Nail Discoloration Research Articles

Melanonychia and skin hyperpigmentation with hydroxyurea therapy

Sir, Hydroxyurea or hydroxycarbamide is an antineoplastic drug used in myeloproliferative disorders (chronic myeloid leukemia, polycythemia vera, and essential thrombocythemia), psoriasis (second-line systemic agent), and AIDS (antiretroviral properties potentiate the activity of the nucleoside reverse transcriptase inhibitor didanosine). The adverse mucocutaneous effects include hyperpigmentation, alopecia, leg ulcers, and lichenoid eruptions. We report a patient who developed hyperpigmentation of the skin and nails 10 weeks after the start of hydroxyurea therapy. A 31-year-old man presented to the dermatology outpatient department with gradually progressive pigmentation of hands, legs, and all finger-nails since 1 month. The pigmentation started from proximal parts of nail plates and progressed distally. The patient was receiving hydroxyurea for chronic myeloid leukemia in a dose of 1 g/day for last three and half months. On examination, diffuse uniform hyperpigmentation was noted on all 10 finger-nails involving approximately half to two-thirds of the nail plates [Figure 1]. Hyperpigmentation was seen on hands and legs with sparing of toe nails. All routine investigations were normal except for mild anemia (hemoglobin 12.2 g/dL and hematocrit 43.8%). All necessary investigations were carried out to eliminate Vitamin B-12 deficiency, hyperbilirubinemia, Addison's disease, Cushing's syndrome, hyperthyroidism, hemosiderosis, scleroderma, and HIV. At the time of presentation, he was not taking any other drug that could have caused the nail hyperpigmentation. We considered temporary discontinuation of the drug and restart it to observe the outcome. However, the patient was lost to follow-up. According to causality assessment by Naranjo's algorithm, this event could be defined as “probable”.[1] Figure 1 Hyperpigmentation involving hands and all 10 finger-nails; involving proximal half to two-third of the nail plates. Nail grows at a rate of 0.1 mm/day. It takes approximately 100–120 days for the whole nail to grow. Finger nails grow faster than the toe nails. Nail changes as a result of antineoplastic drugs are asymptomatic and entirely reversible within few months after withdrawal of the offending agents. The most frequent presentation of chromonychia (various patterns of nail discoloration) induced by antineoplastic drugs is melanonychia, a dark pigmentation of nails seen in diffuse, transverse, or longitudinal band patterns. It may co-exist with diffuse pigmentation of skin, also known as melanoderma. The mechanism of hydroxyurea-induced melanonychia is still unknown; the potential causes include toxicity affecting the nail bed or nail matrix, focal stimulation of nail-matrix, melanocytes, and photosensitization. The differential diagnosis includes subungual melanoma, pigmented squamous-cell carcinoma, subungual hematoma, nevus, and hyperpigmentation owing to other drugs, including cyclophosphamide, doxorubicin, minocycline, and zidovudine. Aste et al. reported nail hyperpigmentation in nine patients appearing between 6 and 24 months of hydroxyurea-therapy, the commonest presentation being longitudinal melanonychia.[2] Longitudinal melanonychia, diffuse melanonychia affecting all nails and hyperpigmentation of the skin were observed in one patient. However in our case, presentation was noted early; within 10 weeks of starting of therapy. There are reports of progressive transverse melanonychia of all 20 nails within 7 weeks of starting hydroxyurea in a patient of thrombocytosis.[3] Gropper et al. and Issaivanan et al. reported melanonychia of all 20 nails with involvement of all three mucocutaneous areas (skin, nails, and mucosa) in a 63-year-old black woman and a 10-year-old boy, respectively, within 3 months of therapy.[4,5] A dermatomyositis-like eruption was observed in two reported cases.[6] Jeevankumar et al. reported a rare case of hydroxyurea-induced blue lunula.[7] Sometimes both longitudinal melanonychia and periungual hyperpigmentation may be observed together.[8] This presentation may be confused with Hutchinson's sign in malignant melanoma. Ideally, all cases of melanonychia should be distinguished from subungual malignant melanoma. We, therefore, report this interesting case where progressive diffuse melanonychia was observed in all 10 finger-nails with noticeable sparing of the toe nails, associated with pigmentation of hands and legs 10 weeks after starting hydroxyurea therapy.

