Chemotherapy-associated paronychia: don't forget the children.

To the Editor: The publication by Wetzel et al1Wetzel M.L. Rubin A.I. Hanania H. Patel A.B. Treatment recommendations for nail unit toxicities secondary to targeted cancer therapy based on collective experience and evidence-based literature review.J Am Acad Dermatol. 2022; 87: 180-183Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar provides an excellent algorithm based on the literature review for the management of chemotherapy-associated paronychia in adults. Among the reviewed chemotherapy agents, we deem of particular interest the update concerning selumetinib, which is a MEK inhibitor recently approved for the treatment of inoperable plexiform neurofibromas in children. We would like to point out that the incidence of selumetinib-induced paronychia reported by the authors includes both pediatric and adult populations (9% to 48%).1Wetzel M.L. Rubin A.I. Hanania H. Patel A.B. Treatment recommendations for nail unit toxicities secondary to targeted cancer therapy based on collective experience and evidence-based literature review.J Am Acad Dermatol. 2022; 87: 180-183Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar However, according to the existing literature, paronychia occurs more frequently in children compared to adults with an incidence ranging between 31.6% and 51.2%.2Gross A.M. Wolters P.L. Dombi E. et al.Selumetinib in children with inoperable plexiform neurofibromas [published correction appears in N Engl J Med. 2020 Sep 24;383(13):1290].N Engl J Med. 2020; 382: 1430-1442Crossref PubMed Scopus (264) Google Scholar, 3Boull C.L. Gardeen S. Abdali T. et al.Cutaneous reactions in children treated with MEK inhibitors, BRAF inhibitors, or combination therapy: a multicenter study.J Am Acad Dermatol. 2021; 84: 1554-1561Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 4Coltin H. Perreault S. Larouche V. et al.Selumetinib for symptomatic, inoperable plexiform neurofibromas in children with neurofibromatosis type 1: a national real-world case series.Pediatr Blood Cancer. 2022; 69e29633Crossref PubMed Scopus (3) Google Scholar This difference may be imputable to the higher physical activity level of children resulting in recurrent trauma to the nails. Nevertheless, evidence-based approaches for treating dermatologic toxicities in pediatric patients on selumetinib are lacking. Although we are grateful for the management algorithm proposed by the authors,1Wetzel M.L. Rubin A.I. Hanania H. Patel A.B. Treatment recommendations for nail unit toxicities secondary to targeted cancer therapy based on collective experience and evidence-based literature review.J Am Acad Dermatol. 2022; 87: 180-183Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar we believe that it could not be completely applicable to the pediatric setting due to various issues such as patients' compliance and drug prescription limitations. Specifically, the use of doxycycline is known to be effective in refractory paronychia for its anti-inflammatory properties, but it is not approved for children under the age of 8. In the age group of 2 to 7 years, we speculate that the use of azithromycin may be a valid therapeutic option for the long-term and low-dose administration, taking advantage of its anti-inflammatory and immunomodulatory effects on chronic inflammatory dermatoses.5Parnham M.J. Erakovic Haber V. Giamarellos-Bourboulis E.J. et al.Azithromycin: mechanisms of action and their relevance for clinical applications.Pharmacol Ther. 2014; 143: 225-245Crossref PubMed Scopus (382) Google Scholar Additional studies are needed to assess the efficacy of macrolide therapy in refractory paronychia. Also the management of simple preventive skin care measures may be challenging in this class of patients. Restricting systematically children's sports practices to minimize nail trauma may compromise quality of life. However, caregivers should be advised on the importance of wearing comfortable shoes, avoiding aggressive manicuring, and diverting children from onychophagia or onychotillomania. In order to avoid therapy discontinuation and to maximize children's quality of life, we need to define specific pediatric treatment guidelines by considering these aspects. None disclosed.