A, Diagram showing how the gutter method is performed. An incised plastic tube, eg, a vinyl intravenous drip infusion tube, is inserted between the nail plate and the nail fold and is reinforced with an adhesive to prevent it from falling off. Details are described in the Supplement. B, Changes in visual analog scale (VAS) scores of pain before and 1 week after receiving the first gutter method treatment. Scores were not obtained in 4 patients. Wilcoxon matched-pairs signed rank test was used. C and D, Representative photographs of the digits of the patient with EGFR inhibitor–induced nail changes (No. 2 in the Table) before (C) and 1 week after the first treatment with the gutter method (D). Arrowheads show the tubes that had been inserted by the gutter method treatment.
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Agematsu A, Kamata M, Namiki K, Yabuuchi Y, Nagata M, Tada Y. Usefulness of Noninvasive Management With the Gutter Method for Epidermal Growth Factor Receptor Inhibitor–Induced Paronychia, Pyogenic Granuloma–Like Lesion, and Ingrown Nail. JAMA Dermatol. 2022;158(5):583–585. doi:10.1001/jamadermatol.2022.0725
Nail changes, such as paronychia, pyogenic granuloma–like lesions, and ingrown nail, are common adverse events of epidermal growth factor receptor (EGFR) inhibitors1 and frequently cause severe pain and are refractory to conventional treatment.2 The gutter method is a nonsurgical treatment for ingrown nail in which a plastic tube is placed between the nail plate and nail fold3,4 (Figure, A). This method is easy to perform and does not require a special apparatus or chemicals. However, reports on its effectiveness for EGFR inhibitor–induced nail changes are limited. We investigated the characteristics of EGFR inhibitor–induced nail changes and usefulness of the gutter method.
This study was approved by the ethics committee of Teikyo University (21-082) and was carried out under the principles of the Declaration of Helsinki. Patient informed consent was obtained in the form of opt-out on the website; those who rejected were excluded. Patients with EGFR inhibitor–induced nail changes visiting our department from July 2018 to August 2020 who were treated with the gutter method (eMethods in the Supplement) were included in this study. All data were collected retrospectively from the patients’ medical records. The pain visual analog scale (VAS) scores were evaluated before and 1 week after the first treatment with the gutter method. The proportion of patients achieving treatment success, which was defined as the condition in which no ulcer, pyogenic granuloma–like lesion, or pain was observed within 1 month after the first gutter method treatment, was also assessed.
Data on 11 patients were analyzed. The background characteristics, results of the gutter treatment, and concomitant treatment of patients in this study are summarized in the Table. The gutter method was performed on EGFR inhibitor–induced ingrown nails with severe pain and skin manifestations including inflammation, ulcer, and granuloma, typically once weekly in the first 2 to 4 weeks, once every 2 weeks in the next month, and then once monthly thereafter until remission or for prevention. No patient required conduction anesthesia. Among each hand or foot, nail changes were observed most frequently at the third finger in each hand and at the great toe in each foot. All but 1 patient presented with nail changes in multiple digits. Nine of the 11 patients (82%) achieved treatment success. The pain VAS score significantly decreased (Figure, B). The representative case is shown in the Figure, C and D.
The time at onset of nail changes after initiating EGFR inhibitor treatment and the affected digits observed in our study are mostly compatible with the previous literature.5,6 Regarding treatment of nail changes, the avoidance of friction, use of topical corticosteroid with or without antibiotics, and silver nitrate application are recommended in addition to common treatments such as liquid nitrogen cryotherapy and the taping method; however, EGFR inhibitor–induced nail changes are intractable.2 Because of their intractability, even total nail extraction with destruction of nail matrix, resulting in permanent loss of the nail, has been considered as a treatment option.2 Our study demonstrated that noninvasive management with the gutter method was highly effective for EGFR inhibitor–induced ingrown nails with severe pain and skin manifestations including inflammation, ulcer, and granuloma. It is a simple procedure performed without anesthesia in most cases. Furthermore, this treatment alleviated the pain rapidly, which could improve patients’ quality of life. Although patients usually experience painful changes in several nails, it takes only 5 to 10 minutes to perform the gutter treatment per nail, allowing us to perform this treatment on all affected nails in 1 session. Clinicians should be aware that tubes placed in nails of the hand fall off more easily than those in the foot. The nails in the hand may need more frequent treatment. The limitation of this study is that there was no control group owing to the small number of patients. However, considering the intractability of these adverse events, our study suggests that the gutter treatment can be a good treatment option for EGFR inhibitor–induced nail changes.
Accepted for Publication: February 20, 2022.
Published Online: April 13, 2022. doi:10.1001/jamadermatol.2022.0725
Corresponding Author: Masahiro Kamata, MD, PhD, Department of Dermatology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan (firstname.lastname@example.org).
Author Contributions: Dr Agematsu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Agematsu, Kamata, Tada.
Acquisition, analysis, or interpretation of data: Kamata, Namiki, Yabuuchi, Nagata, Tada.
Drafting of the manuscript: Agematsu, Kamata.
Critical revision of the manuscript for important intellectual content: Kamata, Namiki, Yabuuchi, Nagata, Tada.
Statistical analysis: Agematsu, Kamata.
Administrative, technical, or material support: Kamata, Namiki, Yabuuchi, Nagata, Tada.
Supervision: Kamata, Tada.
Conflict of Interest Disclosures: None reported.
Meeting Presentation: This work was presented as an ePoster at the American Academy of Dermatology Annual Meeting; March 25, 2022; Boston, Massachusetts.