1 Emerging nail reactions to anti‐cancer therapy Anisha B. Patel, M.D. Assistant Professor, Dermatology UT MD Anderson Cancer Center UT Health Science Center‐ Houston Outline and Objectives • Background: cytotoxic versus targeted cancer therapies • Nail reactions to cytotoxic chemotherapy • Nail reactions to novel cancer therapies Background Cytotoxic chemotherapy • Target rapidly replicating cells • Hair: Anagen effluvium • Skin: Toxic erythema • Nails: Onycholysis, Beau’s lines, Pigmentation change Targeted therapies • Targeted inhibition of small molecules • Emergence in 1990s • Higher efficacy for cancer treatment • Decreased systemic toxicities • New hair, skin, nail toxicities
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Outline and Objectives - American Academy of Dermatology · 5 Paronychia and Periungual pyogenic granuloma • Pathogenesis: Nail folds • Clinical presentation: Nail folds erythematous,
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Emerging nail reactions to anti‐cancer therapy
Anisha B. Patel, M.D.Assistant Professor, DermatologyUT MD Anderson Cancer Center
UT Health Science Center‐ Houston
Outline and Objectives
• Background: cytotoxic versus targeted cancer therapies
Lacouture ME. Mechanisms of cutaneous toxicities to EGFR inhibitors. Nat Rev Cancer. 2006;6(10):803‐12.
Paronychia and Periungual PG
• EGFR inhibitors
• MEK inhibitors
• mTOR inhibitors
Paronychia and Periungual PG
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Nail fragility• Pathogenesis: Alteration of the nail plate production
– Superficial nail fragility: proximal nail matrix– Thin brittle plate: diffuse damage to the nail matrix
• Clinical presentation:– Onychoschizia: upper layers of the plate are detached – Elkonyxis: fragility of the surface of the proximal part of the plate– Onychorrhexis: ridging of the nail plate
• Complications: Ingrown toenails and pyogenic granuloma
Onychoschizia
Onychoschizia
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Onychorrhexis
Onychorrhexis and onychoschyzia
• Ibrutinib (CD20 targeted inhibitor)
– 66 study participants
– 55 to 85 years old
– 43 men and 23 women
– 44 (67%) with new‐onset fingernail changes (median 6.5 months)
– 15 (23%) with brittle toenails (median 9 months)
– mild to moderate onychoschizia and onychorrhexis, Grade 1 and 2
Bitar C, FarooquiMZ, Valdez J, et al. Hair and Nail Changes During Long‐term Therapy With Ibrutinib for Chronic Lymphocytic Leukemia. JAMA Dermatol. 2016;152(6):698‐701.
Splinter subungual hemorrhage
• Clinical presentation: – Asymptomatic red, brown, or
• Targeted inhibitors and immune therapies have overlapping nail reactions with cytotoxic chemotherapies– Onychomadesis, onycholysis, paronychia, nail fragility, melanonychia,
• Some can be dose limiting – Paronychia, pyogenic granuloma
• Inflammatory and neoplastic cutaneous toxicities can have classic nail manifestations/toxicities– Psoriasis, lichen planus
• Future questions: predictive of tumor response or further, more severe adverse events?
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