Reactive Management for Nail Changes

General Recommendation

Early intervention is important. Nail changes are associated with considerable morbidity and are difficult to treat – emphasise prevention and early intervention to prevent superinfection.1-3

Treatment Overview

Management of paronychia aims to minimise trauma, reduce inflammation, prevent superinfection and eliminate any excessive granulation tissue.1 Treatment recommendations are based on anecdotal reports and expert opinion.

High-potency topical corticosteroids are recommended as the first-line therapy for paronychia.1 Calcineurin inhibitors are another option. Tetracyclines are also used to reduce inflammation. However, antimicrobials should only be given for culture-proven infections.1

Due to the potential for superinfection in paronychia, skin culture should be performed to guide antimicrobial treatment.1 Antimicrobial soaks (e.g. dilute solutions of bleach iodide compounds or white vinegar; see below) are recommended to prevent superinfection,1 and may be intensified if infection does occur.2

In patients who develop pyogenic granuloma, excessive granulation tissue may be eliminated using electrocautery, silver nitrate chemical cauterisation and if these do not work, nail avulsion.1

Among the other nail changes potentially associated with targeted therapy, subungual splinter haemorrhages are relatively common but resolve spontaneously without treatment.4 Similarly, retarded nail growth and brittle nails do not require treatment but application of nail polish, liquid bandages or glue may prevent nail fragmentation.5 Biotin has been successfully used to treat brittle nails in the general population.1

Finally when all of the above options fail, consider nail avulsion.

Patients should be evaluated weekly. With the second or third occurrence of nail changes intensifying supportive measures is advised. If symptoms worsen despite the intensified measures, interruption or discontinuation of the multikinase inhibitor should be considered.

Treatment of NCI-CTCAE V4.03 Grade 11,6,7,8

  • Antimicrobial soaks: 1:1 vinegar in warm water, diluted bleach (0.005%), povidone iodine 1:10, potassium permanganate 1:10,000, 2-3 times a day 15-20 minutes each time
  • Povidone-iodine-based ointments
  • Ultrapotent topical corticosteroid (first-line therapy)
  • Topical calcineurin inhibitors
  • Topical analgesic (e.g. lidocaine 4% gel)
  • Povidone-iodine-based ointment
  • Ultrapotent topical corticosteroid
  • Calcineurin inhibitors
  • Topical analgesic (e.g. lidocaine 4% gel)
  • Oral tetracycline (e.g. doxycycline or minocycline)
  • Antimicrobial treatment as indicated
  • Silver nitrate

Treatment of NCI-CTCAE V4.03 Grade 21,6,7,8

  • Povidone–iodine ointment
  • Oral antibiotics (tetracyclines if not superinfected, otherwise consider oral quinolones)
  • Oral analgesic
  • Pyogenic granuloma: electrocautery or weekly silver nitrate application

Treatment of NCI-CTCAE V4.03 Grade 31,6,7,8

  • Continue systemic antibiotics and weekly silver nitrate; consider nail avulsion
  • Intravenous antibiotics if needed


  • Povidone-iodine-based ointment
  • Ultrapotent topical corticosteroid
  • Calcineurin inhibitors
  • Topical analgesic (e.g. lidocaine 4% gel)
  • Oral tetracycline (e.g. doxycycline or minocycline)
  • Antimicrobial treatment as indicated
  • Silver nitrate

Multikinase Inhibitor Treatment

Continue with/withhold the selected multikinase inhibitor treatment regimen, as recommended in the current and relevant SPC and according to the patient’s condition.


1Lacouture ME, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011;19:1079-95.
2Boers-Doets CB. The TARGET SYSTEM. Approach to assessment, grading, and management of dermatological & mucosal side effects of targeted anticancer therapies. ISBN 978-94-92070-00-5. 2014
3Lynch TJ Jr, et al. Epidermal growth factor receptor inhibitor-associated cutaneous toxicities: an evolving paradigm in clinical management. Oncologist. 2007; 12: 610-21.
4McLellan B & Kerr H. Cutaneous toxicities of the multikinase inhibitors sorafenib and sunitinib. Dermatologic therapy. 2011; 24: 396-400.
5Bensadoun RJ, et al. Daily baseline skin care in the prevention, treatment, and supportive care of skin toxicity in oncology patients: recommendations from a multinational expert panel. Cancer Manag Res. 2013; 5:401-8.
6Balagula Y, et al. Dermatologic toxicities of targeted anticancer therapies. J Support Oncol. 2010;8(4):149-61.
7Potthoff K, et al. Interdisciplinary management of EGFR-inhibitor-induced skin reactions: a German expert opinion. Ann Oncol. 2011;22:524-35.
8Grande E, et al. Vandetanib in Advanced Medullary Thyroid Cancer: Review of Adverse Event Management Strategies Adv Ther. 2013; 30: 945-66.

Last update: 22 August 2014