Side Effect: Nail Changes

Nail changes in patients with cancer can be caused by an underlying condition (such as diet or cancer), cancer treatment, infection, or radiation exposure. The exact mechanism behind these changes from chemotherapy is not fully understood, but it is thought to be related to the effect of chemotherapy drugs on rapidly dividing cells in the nail matrix and nail bed.

Nail changes can occur in fingernails, toenails, or both. Some common nail changes include:

• Separation of the nail from the nail bed (onycholysis) which makes the nail likely to come off
  • Separation can also create a place where an infection can happen
• Nail Shedding (onychomadesis)
• Discoloration and darkening of the nail or nail bed
• Brittle, dry or cracked nails
• Ridges or lines across the nail (beau’s lines)
• Thickening of the nail
• Pitting of the nails (small dents or depression in the nail)
• Nail appears wider or swollen, like an upside down spoon (clubbed nail)
• Slow nail growth or no nail growth
• Redness or swelling of the nail bed (paronychia)
• Nail infection

Chemotherapy drugs that are associated with nail changes include:

• Taxanes (paclitaxel, docetaxel, Abraxane®)
• Anthracyclines (doxorubicin, adriamycin, idarubicin, daunorubicin, epirubicin, mitoxantrone)
• Alkylating agents (cyclophosphamide, ifosfamide, dacarbazine, melphalan)
• Antimetabolites (5-fluorouracil, hydroxyurea, methotrexate, capecitabine)
• mTOR inhibitors (everolimus, temsirolimus)
• VEGF inhibitors (sorafenib, sunitinib)
• EGFR inhibitors (cetuximab, panitumumab, necitumumab, erlotinib, gefitinib, dacomitinib, afatinib, amivatamab, lapatinib, neratinib, osimertinib, vandetanib)

Preventing nail changes during cancer treatment can be challenging, however some strategies include:

• Check your fingernails and toenails every day for changes.
• Keep fingernails and toenails clean and dry.
• Use nail lacquer on nails that are delicate, splitting, cracking, or brittle to strengthen and protect the nail.
• Use good hand and foot hygiene to avoid infections.
• Avoid trauma and pressure to the nails and nail bed.
• Avoid professional manicures while receiving treatment with chemotherapy.
• Keep nails trimmed and short.
• Wear protective gloves and shoes during physical activity when possible.
• If you are receiving a taxane drug with your cancer treatment, consider applying a cold ice pack to nails starting 15 minutes before the infusion of the drug, during the infusion, and for 15 minutes after infusion. This could prevent nail separation from the nail bed.

Some nails changes are not harmful or painful and just affect appearance. These usually do not need treatment and generally resolve once cancer treatment has completed. This includes nail discoloration, ridges or lines across the nail, thickening, pitting, and slow nail growth.

Biotin (vitamin B₇) is a dietary supplement that may help to strengthen nails that are brittle. Nail lacquer or prescription nail polish can also protect splitting or delicate nails. Ask your doctor if biotin, nail lacquer, or nail polish are safe before using.

Some types of nail changes are more serious, painful, or involve an infection and require treatment. Some treatments include:

• Removing the nail
• Topical treatments you paint on the nail, or oral antimicrobials in pill form that your doctor prescribes
• Disinfecting soaks
• White vinegar and water soaks (1 part vinegar to 1 part water) for nail bed swelling
• Topical steroids for nail bed swelling

If you have any nail changes, let your doctor know as soon as possible.