Taxane-induced nail changes

Nail changes are one of the most common mucocutaneous adverse effect of chemotherapeutic agents.Usually limited to a cosmetic concern and reversible with drug withdrawal, they may occasionally be painful and disabling.Since chemotherapeutic agents target rapidly dividing cells, nail matrix is an easy target.All or some nails may be affected.Fingernails are more commonly affected than toenails.A 75-year-old male was referred from oncology in view of nail changes noticed for one month.He was a known case of squamous cell carcinoma of the upper thoracic oesophagus post radiotherapy and had received four cycles of paclitaxel in the past year.He was started on docetaxel about a month ago.There was no history of trauma.On examination, all fingernails were involved, and toenails were spared.Mees lines, onycholysis, longitudinal ridging and Beau's lines were observed.Subungual hyperkeratosis in second digit of the left hand suggested onychomycosis; however, direct microscopy was negative for fungal elements.Periungual changes, including paronychia, were also present [Figure 1].The rest of the mucocutaneous examination was normal.Onychoscopy demonstrated diffuse yellow-brown pigmentation with occasional white streaks, Mees lines, onycholysis with a sharp irregular border, onychoschizia and subungual hyperkeratosis in non-polarised mode.Crosspolarised mode and UV dermoscopy highlighted the subtle surface changes including onychorrhexis and Beau's lines.Although faint scattered accentuation was seen, no intense bright green or yellow fluorescence pattern typical for fungal infection was observed, corroborating our negative microbiological examination [Figures 2 and3].No vascular proliferation or subungual haemorrhages were seen.The patient was started on topical corticosteroids and showed mild improvement at one-month follow-up.The pathogenesis and morphology of nail changes caused