A Hydroxyurea-induced Leg Ulcer

Hydroxyurea is a cytostatic agent that has recently become the drug of choice in the treatment of various myeloproliferative diseases. The cutaneous side effects of hydroxyurea include xerosis, hyperpigmentation, nail discoloration, and scaling. Leg ulcers have only rarely been reported in association with hydroxyurea treatment. A 75-year-old woman presented with leg ulcers, nail discoloration, and xerosis. The leg ulcers were refractory to conventional treatment. She had been taking oral hydroxyurea since being diagnosed with essential thrombocytosis in 2002. Hence, we suspected hydroxyurea-induced leg ulcers and discontinued her hydroxyurea treatment; the ulcers gradually healed thereafter. We present a rare case of hydroxyurea-induced leg ulcers in Korea.

Randomized open comparative trial of dexamethasone-cyclophosphamide pulse and daily oral cyclophosphamide versus cyclophosphamide pulse and daily oral prednisolone in pemphigus vulgaris

In various case series, pulse therapy has shown good results in pemphigus vulgaris (PV), with long-term remissions. To compare the efficacy and side-effects of dexamethasone-cyclophosphamide pulse and daily oral cyclophosphamide (DCP+C) versus cyclophosphamide pulse and daily oral prednisolone (CP+P) in PV. Twenty-eight active PV patients were randomized to receive either DCP with daily oral cyclophosphamide (Group A, n = 15) or CP with tapering doses of daily oral prednisolone (Group B, n = 13) for 12 months and followed-up for at least 3 months after stopping therapy. They were compared for time taken to achieve mucocutaneous disease control, achieve remission, relapse during treatment period, relapse after stopping therapy and side-effects. Of 28 cases, 25 (Group A - 15, Group B - 10) completed the study period and were analyzed. The time for initiation of cutaneous response and time to achieve complete disease remission were significantly lesser in group B. However, other efficacy parameters were comparable. In Group A, significant adverse events were dysgusea, hiccups, palpitation, nail discoloration, bone pain and urinary tract infection while in Group B, they included nausea, moon facies, flushing, secondary amenorrhea, steroid withdrawal symptoms and dyspnea due to weight gain. Early remission was achieved in group B but the relapse rates during the treatment phase or after stopping therapy were comparable. Both therapies had comparable side-effect profiles, although Group B showed greater steroid-induced adverse events.

A Case of Yellow Nail Syndrome Manifesting as Chronic Recurrent Pleural Effusion

Yellow nail syndrome is a rare cause of pleural effusions. This syndrome is characterized by yellow discoloration of nails, lymphedema, and respiratory disorders, including pleural effusion, chronic bronchitis, bronchiectasis, and chronic sinusitis. The etiology of this syndrome is obscure, but the pathogenesis seems to be related with impaired lymphatic drainage. We report a case of yellow nail syndrome in a 70-year-old female with the typical clinical findings (yellow discoloration of nails, lymphedema, and chronic pleural effusion) of this disorder and with proven lymphatic obstruction on lymphoscintigraphy.

