Paclitaxel Induced Subungual Hemorrhage: A Case Report

The New Journal of Medicine 2013;30:202-203
Case report
Paclitaxel Induced Subungual Hemorrhage:
A Case Report
(Paklitakselin neden olduu subungual kanama: bir olgu)
Bengü Çevirgen CEML 1 , Nazan EMROLU 1 , Göksen nanc MAMOLU 2 , Fatma Pelin CENGZ 1 ,
Rustem AMAZ 1
1 Ministry of Health Dkap Yldrm Beyazit Education and Research Hospital Department of
Dermatology, ANKARA
2 Ministry of Health Dkap Yldrm Beyazit Education and Research Hospital Department of Medical
Oncology, ANKARA
ÖZET
nfiltratif duktal karsinomu tans olan 46 yandaki bir
kadn hastann paklitaksel ile tedavisinin on ikinci haftasnda
trnak toksisitesi geliti. Paklitaksel taksan ailesinden
bir kemoterapötik ajandr. Taksan grubu kemoterapötik
ajanlarn trnak deiiklikleri de dahil olmak üzere
çeitli kutanöz yan etkileri bildirilmitir. Subungual kanamalar
da paklitaksel kullanm sonrasnda geliebilir.
Anahtar Kelimeler: Kemoterapötik ajanlar; kanamalar;
paklitaksel; subungual; taksan
ABSTRACT
A 46-year-old woman with infiltrating ductal carcinoma
of the breast cancer developed nail toxicity while she
was being treated with paclitaxel for twelve weeks.
Paclitaxel is a chemotherapeutic agent of the taxane
family. Various cutaneous side effects, including nail
changes, have been associated with taxane chemotherapeutic
agents. The subungual haemorrhages could be
developed following to paclitaxel usage.
Key Words: Chemotherapeutic agents; hemorrhages;
paclitaxel; subungual; taxane
INTRODUCTION
Taxanes, including paclitaxel (Taxol®) and docetaxel
(Taxotere®), are chemotherapeutic agents that
are used in the treatment of breast, ovarian and
lung carcinomas. Their mechanisms of action are
by stabilizing microtubule assembly and preventing
microtubule depolymerization, which then
results in mitotic arrest 1 .
Nail changes are often noted with cytotoxic
agents and described in different series and case
reports but the real incidence is not known very
well. A wide clinical spectrum of nail changes is
possible but we focus a case presented with
subungual hemorrhages secondary to paclitaxel.
CASE
A 46 year-old woman was admitted to our
clinic for nail changes. The patient had suffered
from infiltrating ductal carcinoma of the breast
treated with modified radical mastectomy and
axillary lymph node dissection. And then she had
received four cycles of anthracycline 60 mg/m 2
and cyclophosphamide 600 mg/m 2 chemotherapy.
Following these treatments weekly paclitaxel (80
mg/m 2 ) and trastuzumab (4 mg/m 2 first week,and
than 2 mg/m 2 maintenance) therapy were planned
for 12 week. After 11 courses of weekly paclitaxel
and trastuzumab she presented with nail changes
of her left big toe nail. Dermatological examination
revealed red–brown discolouration of the left
big toe nail (Figure 1). Despite nail changes, the
patient received 12 th dose. In addition, the right
big toe nail was affected after 12
th dose of
paclitaxel (Figure 2).
Figure 1. Painless subungual hemorrhage is evident in
the left big toe nail
Correspondence:
Bengu Cevirgen CEML M.D.
Ministry of Health Diskapi Yildirim Beyazit Education and Research Hospital
Department of Dermatology, Ankara
e-mail: dbcemil@yahoo.com
Arrival date : 27.11.2012
Acceptance date : 04.01.2013
Figure 2. Painless subungual hemorrhage is evident in
both big toe nails
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B. evirgen Cemil et al.
There was no pain on her both toes. At 6 months
after completion of chemotherapy, residual
hyperpigmentation has also remained.
DISCUSSION
Paclitaxel belongs to the taxane group of
antineoplastic agents. The taxanes were
introduced in the late 1980s. Since then it has
proved that taxanes were effective in the
treatment of a variety of solid tumors including
breast, ovarian, lung and bladder cancers 2 .
Taxanes exert their cytotoxic effect by
reversibly binding the -subunit of tubulin, thereby
inducing tubulin polymerization and inhibiting
microtubule depolymerization 3,4 . Nail changes are
a common and well-known side-effect of many
antineoplastic drugs, especially methotrexate, 5-
fluorouracil, mitoxantrone, etoposide, and
doxorubicin 5,6 . In addition, it has previously been
reported that antineplastic drugs cause reactions
such as onycholysis, pigmentation, bands,
thickening or thinning of the nail bed, and nail
shedding 7 .
Paclitaxel usage may cause hypersensitivity
reactions 8 and radiation recall dermatitis resulting
in extensive desquamation and cutaneous necrosis 9
which are occasionally observed. A generalized
pustular reaction secondary to paclitaxel treatment
has been also reported 10 . The most frequent skin
reaction to paclitaxel is a complete sudden
alopecia, reversible when the drug is discontinued 11 .
Nail abnormalities include different clinical
manifestations such as onycholysis, subungual
hemorrhages and abscesses with secondary
pigmentation and less frequently Beau’s lines and
acute paronychia 3 . These paclitaxel-induced nail
abnormalities suggest that this drug not only is
toxic to the nail matrix and nail bed keratinocytes
but also may affect the vascularization of the nail
unit structures 6 .
The mechanism of how paclitaxel induces the
observed nail abnormalities remains unclear 5 .
Possible explanations for subungual hematoma
and hemorrhagic onycholysis are the taxaneinduced
thrombocytopenia and vascular
abnormalities 3 . Premedication with steroids and
antihistaminics prevents fluid retention and acute
hypersensitivity reactions, like flushing, dyspnea
or hypotension, but do not seem to protect
against skin toxicity 12,13 .
Our patient developed painless subungual
hemorrhages on only big toe without abcess. In
addition, subungual hemorrhage showed firstly on
the left big toe and then fifteen days later it
revealed on the right big toe. After paclitaxel
treatment had been finished, subungual hemorrhages
resolved without using any medication.
Subungual haemorrhages due to taxanes may,
in fact, be painful or not, and associated or not
with purulent discharge in different patients. The
variation in nail symptom severity may be related
to drug dosage 14 , to dosing interval 15 and to the
individual patient’s susceptibility. Flory et al.
reported that the occurrence and severity of nail
changes in their series of four patients were not
related to drug dosage 5,15 .
In conclusion, paclitaxel is used for cancer
therapy that can affect the nail unit. Subungual
haemorrhages could be associated with paclitaxel.
Clinicians should recognize the different spectrum
of skin and nail changes induced by paclitaxel, and
patients should be informed of this distressing
side-effect.
Confinct of interest statement none declared.
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