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Brief Report |

Hair and Nail Changes During Long-term Therapy With Ibrutinib for Chronic Lymphocytic Leukemia

Carole Bitar, MD1,2; Mohammed Z. H. Farooqui, MD2; Janet Valdez, PA2; Nakhle S. Saba, MD2,3; Susan Soto, RN2; Amanda Bray, RN2; Gerald Marti, MD, PhD2; Adrian Wiestner, MD, PhD2; Edward W. Cowen, MD, MHSc4
[+] Author Affiliations
1Department of Medicine, Tulane University, New Orleans, Louisiana
2Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
3Section of Hematology and Medical Oncology, Department of Medicine, Tulane University, New Orleans, Louisiana
4Dermatology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
JAMA Dermatol. 2016;152(6):698-701. doi:10.1001/jamadermatol.2016.0225.
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Importance  Ibrutinib, a Bruton tyrosine kinase inhibitor, is a new targeted agent approved by the US Food and Drug Administration for the treatment of chronic lymphocytic leukemia (CLL), mantle cell lymphoma, and Waldenström macroglobulinemia. Ibrutinib is overall well tolerated but long-term treatment is required until disease progression or intolerable toxic effects occur. Little is known regarding its cutaneous adverse effects.

Objective  To describe the hair and nail manifestations associated with the long-term use of ibrutinib for the treatment of CLL.

Design, Setting, and Participants  Prospective study of 66 patients with CLL enrolled in a single-arm phase 2 clinical trial of ibrutinib for CLL between March 2014 and October 2015 at the National Institutes of Health.

Main Outcomes and Measures  The primary outcome, nail and hair changes associated with ibrutinib therapy, was assessed by an 11-question survey. In addition, the severity of nail changes was determined from a 0 to 3 rating scale for both onychoschizia and onychorrhexis.

Results  Among 66 patients (43 men and 23 women with ages ranging from 55 to 85 years), 44 (67%) reported brittle fingernails at a median of 6.5 (95% CI, 6-12) months after starting ibrutinib therapy. Fifteen patients (23%) developed brittle toenails after a median of 9 (95% CI, 6-15) months of ibrutinib therapy. Textural hair changes were reported in 17 patients (26%), at a median of 9 (95% CI, 6-12) months of ibrutinib treatment.

Conclusions and relevance  Hair and nail abnormalities are commonly associated with ibrutinib and appear several months after initiating therapy. Ibrutinib inhibits Bruton tyrosine kinase by covalently binding to cysteine 481. Whether ibrutinib affects the hair and nails by binding and altering cysteine-rich proteins of hair and nails or by means of another mechanism remains unknown.

Trial Registration  clinicaltrials.gov Identifier: NCT01500733

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Figure 1.
Ibrutinib-Associated Onychorrhexis of the Fingernails

Moderate onychorrhexis of the fingernails in a patient with chronic lymphocytic leukemia after 6 months of ibrutinib therapy.

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Figure 2.
Ibrutinib-Associated Onychoschizia of the Toenails

Onychoschizia of the toenails 11 months after initiation of ibrutinib therapy.

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