Cyclophosphamide-induced nail discoloration and skin hyperpigmentation: a rare presentation

Clinical and Experimental DermatologyVolume 34, Issue 3 p. 405-406 Cyclophosphamide-induced nail discoloration and skin hyperpigmentation: a rare presentation K. Chittari, K. Chittari Departments of DermatologySearch for more papers by this authorS. Tagboto, S. Tagboto Nephrology, University Hospital of North Staffordshire, Stoke-on-Trent, ST4 7LN, UKE-mail: kimchittari@yahoo.co.ukSearch for more papers by this authorB. B. Tan, B. B. Tan Departments of DermatologySearch for more papers by this author K. Chittari, K. Chittari Departments of DermatologySearch for more papers by this authorS. Tagboto, S. Tagboto Nephrology, University Hospital of North Staffordshire, Stoke-on-Trent, ST4 7LN, UKE-mail: kimchittari@yahoo.co.ukSearch for more papers by this authorB. B. Tan, B. B. Tan Departments of DermatologySearch for more papers by this author First published: 12 March 2009 https://doi.org/10.1111/j.1365-2230.2008.02896.xCitations: 7 Conflict of interest: none declared. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume34, Issue3April 2009Pages 405-406 RelatedInformation

Nail discoloration occurring after 8 weeks of minocycline therapy

Minocycline-induced nail pigmentation is an uncommon side-effect. It usually develops after years of the therapy, and coincides with other pigmented sites. We report a 73-year-old male and a 33-year-old female developing nail discoloration after 8 weeks of therapy of 100 mg minocycline twice daily. No other pigmentation was found elsewhere on the skin, mucous membranes, teeth or sclerae of them. Our cases demonstrate that nail pigmentation can occur after short-term minocycline therapy, and propose the possibility that nail discoloration may precede other pigmentary changes.

Congenital Curved Nail of the Fourth Toe—Three Different Clinical Presentations

A congenital curved nail of the fourth toe (NIM 219070) is a rare nail deformity with no other associated abnormalities. Three patients with this congenital anomaly are reported here. Radiologic examination in all three revealed distal symphalangism of the fourth toes bilaterally. The clinical manifestations in these patients included white discoloration of the proximal nails and hyperkeratotic tylosis.

A 72-year-old male with episodic dyspnea on exertion

A 72-year-old male with a history of histiocytic lymphoma of the gastrointestinal tract after undergoing a partial gastrectomy and radiation and chemotherapy of regional lymph nodes presents with dyspnea on exertion and progressive nail discoloration. On examination, his blood pressure is 90/60. Cardiac and abdominal exams are within normal limits. His lung exam shows symmetric expansion but is reduced in volume, and features very severely reduced breath sounds in both lung bases without any wheezes, rales, or rhonchi. Marked discoloration and shortened corrugated appearance of the nails is noted, without any peripheral cyanosis as shown in Fig 3. A previously performed computed tomography scan of the chest reveals the presence of chronic bilateral pulmonary effusions and multiple areas of bronchiectasis. Pulmonary function tests reveal moderate obstructive and restrictive impairment.7.What is this patient's most likely diagnosis for the nail findings? (Choose single best response.)a.Muehrcke linesb.Pseudomonas pyocyanea nail infectionc.yellow nail syndromed.leukonychiae.half-and-half nail8.In addition to yellow nails, which of the following are the other two symptoms in the classic triad of yellow nail syndrome? (Choose single best response.)a.pleural effusion and lymphedemab.sinusitis and bronchiectasisc.lymphedema and bronchiectasisd.pleural effusion and sinusitise.pleural effusion and bronchiectasis9.In most cases, which of the following is the initial symptom of yellow nail syndrome? (Choose single best response.)a.pleural effusionb.yellow nailsc.bronchiectasisd.lymphedemae.sinusitis10.What percentage of patients with yellow nail syndrome show spontaneous resolution of their condition? (Choose single best response.)a.10%b.30%c.50%d.70%e.90%11.Which of the following treatment options have been reported anecdotally to be effective in treating yellow nail syndrome? (Choose single best response.)a.vitamin E 1200 IU/dayb.topical antifungal creamc.vitamin A 1200 IU/dayd.prednisone 40 mg/day for 1 weeke.thoracocentesis12.Yellow nail syndrome is known to be associated with which of the following conditions? (Choose single best response.)a.thyroiditisb.rheumatoid arthritisc.hypogammaglobulinemiad.A and Be.A, B, and C13.Which of the following cell types predominate the pleural exudates found in yellow nail syndrome? (Choose single best response.)a.neutrophilsb.lymphocytesc.eosinophilsd.basophilse.erythrocytes

