Reactive management

Reactive management of nail changes induced by multikinase inhibitor treatment

General recommendation: Early intervention is important. Paronychia is associated with considerable morbidity and is difficult to treat – emphasise prevention and early intervention to prevent superinfection.^1-2

Treatment overview

Management of paronychia aims to minimise trauma, reduce inflammation, prevent superinfection and eliminate any excessive granulation tissue.^1-3 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 table below) are recommended to prevent superinfection,¹ and may be intensified if infection does occur.⁴

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

Finally when all of the above options fail, consider nail avulsion or surgical debridate interventions.

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, drug interruption or discontinuation should be considered.

Table 33: Management of nail changes associated with multikinase inhibitors by CTCAE grade^{1-3, 6-10}

Grade	Description
1	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)
2	Povidone–iodine ointment Oral antibiotics (tetracyclines if not superinfected, otherwise consider oral quinolones) Oral analgesic Pyogenic granuloma: electrocautery or weekly silver nitrate application
3	Continue systemic antibiotics and weekly silver nitrate; consider nail avulsion Intravenous antibiotics if needed
4	Not applicable

Products

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.

References

Lacouture ME, et al. MASCC Skin Toxicity Study Group. Support Care Cancer. 2011; 19: 1079-95.
Califano R. et al. Drugs. 2015;75:1335-48.
Beech J. et al. Future Oncol. 2018;14:2531-2541.
Boers-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.
Lynch TJ Jr, et al. Oncologist. 2007; 12: 610-21.
McLellan B & Kerr H. Dermatologic therapy. 2011; 24: 396-400.
Bensadoun RJ, et al. Cancer Manag Res. 2013; 5: 401-8.
Balagula Y, et al. J Support Oncol. 2010; 8(4): 149-61.
Potthoff K, et al. Ann Oncol. 2011; 22: 524-35.
Grande E, et al. Adv Ther. 2013; 30: 945-66.