A 7-year-old boy with acute lympho-blastic leukemia underwent chemotherapy with Vincristine, Adriamycin and L-Asparaginase. After 6 weeks of induction therapy, he went into complete remission. On routine following up, while on consolidation phase of chemotherapy he was found to have transverse pigmented bands of bluish-gray hue, of varying degree of intensity, involving all the finger nails (Fig. 1) and the great toe nails (Fig. 2). The nail plates and the proximal and lateral nail folds had a normal morphology. There was also patchy macular hyperpigmentation of the dorsal hands and feet, especially of the fingers (Figs. 1 & 2). There was no mucosal pigmentation.

Fig. 1. Transverse pigmented bands of finger nails and hyperpigmented skin of dorsum of hand.

Fig. 2. Transverse melanonychia of great toes.

Melanonychia (pigmentation of nails) in childhood can be caused by drugs (antibiotics, chemotherapeutic agents), infections (e.g., pseudomonas, onychomycosis), skin diseases (like psoriasis) and rarely subungual malig-nant melanoma. Chemotherapy induced hyperpigmentation of the skin and nails is reversible and most commonly seen with drugs like doxorubicin, cyclophosphamide and hydroxyurea. Cytotoxic drug induced melanonychia occurs most frequently in women and also has a racial predilection to blacks and dark skinned individuals. Trans-verse melanonychia seems to occur in relation to intermittent courses of chemotherapy because of a direct toxic effect on the nail matrix. The time interval between the start of therapy and the first signs of nail pigmentation might depend on the rate of nail growth. This would explain the later and less frequent appearance of changes in the toenails.

Issaivanan M,
Praveen H. Khairkar,
Department of Hematology,
AIIMS, New Delhi 110 029, India.
E-mail: [email protected]