NAIL DISCOLORATION INDUCED BY DOXYCYCLINE

All tetracyclines are deposited in calcifying areas of the bones and teeth and may cause discoloration. Although hyperpigmentation of the skin, teeth and nails have been reported and well documented due to other tetracycline intake, it has been rarely reported that discolored nails induced by doxycycline in pediatric patients. Here we report an 11-year-old-boy with nail discoloration caused by doxycycline intake.

Sparfloxacin induced blue/black discoloration of all nails: Report of three cases

Sparfloxacin induced blue/black discoloration of all nails: Report of three cases

FD&C blue dye no. 1 and blue nail discoloration:: Case report

FD&C blue dye no. 1 and blue nail discoloration:: Case report

Yellow Nail Syndrome in Association with Protein-Losing Enteropathy in a Diabetic Patient

The yellow nail syndrome is a rare disorder which is characterized by the triad of y ellow nails, lymphedema and pleural effusion. The etiology of the syndrome is unknown, but impaired lymphatic drainage may play a role in its pathogenesis. The yellow nail syndrome has been reported in association with various conditions such as thyroid disease, hypogamma-globulinemia, nephrotic syndrome, rheumatoid arthritis, obstructive sleep apnea, keratosis obturans in the external ear, carcinoma of the gall bladder, xanthogranulomatous pyelonephritis, onychomycosis and proteinlosing enteropathy (PLE) in the literature. 1-3 A case of a diabetic woman with chronic recurrent pleural effusion, lymphedema, yellow discolored nails, chronic sinusitis, bronchiectasis and PLE is presented here. Case Report

Which antifungal agent for onychomycosis? A pharmacoeconomic analysis.

The incidence of fungal nail infections is increasing and this is possibly because of several factors: better methods of detection, a growing population of immunocompromised patients who have a greater susceptibility to such infections, the increased use of immunosuppressive drugs, the increasing number of elderly people, worldwide travel, and the use of communal bathing facilities. Onychomycosis is a fungal infection of the fingernails and toenails that accounts for about 30% of all superficial fungal infections. It is characterised by nail discoloration, thickening and ultimately destruction of the nail plate. Management of this disease has improved significantly and treatment patterns have dramatically changed in recent years as a result of advances in new treatment options (e.g. oral antifungal agents) and changes in treatment regimens (e.g. pulse therapy). Also, newer drugs for onychomycosis have improved tolerability profiles compared with older agents. The overall costs of treating onychomycosis are substantial, and it has been estimated that direct cost for US Medicare patients with the disease is 43 million US dollars per year (year of costing not available). Pharmacoeconomic studies help in the decision-making process when selecting the most cost-effective antifungal agents to treat onychomycosis. To date there have been a number of national and international economic studies aimed at effectively assessing the efficacy and costs of the treatment options available to cure onychomycosis. The objectives of this paper are to (i) review the published findings regarding the epidemiology of onychomycosis; (ii) summarise the original pharmacoeconomic studies that describe the economic impact of the disease; and (iii) address the impact of the disease on patients' health-related quality of life.

Yellow nail syndrome presenting as non‐immune hydrops: Second case report

The yellow nail syndrome is characterized by slowly growing yellow discolored nails and lymphoedema, with onset generally after puberty. We report on a newborn infant who, at 23 weeks, was found to have hydrops on antenatal ultrasonography and bilateral chylothorax at delivery. His mother has the yellow nail syndrome, with typical nail changes, and bronchiectasis. There seemed to be no other etiology for the non-immune hydrops, and this is the second documented case of the prenatal manifestation of this condition. Am. J. Med. Genet. 93:1–4, 2000. © 2000 Wiley-Liss, Inc.

