[Lichenoid drug eruption with antituberculosis drugs associated with an anonychia]. / Toxidermie lichénoïde aux antituberculeux associée à une anonychie.

INTRODUCTION: Lichenoid cutaneous reactions to antituberculosis drugs are rare. Herein we report a new case. PATIENTS AND METHODS: A 41-year-old patient was seen for a profuse and pruriginous rash occurring 2 weeks after administration of rifampicin and isoniazid for pulmonary tuberculosis. Dermatological examination revealed polymorphic erythemato-squamous plaques with lichenoid, psoriatic and eczematous features, associated with cheilitis, erosions on the cheeks and diffuse onychodystrophy. The skin biopsy confirmed a lichenoid reaction. The pharmacovigilance investigation incriminated isoniazid and rifampicin. The patient was treated with topical corticosteroids and UVB phototherapy. The outcome involved complete regression of the eruption but with secondary anonychia. DISCUSSION: Antituberculosis drugs including isoniazid and rifampicin are known to induce lichenoid reactions. It is difficult to distinguish the results from lichen planus. The clinical polymorphism of the rash as well as the patient's drug intake militate in favour of a diagnosis of lichenoid reaction. Widespread ungual involvement, which is extremely rare, warranted early management in order to avert irreversible anonychia.

[Influence of diagnostic pathway on clinical and non-conventional therapies use in women with breast cancer of the cohort DAMA]. / Influencia de la vía diagnóstica en la clínica y el uso de terapias no convencionales en mujeres con cáncer de mama de la cohorte DAMA.

OBJECTIVE: To describe and analyze the characteristics of breast cancer tumours according to the diagnostic pathway. We analyse the adverse effects of the treatments and the use of unconventional therapies in order to alleviate them. METHOD: Descriptive design nested in a mixed cohort (Cohort DAMA). The dependent variable was the route to diagnosis of breast cancer. The independent variables were age, body mass index, social class, disposable family income, type of tumour, histological degree, tumour stage, recurrences, treatment, adverse effects derived from treatments and unconventional therapies. Bivariate descriptive analyses were performed and univariate and multivariate regression models were adjusted; and graphic representations of the unconventional therapies. RESULTS: There are differences in the characteristics of the tumours, and the impact of the adverse effects derived from the treatments. The patients diagnosed by screening were older, from a high social class, had a higher percentage of tumours of grade I differentiation, initial stages, fewer recurrences and fewer adverse effects due to treatment, although this was not different in the screening group compared to the rest. There was also less use of unconventional therapies. CONCLUSIONS: The results indicate that the implementation of screening programmes increases the possibility of detecting tumours in initial stages and with therapies with fewer adverse effects. As a result, there is less need to resort to unconventional therapies.

Prophylactic management for taxane-induced nail toxicity: A systematic review and meta-analysis.

OBJECTIVE: This meta-analysis was performed to assess the efficacy of cryotherapy and nail solution (NS) use in preventing nail toxicity (NT) induced by taxane-based chemotherapy. METHODS: PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov registry databases were searched for relevant studies published up to December 2018. The primary outcome was taxane-induced NT. Secondary outcomes were skin toxicity (ST), time to toxicity and patient comfort. RESULTS: We reviewed three randomised control trials and six prospective studies with 708 patients. For meta-analysis, taxane-induced NT grading was compared. NT and ST were significantly lower in the cryotherapy patients than in the controls (grade 1 NT: risk ratio [RR] = 0.51, 95% confidence interval [CI] = 0.30-0.89; grade 2-3 NT: RR = 0.36, 95% CI = 0.11-1.12; total NT: RR = 0.49; 95% CI = 0.30-0.79; ST: RR = 0.46, 95% CI = 0.33-0.64). The NS-treated patients exhibited significantly lower NT than the controls. CONCLUSIONS: Nail solution-treated or cryotherapy patients exhibited lower NT incidence and severity associated with taxane-based chemotherapy than the controls. For patients who can afford and comply with NS use or cryotherapy, these measures represent effective prophylactic management for taxane-induced NT and improve their quality of life and functional statuses. Further studies are needed to establish the routine usage protocols, long-term efficacy and safety for these interventions.

