Mees' lines because of chemotherapy for Hodgkin's lymphoma

Mees’ lines because of chemotherapy for Hodgkin’s lymphoma Dear Editor, A 21-year-old man presented with transverse white bands affecting his fingernails (Fig. 1) that appeared soon after the first course of chemotherapy for Hodgkin’s lymphoma. In particular, the patient had been administered Adriamycin, Bleomycin, Vinblastine, and Dacarbazine (ABVD) about 3 weeks before the appearance of nail changes. The white bands were homogeneously spread across all the fingernail plates, showing the same convexity as the proximal lunula, as a sign of exogenous injury or trauma. Pressure on nail plates did not induce disappearance of transverse bands, indicating a true leukonychia. Color changes were not detectable on the toenails. On the basis of these findings, a diagnosis of Mees’ lines (ML) secondary to chemotherapy was made. ML, also known as transverse leukonychia, are a peculiar clinical presentation consisting of single white horizontal nail bands described for the first time by Mees et al in 1919 secondary to arsenic poisoning. Some authors prefer the term ML only in association with arsenic intoxication, suggesting to name “transverse leukonychia” all the other forms. Other conditions could induce this phenomenon, such as heart failure, infectious disease, psoriasis, respiratory disorders, chemotherapeutic agents, and traumas. The latter is associated with transverse white bands that tend to follow the same curvature as the proximal nail fold as shown in our patient, whereas systemic disease-associated lines usually have a contour similar to distal lunula. The cause of ML is an abnormal keratinization, particularly in the inner side of the nail plate because of temporary dysfunction of the nail growth induced by systemic disorders, and these disappear when the cause has been eliminated. In our case, the cause can be attributed to ABVD treatment for Hodgkin’s lymphoma, potentially inducing a transient matrix injury. Differential diagnosis can be made with (i) congenital transverse leukonychia, usually present since birth and also affecting toenails, (ii) pseudoleukonychia, also known as Muehrcke’s lines secondary to hypoalbuminemia, liver disease, or malnutrition usually disappearing after nail plate pressure, or (iii) Beau’s lines, palpable transverse linear lines of the nail plate caused by processes involving the nail matrix such as myocardial infarction, rheumatic fever, or chemotherapy. ML are benign conditions that do not require specific intervention and disappear with the end of the inducing injury. In our case, the interruption of the ABVD therapy induced full recovery of nail condition. As chemotherapy is often associated with cutaneous adverse reactions, dermatologists should be aware of this condition and promptly recognize the most typical and the least common ones, including nail changes, and learn when patient’s reassurance may be the best strategy for management.