Docetaxel-induced palmoplantar erythrodysesthesia syndrome and long-lasting multiple nail changes
A 52-year-old female patient had undergone left radical mastectomy with axillary lymph node dissection for invasive ductal breast carcinoma. She had completed the third cycle of docetaxel chemotherapy (CT) with the dose of 100 mg/m2 and a cumulative dose of 480 mg. One week after the cycle, she presented to the out-patient department with palmoplantar redness, pain, tingling and burning sensation which had started 3 weeks back. In her medical history, the patient was on insulin and atorvastatin for diabetes mellitus and hyperlipidemia.\nExamination of the patient revealed palmoplantar erythema, tenderness, desquamation and onycholysis of the second fingernail of the right hand [Figure and ]. The patient had noticed onycholysis after the first cycle; palmoplantar erythema had emerged 1 week after the second cycle of docetaxel CT. Examination of the feet for fungal infection was negative. The laboratory examinations including complete blood count, liver and kidney functions tests were within normal limits except higher total cholesterol and low density lipoprotein levels (270 mg/dl and 199 mg/dl, respectively). Whole-body bone scintigraphy, abdominal ultrasonography and electromyography were normal.\nThe clinical findings of the patient were compatible with a diagnosis of palmoplantar erythrodysesthesia (PPES) and nail toxicity due to docetaxel CT. The severity of PPES was grade 2 according to the National Cancer Institute Common Toxicity Criteria (NCI-CTC). Potent topical steroids, oral pyridoxine (250 mg/day), elevation of extremities during infusion and cold pack application were recommended. PPES regressed completely after 1 week and the patient tolerated the next CT infusions more comfortably. However, the dysesthesia symptoms did not lessen. After completion of CT treatment, the patient was put on radiotherapy of the operated region for 25 days. During the follow ups, the nail changes began to worsen 2 months after docetaxel CT. All fingernails of hands and feet had onycholysis; some of them had subungal hyperkeratosis, nail pain, brown discoloration and four consecutive Beau's lines []. Examination for fungal infection was negative. According to NCI scale, nail changes were compatible with grade 2 nail toxicity. About 6 months after CT, all fingernails of both hands completely recovered while toe nails had still minimal distal subungal hyperkeratosis and brown-yellow discoloration. The severity of dysesthesia symptoms regressed by more than 50%. The relationship between docetaxel and PPES and nail changes was considered ‘certain/definite’ using the WHO-UMC scale[] and Naranjo's algorithm.[]