1970 and May 2013.

RESULTS

Available evidence suggests that regional hypothermia decreases the burden of chemotherapy-related oral mucositis, alopecia, ocular toxicity, and onycholysis. The major limitations of studies include the absence of blinded control groups and variable clinical end points.

CONCLUSION

Regional hypothermia decreases the burden of these four chemotherapy-induced complications and is well tolerated. More research is needed to determine what subgroups of cancer patients are most likely to respond to different types of regional hypothermia, the ideal duration of cooling needed, and further improve the ease of use of the cooling devices.

A Modified Weekly Docetaxel Schedule as First-Line Chemotherapy in Elderly Metastatic Breast Cancer: A Safety Study

Standard dose docetaxel is burdened by severe toxicity. Weekly schedules have been shown to be active as standard scheme with reduced side effects. In 20-30% of elderly patients (pts) the classic 6-week schedule induces grade 3/4 fatigue and other cumulative toxicities. We carried out this safety study in order to evaluate whether a modified weekly docetaxel schedule would improve the toxicity profile. Twenty-one untreated elderly (> or = 70 years) pts suffering from metastatic breast cancer were enrolled in the study. Pts were treated with a weekly dose of 35 mg/m2 docetaxel for 6 weeks, followed by a 2-week rest. Further cycles were performed with this modified schedule: docetaxel days 1, 8 and 15 every 29 days. All pts received at least the first cycle (6 weeks). A total of 261 doses were delivered. No toxic deaths occurred. The toxicity was mild: we recorded 1 episode of grade 3 neutropenia and severe asthenia in only 2 pts (10%). We recorded an overall response rate of 33% (1 CR, 6 PR). Our data showed a reduced incidence of severe asthenia (2/21), obtained with a light modification of a weekly docetaxel schedule.

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.

Cutaneous reaction associated with weekly docetaxel administration

Background. Docetaxel-based chemotherapy will remain clinically relevant and many of our patients will continue to receive the drug. In a recent phase 2 study of docetaxel 35 mg/m2 (weekly) in patients with metastatic breast cancer, the incidence of grade 3 cutaneous toxicity is 19%. The skin toxicity observed consists of limb/palmar-plantar erythematous reactions, or fixed-plaque erythrodysesthesia. Case series or reports have reported varied manifestations of skin reactions and include erythema multiforme, nail changes (onycholysis, pigmentation, paronychia), scleroderma, supravenous discoloration, radiation recall dermatitis, and flagellate erythema.

Method. We would like to report four patients with cutaneous reactions resulting from weekly administration of docetaxel.

Results. All cases are heavily pre-treated patients, receiving docetaxel as second or third line therapy. The cutaneous reactions occur at cycle 5. The time between chemotherapy to development of skin lesions is from 1 to 7 days. Lesions usually resolve with desquamation leaving behind areas with hyper-pigmentation or hypo-pigmentation over a period of 2 to 3 weeks. The management strategies include hand elevation, warm or cold compresses, topical and/or systemic antibiotics, topical and/or systemic corticosteroids, and cessation of drug.

Conclusions. There is a need for a systematic approach to manage these cutaneous reactions. Oncology trained pharmacists play vital roles in assessing, managing, documenting and patient education. J Oncol Pharm Practice (2009) 15: 29—34.

Chemotherapy-induced dermatological toxicity: frequencies and impact on quality of life in women’s cancers. Results of a prospective study

PURPOSE

The study aimed to determine the prevalence of dermatological side effects and its impact on quality of life in patients receiving systemic chemotherapy for women's cancers.

MATERIALS AND METHODS

A prospective study was conducted on patients with histologically confirmed advanced women's cancers who were deemed candidates for adjuvant or palliative chemotherapy. Patients were systemically examined for skin, hair, and nail side effects. The impact of those side effects on their quality of life was assessed using the health-related quality of life score (HRQL).

RESULTS

Between April 2001 and October 2001, 91 patients received 1 to 17 (median 4) courses of chemotherapy. Malignancies included breast cancer (n = 39, 43%), ovarian cancer (n = 32, 35%), cervical cancer (n = 12, 13%), endometrial cancer (n = 5, 6%), fallopian tube cancer (n = 2, 2%), and vaginal cancer (n = 1, 1%). Chemotherapy agents included taxanes (n = 42, 46%), PEG doxorubicin (n = 17, 7%), other anthracyclines (epirubicin and doxorubicin; n = 6, 19%), topotecan (n = 13, 14%), and other agents (n = 13, 14%). Overall incidence of skin, nail, and hair side effects was 86.8% (n = 79). Seventeen patients (18.7%) developed a palmo-plantar erythrodysesthesia (PPE), and nine of those (53%) were of grade 3 in common toxicity criteria scale (NCI). Twenty-one patients (23.1%) developed nail changes such as subungual hematomas, onycholysis, and leukonychias or nail loss, while 69 (75.8%) developed hair loss. There was a higher incidence of PPE in patients receiving chemotherapy for palliation rather than cure (percent over percent, p < 0.001, Fisher's exact test). Using the HRQL score, skin changes were the most frequently reported unpleasant side effect (34.1%), and of those patients who developed PPE, this was reported by n = 8 (47%) as the most unpleasant.