Glomus Tumor:a Clinical and Histopathologic Analysis of 17 Cases

Background: Glomus tumor is a benign neoplasm derived from the normal glomus body. This tumor includes the following types; solitary, multiple, proliferating, and acral arteriovenous. Histologically, it was subdivided into solid type, glomangioma, and glomangiomyoma. Its malignant counterpart - glomangiosarcoma - was reported. Objectives: The purposes of this study were aimed to evaluate the clinical and pathologic presentations of glomus tumor. Methods: A total of 17 patients who have been diagnosed with glomus tumor by histopathologic examination were reviewed. Results: Male patients were ten and female patients were seven. The age of the onset of glomus tumor varied from birth to 61 years. The location of tumors were as follows: arm (7 cases), finger (6 cases), back (2 cases), leg (1 case), foot (1 case). The digit was the most common site for female patients. Clinical manifestations showed solitary bluish papule (6 cases), subcutaneous nodule (5 cases), nail discoloration (3 cases), nail dystrophy (1 case), bluish plaque (1 case). One patient had no specific lesion but tenderness. The most characteristic symptom was pain in 15 (88.2%) of the 17 patients, and the other two patients had no symptom. Two asymptomatic lesions were located on the forearm and histopathologically showed glomangioma. Histopathologically, 13 (76.5%) of the 17 patients classified as solid type, and 4 (23.5%) the glomangioma variety. Conclusion: Glomus tumors were most commonly seen as a painful nodule on the upper extremity and especially female patients showed predilection for subungual location. We speculate that multiple, mild symptomatic lesions might be a tendency to be glomangioma. (Ann Dermatol 12(2) 95~101, 2000).

Yellow nail syndrome presenting as non-immune hydrops: Second case report

The yellow nail syndrome is characterized by slowly growing yellow discolored nails and lymphoedema, with onset generally after puberty. We report on a newborn infant who, at 23 weeks, was found to have hydrops on antenatal ultrasonography and bilateral chylothorax at delivery. His mother has the yellow nail syndrome, with typical nail changes, and bronchiectasis. There seemed to be no other etiology for the non-immune hydrops, and this is the second documented case of the prenatal manifestation of this condition.

Running-Related Toenail Abnormality

A 33-year-old man presented with a keratotic plaque on his distal second toe. The plaque had been present for several months, and he also reported nail discoloration. The patient had no other related complaints. There was no family history of a similar eruption.

Pigmented nail with atypical melanocytic hyperplasia

We report two cases showing black discoloration of the thumb nail which were histologically found to be acral lentiginous melanoma (ALM) in situ. A pigmented subungual lesion is more frequently malignant than benign and it is generally believed that diagnosis of subungual melanoma during the radial-growth phase is very difficult. Our cases are particularly interesting because atypical melanocytic hyperplasia was confined to the epidermis despite the lesion being present for a long time.

Onycholysis in Doxorubicin-Treated Patients

To the Editor.— Six cases of onycholysis associated with doxorubicin have been reported to Adria Laboratories, Columbus, Ohio, since 1987. The reactions were occasionally accompanied by fingertip erythema, palmar erythema, or nail discoloration, and proceeded to the loss of one or more nails in three patients. Nail loss did not occur in the other three patients. Of the three patients experiencing no nail loss, one had an intercurrent fungal infection of the nails. Coagulase-positive Staphylococcus and α-hemolytic Streptococcus were isolated from clear drainage in the second patient. The last patient showed nail loosening in the absence of any pathogen. Mean onset of onycholysis was 15 weeks following initiation of doxorubicin therapy (range, 12 to 22 weeks). Doxorubicin was the sole form of chemotherapy used in three patients, and was combined with cyclophosphamide in three patients. Dexamethasone pretreatment was used in all patients in this series, and was discontinued in five

Nail discoloration and human immunodeficiency virus infection

Nail discoloration and human immunodeficiency virus infection