Cancer Therapies and Nail Toxicities

On the fourth day of the 2023 AAD Annual Meeting, Beth McLellan, MD, FAAD, presented the nail changes related to cancer therapies during her session, “Management of Nail Toxicities Due to Cancer Therapy.”

She started with cytotoxic chemotherapy, noting that cytotoxic chemotherapy toxicities commonly present as Beau's lines and hyperpigmentation, which are often temporary. She shared that these patients are undergoing cycles of chemotherapy and when finishing their treatment, they start to see the changes in their nails. This can be confusing to patients because as they finished treatment, and their hair is starting to grow back, that is when they see the nail changes. This is because it can take a couple of months before the nail matrix declares itself in the nail grade.

Next, she introduced taxanes, which are a class of chemotherapy drugs in this cytotoxic category that cause a variety of nail changes, the most common being oncolysis. These are commonly used in breast cancer treatment, and up to 58% of patients will develop oncolysis or other nail changes, such as subungual hemorrhage, in addition to neuropathy. She noted this can be disruptive to patients’ quality of life and their ability to function. She shared that taxane-induced oncolysis has been lumped into a syndrome known as periarticular thenar erythema with onycholysis.

Next, Dr McLellan transitioned by asking, “When you see a patient in chemotherapy, does it really matter which drug is causing it?”

Her response was that it definitely does. She presented cryotherapy, which can be very effective in preventing nail changes related to taxanes. There are several methods to do this. For one, physicians can encourage patients to use cold gloves and booties. If not financially feasible, they can also use ice water baths by putting their hands in bowls full of ice water. Whatever they can do to keep their hands cold during the infusion will help prevent this toxicity and may also prevent neuropathy.

She also presented fibroblast growth factor receptor (FGFR) inhibitors, which are a new class of medications currently approved to treat urothelial carcinoma. They are shown to develop a new set of oncolysis and subungual hemorrhage in about 20% of patients.

She then transitioned to psoriasis and immune checkpoint inhibitors, noting that checkpoint inhibitors are a new class of cancer therapy that works by unleashing the immune system. With this comes autoimmune adverse reactions. She shared the treatments options, which include:

• Acitretin
• Apremilast
• Phototherapy
• Topicals

Next, Dr McLellan introduced epidermal growth factor receptor (EGFR) inhibitors, which commonly affect the perioral tissue, meaning that paronychia can commonly be seen related to this drug. Typically, this can present as excessive granulation tissue development, as well as pyogenic granulomas.

She then showcased an online grading system for nail changes from the National Cancer Institute that physicians can use to communicate with oncologists about toxicity.

“I always include grading in my notes when I send it back to the oncologist. This really helps direct the oncologist,” she stated.

She continued with her recommendations for general care in cancer patients. She shard that physicians should always look for signs of infection, especially in those patients with oncolysis. She added that physicians should continue typical care, such as encouraging patients to protect their hands from moisture when they're doing housework using cotton gloves and moisturizers.

Finally, she concluded with a review of some chemotherapy reactions, reminding phsycians that when it comes to cytotoxic chemotherapy, they should think about Beau's lines, pigmentation, oncolysis from taxanes, and now FGFR inhibitors. She added that psoriasis and lichen planus are common adverse reactions of new checkpoint inhibitors that so many cancer patients are undergoing. She concluded with paronychia in patients undergoing EGFR inhibitors, encouraging physicians to think about topical steroids and possibly beta blockers.

Reference
McLellan B. Management of nail toxicities due to cancer therapy. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.