CONCLUSIONS

Dermatological chemotherapy side effects are frequent after treatment of women's cancers and have a major impact on quality of life as assessed by HRQL. Counseling of patients with women's cancers and the profile of side effects of chemotherapeutic agents should be considered before considering an adjuvant or palliative chemotherapy regimen.

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

Nail changes are common side effects of taxane chemotherapeutic agents. Docetaxel (Taxotere) is known to cause a great incidence of nail change. Various types of nail changes have previously been reported as a result of treatment with taxanes. We describe 2 cases of severe nail changes induced by docetaxel. The patients had previously been diagnosed with breast cancer and advanced gastric cancer, respectively. During the course of treatment with docetaxel, nail changes became apparent in both patients. Initially, they complained of nail bed purpura. Subungual hematomas with hemopurulent discharge were later observed in several fingers. Drainage of the hemopurulent material occurred spontaneously in our cases, leading to onycholysis. Following drainage, the pain in the nail with subungual hemoprulent material was relieved immediately and spontaneous healing of the patients' nails was noticed after few months. Subungual hemorrhage and suppuration therefore are considered causes of onycholysis and the pain in these patients. Although systemic or topical antibiotics were not used to treat these patients, antibiotics may be also worthwhile to hasten the drainage of the subungual hematomas and suppuration in patients for quick relief of pain.

Onycholysis and subungual haemorrhages secondary to systemic chemotherapy (paclitaxel)

Paclitaxel is a chemotherapic agent of the taxane family used in treatment of malignant solid tumory. We report here the case of a 40-year old woman referred to our clinic for nail changes involving all 20 digits and developed after 5 months of paclitaxel intake, due to a breast carcinoma. Clinical examination revealed red-brown discoloration of the nails associated with hematomas and onycholysis. The nail changes were very painful and the patient complained of discharge of bad-smelling yellow brown opaque fluid from underneath the nail plate. Hemorrhagic onycholysis and subungual abscesses are a possible side effect of taxane treatment that should be early recognized to prevent serious complications.

Taxane-induced nail changes: incidence, clinical presentation and outcome

The clinical characteristics of nail changes in seven patients receiving taxane-containing chemotherapy are described. They include nail pigmentation, subungual hematoma, Beau's lines and onycholysis and subungual suppuration. The incidence of such changes (ranging from 0% to 44%) is reviewed from a Medline search of the literature.

Docetaxel-induced nail dystrophy

A 73-year-old man with metastatic prostate cancer treated with weekly docetaxel chemotherapy for 5 months developed an acute nail dystrophy restricted to the fingernails. This was characterized by onycholysis, subungual haemorrhage and acute paronychia, progressing to a subungual abscess of the right index finger. Nail bed hyperaemia and haemosiderin-like nail bed discoloration were present. Nail plate avulsion was performed to decompress the acutely painful subungual abscess. The right thumb, middle finger and left index finger demonstrated early, proximal white subungual collections of pus obscuring the lunula (onychophosis). Central nail plate fenestrations with a surgical drill led to exudation of purulent material. Cultures of the subungual abscess material yielded mixed organisms, possibly related to administration of flucloxacillin for 1 week prior to presentation. The patient completed a further two courses of docetaxel without sequelae, and the nail dystrophy appears to be resolving. Docetaxel-induced nail changes are a common adverse effect, occurring in 30-40% of patients. Mild changes do not usually warrant the discontinuation of treatment.

Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature

BACKGROUND

Onycholysis has been reported in association with the use of several noncytotoxic drugs and with chemotherapy in 135 patients. Onycholysis may be precipitated by exposure to ultraviolet radiation.

METHODS

The authors studied 91 patients who received paclitaxel and 187 patients who received doxorubicin.

RESULTS

Onycholysis occurred in 5 of 21 patients who received > 6 courses of weekly paclitaxel, developing in the summer months in all 5 patients. It did not occur in patients who received fewer weekly paclitaxel courses or those who were treated every 3 weeks. Onycholysis did not occur in 187 patients who received doxorubicin. Review of the literature revealed that onycholysis is nearly exclusively associated with anthracycline and taxane therapy.

CONCLUSIONS

Prolonged weekly paclitaxel, other taxanes, and anthracyclines cause onycholysis in some patients, which may be precipitated by exposure to sunlight. Patients receiving these drugs should protect their nails from sunlight.