Drug Reactions Affecting the Nail Unit: Diagnosis and Management
Section snippets
Teratogenesis
Some drugs, if taken during pregnancy, may interfere with nail development of the fetus. This interference becomes evident in nail abnormalities of newborns. These abnormalities range from mild hypoplasia to complete absence of the nail (Fig. 1). Distal digit malformation may be associated. Nail hypoplasia may partially improve during the first months of life. Anticonvulsants (eg, carbamazepine, hydantoin, trimethadione, valproic acid) and anticoagulants (eg, warfarin) are the most common drugs
Beau's lines and onychomadesis
Beau's lines and onychomadesis are typical signs of acute and severe toxicity to the nail matrix keratinization with transient decrease or arrest in the nail plate production. The nail plate shows transverse depressions of the surface (Beau's lines) or a whole thickness sulcus that splits the nail plate into two parts (onychomadesis). In Beau's lines, the depth of the depression represents the extent of damage, the width, or the duration of the insult. Onychomadesis is the extreme expression of
Onycholysis and photo-onycholysis
Onycholysis and photo-onycholysis are nail changes that result from acute toxicity to the nail bed epithelium with loss of the normal adhesion between the nail bed and the nail plate. With onycholysis and photo-onycholysis, the nail plate is detached from the nail bed and appears white. In photo-onycholysis the detachment is caused by a photo-mediated toxic or allergic effect of the drug. Typically the thumbs are spared. Four types of photo-onycholysis can be distinguished, depending on the
Acute paronychia
In drug-induced acute paronychia, the proximal nail fold appears erythematous, inflamed, and painful, and several nails are usually involved soon after drug intake.
Loss of the nail plate can be associated with acute paronychia. The pathogenesis is unclear, but a toxic effect of the drug on nail epithelia or a pyogenic infection may be responsible for the clinical presentation.
Exudative severe paronychia may be observed in patients taking methotrexate [22]. Paronychia due to antiretrovirals [23]
Ischemic changes
Drugs that impair distal digital perfusion may damage the nail unit with ischemic changes or necrosis. Raynaud's phenomenon is the first typical sign of digital ischemia. When Raynaud's phenomenon occurs, the digit becomes cold and gradually develops gangrene if the blood flow is not restored. These side effects may occur during systemic administration of β-blockers as well as after systemic or intralesional administration of bleomycin.
Noncardioselective β-blockers, especially propanolol,
Nail atrophy
Prolonged application of high-potency topical corticosteroids may produce digital atrophy with bone resorption. In such cases, the affected digit shows a sharpened appearance, thinning, erythema, and scaling of the periungual skin [38].
Melanonychia
Several drugs may activate clusters of nail matrix melanocytes to produce melanin, giving rise to the appearance of a band of melanonychia, or multiple longitudinal or transverse bands ranging in color from light brown to black [39]. In drug-induced melanonychia, several nails are generally affected with multiple bands. In some cases only one digit is involved.
When the band is isolated, it is important to distinguish a band of longitudinal melanonychia due to drugs from a band of longitudinal
Summary
An accurate clinical history is essential to diagnose drug-induced nail changes. Drug-induced nail alteration should be suspected when several or all nails are affected. The drugs that most commonly cause nail abnormalities are cancer chemotherapeutic agents, systemic retinoids, and indinavir. Only a few classes of drugs produce reproducible nail changes in a significant number of patients.
How cancer chemotherapeutic agents could have such pleotropic effects on the different parts of the nail
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