Dermatological adverse events with taxane chemotherapy.

Taxanes (docetaxel and paclitaxel) are among the most commonly prescribed anticancer drugs approved for the treatment of metastatic or locally advanced breast, non-small cell lung, prostate, gastric, head and neck, and ovarian cancers, as well as in the adjuvant setting for operable node-positive breast cancers. Although the true incidence of dermatological adverse events (AEs) in patients receiving taxanes is not known, and has never been prospectively analysed, they clearly represent one of the major AEs associated with these agents. With an increase in the occurrence of cutaneous AEs during treatment with novel targeted and immunological therapies when used in combination with taxanes, a thorough understanding of reactions attributable to this class is imperative. Moreover, identification and management of dermatological AEs is critical for maintaining the quality of life in cancer patients and for minimizing dose modifications of their antineoplastic regimen. This analysis represents a systematic review of the dermatological conditions reported with the use of these drugs, complemented by experience at comprehensive cancer centres. The conditions reported herein include skin, hair, and nail toxicities. Lastly, we describe the dermatological data available for the new, recently FDA-and EMA- approved, solvent-free nab-paclitaxel.

Case series of selenium toxicity from a nutritional supplement.

INTRODUCTION: Selenium is an essential trace element, but can be toxic in excess. In May 2008, US FDA reported 201 individuals with adverse reactions to liquid nutritional supplements containing excess selenium and chromium resulting in the largest epidemic of selenosis in the history of the United States. OBJECTIVE: To describe the clinical features, biomonitoring data of selenium levels, and the estimated total dose of selenium ingestions of nine patients with selenium toxicity who presented after use of a liquid dietary supplement with a formulation error. METHODS: A retrospective observational case series was performed on nine patients presenting to our medical toxicology clinic between March 2008 and May 2008 with symptoms of selenosis after consuming a nutritional supplement. Institutional IRB approval was obtained for this case series. RESULTS: Supplement testing revealed almost 200 times the reported amount of selenium. There were 5 males and 4 females and their ages ranged from 15 to 57 years (median 46 years, mean 44.2 years). The mean estimated cumulative dose of selenium ingested in our patients was 1.3 gram over a mean period of 37.5 days (10-60 days). In each case, the symptoms of selenium toxicity manifested within 1 week from the start of ingestion. Initial symptoms included alopecia, dystrophic fingernail changes, GI symptoms, and memory difficulties. The initial whole blood selenium concentrations ranged from 150 to 732 mcg/L (reference mean range 123-193 mcg/L) at an average of 27 days post cessation of the formula. The urinary selenium concentrations ranged from 41 to 220 mcg/g Creat (reference < 25 mcg/g Creatinine). None of the patients required more than supportive care for symptoms and none required hospitalization. CONCLUSION: Selenium is an essential element, which can result in significant toxicity if ingested in large amounts.

Cessation of nail growth following Bajiaolian intoxication.

Bajiaolian (Dysosma pleianthum), a species in the Mayapple family (Podophyllum pelatum), has been widely used as a traditional Chinese herbal medication for the remedies of snake bite, tumor growth, post-partum recovery, and acne. It has also been used in western medicine, especially topically for various skin lesions. Both oral ingestion and dermal application may result in severe toxicity. The clinical presentations reported after Bajiaolian poisoning include nausea, vomiting, diarrhea, abdominal cramps, tachycardia, orthostatic hypotension, paralytic ileus, urinary retention, hepatorenal dysfunction, leukocytosis followed by leukopenia, thrombocytopenia, prolonged areflexia, prolonged paraethesia and sensory ataxia, dizziness, fever, memory impairment, hallucinations, paranoia, convulsion, fainting, and coma. There are no previous reports in the literature about the cessation of nail growth as a clinical presentation following Bajiaolian poisoning. We present a case of nail growth that was halted for more than seven years after a single case of Bajiaolian poisoning.

A complex pattern of melanonychia and onycholysis after treatment with pemetrexed for lung cancer.

