Management   |   Patient advice   |   Grading

 

Adverse event management: paronychia

Management recommendations1

Grade 1:

  • Continue GIOTRIF® (afatinib) treatment at current dose
  • Topical antibiotics or antiseptics*, vinegar soaks** and topical ultrapotent steroids should be considered

 

Grade 2:

  • Continue GIOTRIF® (afatinib) treatment at current dose
  • Topical antibiotic*, vinegar soaks** and topical ultrapotent steroids
  • Weekly application of silver nitrate

 

Grade ≥3 or intolerable Grade 2:

  • Refer to a dermatologist
  • Interrupt GIOTRIF® (afatinib), resuming treatment at a reduced dose (10mg lower) if patient recovers to grade ≤1. Permanent discontinuation should be considered in patients who cannot tolerate 20 mg/day of GIOTRIF® (afatinib) treatment
  • Topical antibiotics* and vinegar soaks**
  • Weekly application of silver nitrate
  • Nail avulsion and systemic antibiotics should be considered

Advice for patients2

  • Avoid biting nails, overly aggressive manicures/pedicures and nail trauma
  • Avoid contact with irritating substances and prolonged exposure to water
  • When it is necessary to wear vinyl gloves, cotton gloves should be worn underneath
  • High risk patients should take extra care to ensure their nails are kept dry and clean. These include:
    • Patients repeatedly exposed to moist environments, e.g. housekeepers, swimmers
    • Diabetic and immunosuppressed patients who may be more prone to infections

Grading3

The paronychia grading system can be used to steer management strategy.

Grade 1 

Grade 2

Grade 3

Nail fold oedema or erythema; disruption of the cuticle

Localised intervention indicated; oral intervention indicated (e.g., antibiotic, antifungal, antiviral);

nail fold oedema or erythema with pain; associated with discharge or nail plate separation; limiting instrumental ADLa

Surgical intervention or IV antibiotics indicated; limiting self-care ADLb

Grade 1 

Nail fold oedema or erythema; disruption of the cuticle

Grade 2

Localised intervention indicated; oral intervention indicated (e.g., antibiotic, antifungal, antiviral);

nail fold oedema or erythema with pain; associated with discharge or nail plate separation; limiting instrumental ADLa

Grade 3

Surgical intervention or IV antibiotics indicated; limiting self-care ADLb

 

Adapted from CTCAE version 3.3


*Topical antibiotics/antiseptics include: clindamycin 1%, chloramphenicol 1% and iodine ointment

**Vinegar soaks consist of soaking fingers or toes in a solution of white vinegar in water 1:1 for 15 minutes every day

aInstrumental ADL=preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc.

bSelf-care ADL=bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden

AE=adverse event


References

1
Lacouture ME, et al. Expert Rev Anticancer Ther 2013;13(6):721–728.
2
Aw DC, et al. Asia-Pac J Clin Oncol 2018;14(1):23–31.
3
Common Terminology Criteria for Adverse Events (CTCAE) Version 3