A 72 y.o. male with chronic lymphocytic leukemia comes in with painful hands.

What does he have?

brittle nails and areas of early paronychia

Our patient was on ibrutinib for his CLL. 67% of patients taking it have nail problems .  The drug is a tyrosine kinase inhibitor and it disrupts disulfide bonds between cysteine residues causing  keratin to breakdown.   Nails are prone to splitting and separating from the nail bed . It also causes drug induced dermatitis resembling paronychia. These effects may be delayed up to a year after starting a chemotherapeutic agent since it takes six months for a nail to regenerate.

Since chemotherapeutic agents target rapidly growing cells, they also target the nail matrix since it is composed of rapidly dividing cells. Almost any chemotherapy can cause nail bed changes including steroids.

nail changes with pembrolizumab

Before attributing nail changes to a chemotherapeutic agent, two things have to be ruled out :melanoma and fungal infection. These can look very similar to chemo related changes and often a biopsy is necessary to determine the cause of nail bed changes.

Melanonychia- refers  to a dark streak in the nail bed.  This can be benign occurring in pregnancy and after trauma but it can also be early melanoma.  Tetracyclines and  minocycline can predisposed to sunburn under the nail which can lead to melanoma. A biopsy is indicated  in many over the age of 50or those in whom the width of the streak is changing. The history is very important.

melanonychia

Fungal infection- This is also called onychomycosis and  affects 10% of the US population.

Athlete’s foot is caused by a number of fungi including: Trichophyton sp., and microsporum. Treatment is difficult .  A study in 2011 found that Vicks VapoRub improved fungal infections in 48 weeks. This is probably the cheapest option.   Intraconazole has also been used but it can cause liver damage.

fungal infection

Our patient was treated with biotin with partial relief of symptoms.

FOR THOSE WHO NEED DETAILS

Manica L, Cohen P. Ibrutinib-associated nail plate abnormalities: case reports and review Drug Saf Case Rep 2017 Nov 1;4:15. Doi: 10.1007/s40800-017-0060-1

Bitar C, Farooqui M, Valdez J, et al. Hair and nail changes during long-term therapy with ibrutinib for chronic lymphocytic leukemia. JAMA Dermatol.  2016 Jun 1;152(6):698-701.

Van Damme C, Sibaud V, Andre J, et al. Anti=programmed cell death protein 1-induced lichenoid changes of the nail unit: histopathological description.  JAAD Case Reports Vol 10 April 2023:110-112.

Elewski B. Onychomycosis: pathogenesis, diagnosis and management Clin Microbiol Rev. 1998 Jul;11(3):414-429.

Emvalomati A, Oflidou V, Papageorgiou C, st al. Narrive review of drug-associated nail toxicities in oncologic patients. Dermatol Practical  Concept. 2023;13(1):e2023064

Derby R, Rohal P, Jackson C, Beutler A, Olsen C. Novel treatment of onychomycosis using over-the-counter mentholated ointment: a clinical case series. J Am Board Fam Med. 2011;24((1)):69–74. doi: 10.3122/jabfm.2011.01.100124.