A 53-year-old black man was diagnosed with poorly differentiated adenocarcinoma of the lung and treated initially with 4 cycles of paclitaxel in combination with carboplatin and external-beam radiation therapy with a good clinicoradiologic response. The patient tolerated the chemotherapy well and did not develop any skin or nail changes during that period of time. His lung cancer recurred 10 months later, when he was found to have bone metastases. Second-line chemotherapy with pemetrexed 500 mg/m2 intravenously every 3 weeks was commenced. A week prior, the patient was started on folic acid 1 mg orally daily and given an injection of vitamin B12 1000 microg intramuscularly that was continued every 3 cycles thereafter. Dexamethasone 4 mg orally twice daily was given around the time of chemotherapy administration to prevent the dermatitis associated with the drug. The patient denied taking other drugs. Two months into his second-line chemotherapy, he developed multiple, concomitant, transverse and longitudinal black lines in all of his fingernails and toenails. After an interval of 3 months, he presented a complex pattern of nail hyperpigmentation, from combined dense horizontal and longitudinal streaks in some nails to diffuse black discoloration in others (Figure). Other associated changes included koilonychia, dystrophy, and friability of nail plates. Along with normal results of a hepatorenal panel and normal serum vitamin B12 and folate levels, no metabolic or endocrinologic alterations were present to explain the nail pigmentation and dystrophic changes. Results of his mycologic examination and cultures came back negative. When questioned, he denied taking any other drugs including other alternative medicine approaches or vitamin supplements, particularly retinoids, well known for causing severe nail dystrophy.

Argyria associated with colloidal silver supplementation.

A 65-year-old male presented for skin examination and was incidentally noted to have discoloration of the fingernails. These findings were completely asymptomatic. The patient had been taking colloidal silver supplementation (Silverzone 140 ppm silver Gifts of Nature, St. George, UT, USA) for 2 years as therapy for diabetes. He first noticed the onset of nail discoloration 1 year ago. His past medical history included type II diabetes and hypertension. His current medications were metformin, glyburide, and benazepril. Physical examination revealed slate-gray discoloration involving the lunulae of the fingernails (Fig. 1). The skin, mucous membranes, and sclerae were unaffected.

Further observations on the human maximum safe dietary selenium intake in a seleniferous area of China.

This report is a summarization of preliminary results from a study of dietary Se intake in a seleniferous area in order to determine safe levels. All patients have symptoms of toxicity: broken hair strands or various levels of nail damage. Finger-nail signs were the first symptoms used for diagnosis of selenosis in this work. Based upon the lowest blood-Se level of five subjects with persistent overt finger-nail signs of selenosis, it was found in 1986 that the individual marginal toxic blood Se level (LOAEL) and the corresponding Se intake were 1054 micrograms/L and 910 micrograms/d, respectively. To re-examine the clinical signs and blood Se levels of the five individuals and to see how the two are correlated, a study was conducted in July 1992 at the same location in the seleniferous area. The results showed that along with the absence of clinical signs, the average blood Se level had decreased from 1346 to 968 micrograms/L. The corresponding safe Se intake per day would be 819 +/- 126 micrograms (15 micrograms/kg B.W. or approximately 800 micrograms per day, which is suggested as the mean No Adverse Effect Level (NOAEL), and the lower limit of the 95% confidence interval, 600 micrograms per day would approximately the maximum individual safe Se intake. For safety, 400 micrograms is again proposed as the Maximum Safe Daily Dietary Se Intake. Problems inherent in this estimation have been discussed.

Onycholysis in a case of atopic eczema treated with PUVA photochemotherapy.

Onycholysis following the ingestion of psoralens and subsequent exposure to natural sunlight has been reported on several occasions and was first reported following photochemotherapy in 1978 by Ortonne and Baran from France and in 1979 by Mackie from Scotland. Mackie commented that she hoped to stimulate further reports of onycholysis induced by PUVA photochemotherapy in order to establish whether or not it was a definite complication of such treatment. Since then, there has been a dearth of similar reports. We describe a patient with severe atopic eczema and alopecia totalis who developed onycholysis of all finger nails and a toe nail during PUVA photochemotherapy.