Transverse leukonychia following chemotherapy in a patient with Hodgkin’s disease

ARTICLE

Diseases of the nails can be associated with systemic and skin disorders or can develop as symptoms of hereditary or congenital syndromes. Among the group of acquired nail changes, alterations of colour (chromonychia) are quite frequent [1], however there are few reports of white discoloration of the nails (leukonychia) [2-4]. This report demonstrates that cytotoxic drugs can induce leukonychias.

Case report

A 21-year-old woman with Hodgkin's lymphoma in clinical stage II B (cardinal symptom progressive pruritus, finally dyspnea), received eight courses of polychemotherapy followed by involved field irradiation (30 Gy). Because of a large mediastinal mass, the patient was treated with a dose-escalated protocol for advanced stages within the German Hodgkin's Lymphoma Study Group (GHSG). The chemotherapy consisted of cyclophosphamide 650 mg/m² (day 1), adriamycin 25 mg/m² (day 1), etopophos 113.6 mg/m² (day 1-3), procarbacine 100 mg/m² (day 1-7), prednisolone 80 mg/m² (day 1-7), vincristine 1.4 mg/m² (maximum 2 mg, day 8) and bleomycine 10 mg/m² (day 8) at two-weekly intervals (BEACOPP-pilot study). The vinca alkaloid was omitted from the fifth course on because of vincristine-induced polyneuropathy. Further side effects were amenorrhea, reversible total alopecia, oral mucositis and gastritis. Two weeks after the end of chemotherapy of 16 weeks duration, the patient was referred to our dermatology clinic with severe changes to her fingernails. The patient presented with multiple transverse white striations across all of her fingernails (Fig. 1a and b).

Treatment was started with oral biotin 5 mg daily for 100 days and retinol acetate (1,000 IE), cystine and gelatine daily for two intervals of three weeks each. Under this supplementary treatment, the nail changes gradually disappeared and were barely visible after three months. One year after therapy was completed, the patient is in persistent complete remission with residual mediastinal abnormality (histologically confirmed necrosis). At follow-up, the patient complained about a split right thumbnail. Leukonychia changes have regressed completely.

Discussion

True leukonychia clinically exhibits white discoloration of the nails in five different patterns (Fig. 2). The cause of leukonychias can be hereditary [5], congenital [6] or acquired [7]. Among the latter, a variety of conditions have been reported to be either associated with or to induce leukonychias (Table I).

In some reported cases, however, the etiology of leukonychias remains unknown. There are several arguments pointing towards a causal relationship between the systemic application of chemotherapy and the appearance of leukonychia in our patient. First, cytotoxic or chemotherapeutic agents have the potential to induce nail changes, because they are known to interfere with the cell cycle [8-12]. Second, there is a temporal coincidence between the application of the chemotherapeutic drugs and the appearance of the nail changes. The leukonychia in our patient was manifest early after the first cycle of the combination chemotherapy, increased during the course of eight cycles of intensive chemotherapy, and eventually resolved three months after the end of the chemotherapy. Third, the specific chemotherapeutic agents used in our patient, particularly cyclophosphamide, adriamycin and vincristine, have been described to produce these effects [13, 14]. In contrast, the possibility that the nail changes were caused by the Hodgkin's lymphoma itself appears to be unlikely. Moreover, local factors which could have been potentially involved, would not have been expected to affect all fingers.

In some leukonychias, histology of the nail plate revealed a temporary defect in the keratinization process in the matrix of the fingernails. Because of the reduced performance status of the patient we refrained from obtaining a specimen for histological examination. Generally acquired leukonychias regress completely as long as the matrix damage has not been irreversible.

CONCLUSION

In conclusion, the reported case demonstrates transverse leukonychia as a possible but rare side effect of systemic chemotherapy in oncological patients.

Article accepted on 27/3/00

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