Nail Changes - Paronychia

Definition

Paronychia is an inflammation in the tissues adjacent to a nail on a finger or toe, with an often tender inflammation of the nail fold.1,2 Secondary superinfection with Staphylococcus aureus may occur and may be responsible for symptomatic impairment and resistance to treatment.2 Paronychia can be extremely painful and mimics an ingrown toenail in severe cases where Pyogenic granuloma of the nail fold develops.1-3

Incidence

Nail abnormalities and disorders are reported to occur in up to 9% of patients treated with the multikinase inhibitors; paronychia is reported to occur with vandetanib.4-9

Pathological Features

Paronychia is probably caused by horny material, caused by Cell growth arrest and differentiation, that gets stuck between the nail plate and nail fold and pricks like a needle into the nail fold.1 These changes in epithelial homeostasis cause the disruption of the cutaneous barrier leading to inflammation.

Onset

Nail changes with sunitinib and sorafenib are reported to typically occur within the first 2 months of therapy.12 Subungual splinter haemorrhage associated with sorafenib and sunitinib therapy is reported to appear 2–4 weeks after initiating therapy.3 Paronychia typically occurs within 4-8 weeks of therapy with vandetanib. 

Resolution

Nail changes are reported to resolve spontaneously.12 Also see management of nail changes, paronychia.

Grading and Lesion Characteristics

According to NCI-CTCAE V4.03,10 paronychia is defined as “A disorder characterised by an infectious process involving the soft tissues around the nail.” Pyogenic granuloma is not mentioned in this grading, so for this adverse event the general grading, “Skin and subcutaneous tissue disorders - Other, specify” should be used and “pyogenic granuloma” added. Within the MESTT both paronychia and pyogenic granuloma are included in the general term “nail fold changes”.11

Grade 1 (mild) Nail Changes

Paronychia

  • The NCI-CTCAE V4.03 definition of grade 1 paronychia reads: Nail fold oedema or Erythema; disruption of the cuticle

Skin and subcutaneous tissue disorders – Other

  • The NCI-CTCAE V4.03 definition of grade 1 skin and subcutaneous tissued disorders, others reads: Asymptomatic OR mild symptoms; clinical or diagnostic observations only; intervention not indicated

Nail fold changes

  • The MESTT definition of grade1 nail fold changes reads: Disruption or absence of cuticle; OR erythema

Grade 2 (moderate) Nail Changes

Paronychia

  • The NCI-CTCAE V4.03 definition of grade 2 paronychia reads: Localised intervention indicated; oral intervention indicated (e.g., antibiotic, antifungal, antiviral); nail fold oedema OR erythema with pain; associated with discharge OR nail plate separation; limiting Instrumental ADL.

Skin and subcutaneous tissue disorders – Other

  • The NCI-CTCAE V4.03 definition of grade 2 skin and subcutaneous tissued disorders, others reads: Moderate; minimal, local or non-invasive intervention indicated; limiting age appropriate instrumental ADL

Nail fold changes

  • The MESTT definition of grade 2 nail fold changes reads: Erythematous/ tender/painful; OR pyogenic granuloma; OR crusted lesions: OR any fold lesion interfering on instrumental ADL

Grade 3 (severe) Nail Changes

Paronychia

  • The NCI-CTCAE V4.03 definition of grade 3 paronychia reads: Surgical intervention or i.v. antibiotics are indicated; limiting self-care ADL.

Skin and subcutaneous tissue disorders – Other

  • The NCI-CTCAE V4.03 definition of grade 3 skin and subcutaneous tissued disorders, others reads: Severe or medically significant but not immediately life-threatening; hospitalisation or prolongation of existing hospitalisation indicated; disabling; limiting self-care ADL

Nail fold changes

  • The MESTT definition of grade 3 nail fold changes reads: Periungual abscess OR fold changes interfering with self-care ADL

Paronychia by grade

References

1Segaert S, et al. Skin toxicities of targeted therapies. Eur J Cancer. 2009;45 Suppl 1:295-308.
2Robert C, et al. Cutaneous side-effects of kinase inhibitors and blocking antibodies. Lancet Oncol. 2005;6:491-500.
3Balagula Y, Lacouture ME, Cotliar JA. Dermatologic toxicities of targeted anticancer therapies. J Support Oncol. 2010;8:149-161.
4Food and Drug Administration. Caprelsa® (vandetanib) Prescribing Information 2014.
5European Medicines Agency. Stivarga® (regorafenib) Summary of Product Characteristics 2013.
6European Medicines Agency. Nexavar® (sorafenib) Summary of Product Characteristics 2014.
7European Medicines Agency. Sutent® (sunitinib) Summary of Product Characteristics 2014.
8European Medicines Agency. Glivec® (imatinib) Summary of Product Characteristics 2014.
9Food and Drug Administration. Gleevec® (imatinib) Prescribing Information 2013.
10National Cancer Institute Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events and Common Toxicity Criteria [v4.0]. 15-12-2010. (accessed 22 August 2014)
11Multinational Association of Supportive Care in Cancer (MASCC) EGFR Inhibitor Skin Toxicity Tool (MESTT) (accessed 22 August 2014)
12McLellan B, Kerr H. Cutaneous toxicities of the multikinase inhibitors sorafenib and sunitinib. Dermatol Ther. 2011;24:396-400.

Last update: 22 August 2014