Nail and skin changes during breast cancer treatment

While some cancer treatment side effects are well-known even to people without cancer, such as hair loss, nausea, and loss of energy, others can be surprising for those who experience them. Some of these side effects are changes to the fingernails, toenails, and skin. Changes to the nails and skin are common with some breast cancer treatments. This is especially true for people in treatment for metastatic breast cancer because treatment is ongoing.

Depending on the kinds of treatment you have, you may notice changes to your skin and nails. In most cases, nail and skin changes disappear within a few weeks to several months after you stop the treatment that causes them. Still, if you have nail and skin changes, they can be upsetting to see and may cause discomfort. For some people, they can interfere with daily activities. Below, we’ll talk about why nail and skin changes happen with some breast cancer treatments. We’ll also share ways to manage nail and skin changes.

Nail side effects

Some breast cancer treatments can affect the physical characteristics of your nails. Fingernails and toenails are made of a hard layer of dead skin cells. They form to protect the tips of our fingers and toes, and they help make it possible for us to pick up small objects by supporting the soft tip of the finger.

The two main parts of the nail are the nail bed, which is the skin underneath the nail, and the nail itself, which is sometimes called the nail body or nail plate. The nail body attaches to our fingers and toes through the nail bed. Blood vessels in the nail bed carry nutrients to the nails, and make the nail bed look pink in most people.

The most common treatment side effects that impact the nails include:

• Painful, thin, weak, brittle, or cracked fingernails and toenails
• Nail blemishes such as white streaks, lines, or small indentations
• Ragged or dry cuticles
• Nail darkening or color changes
• Nails that lift off the nail bed or fall off completely
• Beau’s lines: deep ridges that form horizontally across the nail (from side to side) because treatment temporarily stopped the nail from growing
• Koilonychia, sometimes called “spoon nails,” in which the nails are indented or concave
• Nail infections
• Nail fungus

How to manage nail side effects

Some nail side effects only impact the way your nails look, such as ridges and creases in the nails, or changes in color. But some changes can be painful or may mean you have an infection in the nail bed. Still, there are ways to manage the different kinds of changes that can happen:

• Split, brittle, or ridged nails can be protected with special nail polish recommended or prescribed by your medical team.
• Weak nails may benefit from biotin, a dietary supplement you take by mouth as a vitamin. Be sure to talk to your care team before taking biotin to make sure it’s appropriate for you.
• Swollen, inflamed nails can be treated with prescription steroid creams, disinfecting soaks, and prescription medicines or antibiotics. Your nurse or doctor may also recommend soaking the inflamed nails in a solution of water and white vinegar.
• If nails are pulling away from the nail bed or falling off completely, or if nails develop deep grooves that crack (nail fissures), minor surgery may be needed to remove the nail body and relieve pain.
• A skin infection called paronychia can develop around the nails on the fingers or toes. It can look like fungus and is common after 2 or more months of chemotherapy treatment. Effects include pain, redness, and swelling around the nails; pus; and/or thickening or discoloration of the nail. Let your care team know if you experience any of these. They may recommend:
  • Soaking fingers or toes in a solution of 1-part white vinegar to 10 parts warm water for 15 minutes every night
  • Wearing soft cotton gloves, especially when working with your hands and when sleeping, to reduce the risk of nails lifting off the nail bed
  • Wearing socks with soft padded shoes or slippers to protect the toenails. If the condition worsens, your team may prescribe an ointment or cream
• Nail infections may be treated with antibacterial cream recommended by your care team.

You can also try these at-home tips to protect your nails during treatment:

• Keep nails trimmed and clean.
• Wear gloves when doing household chores, gardening, or cleaning.
• Avoid cutting or removing your cuticles. Instead, use a moisturizer or massage them with natural oils such as olive oil or vegetable oil.
• Ask your care team to recommend brands of nail-strengthening polish.
• Avoid using artificial nails, as they can increase your risk of infection.
• Look for roomier shoes if your toenails become painful.
• If your nails start to lift off the nail bed, keep them clean and protected. You can use a bandage to protect them from any trauma.
• If you regularly visit a dermatologist (a doctor who specializes in skin disorders), explain that you are receiving breast cancer treatment that can cause nail changes.

Skin side effects

The skin is the body’s largest organ. It’s made of layers of skin cells, collagen fibers, fat, and connective tissue. The skin protects the body from germs, sun rays, toxic substances, and extreme temperatures. It gives us our sense of touch, stores water, and produces hormones, among other functions.

Though the skin is a tough barrier against many things, cancer treatments can irritate it, from mildly to severely. Some of the most common skin side effects are:

• Redness
• Thin or fragile skin
• Peeling
• Sensitivity to sunlight
• Skin color changes
• Rashes
• Dry skin
• Blisters
• Scarring
• Numbness
• Pain, soreness, or burning
• Swelling and pus in the skin around the fingernails or toenails (an infection called paronychia)
• Itching
• Acne

How to manage skin side effects

Though changes to the skin can be uncomfortable, there are many ways to manage them throughout breast cancer treatment.

• Moisturize dry skin with alcohol-free body lotion, especially after bathing.
• Consider adding baby or mineral oil to bathwater, or put it on after showering, to moisturize the skin.
• Avoid using very hot water to bathe.
• Avoid practices that rub or irritate the skin, such as shaving, rubbing dry with a towel, or scrubbing with loofas or bath rags. Instead, wash carefully and pat the skin dry.
• Stay hydrated by drinking enough water. Talk to your doctor about how much you should drink while in treatment.
• Use mild, unscented soaps and skin products.
• Wear loose-fitting clothing to avoid fabric rubbing on the skin.
• Sleep in a cool room to avoid sweating.
• Stay out of direct sunlight, and wear sunscreen of SPF 30 or higher on any skin exposed to the sun.
• If your care team confirms that you have paronychia (a skin condition involving pain, redness, and swelling around the fingernails or toenails), they may recommend soaking fingers and toes in a solution of 1-part white vinegar to 10 parts warm water for 15 minutes each night; wearing soft cotton gloves while working with hands and sleeping; and wearing socks with soft padded shoes or slippers. They may also prescribe an ointment or cream if needed.

There are also ways your care team can help. Ask them:

• About skin care tips
• If they can recommend a soothing salve, such as pure aloe
• To prescribe medicine that can help if needed

What causes nail and skin changes?

There are many types of breast cancer treatments that can lead to changes in the skin and nails. But just because a treatment can cause a side effect does not mean that everyone taking that treatment will experience it. Every person reacts differently to cancer treatments, so while some people may have significant, uncomfortable changes to the skin and nails, it is possible to have changes that are mild, or to see no changes at all.

Chemotherapy, radiation therapy, and some hormonal and targeted therapies can all cause nail and skin changes. Surgery can cause scars and skin numbness where nerves have been cut. Other issues that can happen with treatment — injury, irritation, infection, and vitamin deficiency — can also affect the health of your nails and skin.

Below, we’ll talk about how some common breast cancer treatments can lead to changes in the skin and nails.

Chemotherapy

Chemotherapy works well at killing fast-growing cells, such as cancer cells. But some other, healthy cells in our bodies are also fast-growing. These include the cells that help skin stay soft and nails to grow. Chemotherapy can make your skin more sensitive and reduce the oil your skin makes, causing dryness.

In some cases, chemotherapy can cause certain white blood cells, called neutrophils, to drop to low levels, a condition called neutropenia. Neutropenia increases the risk of infections of the skin and nails.

Some common skin effects of chemotherapy are:

• Redness
• Rash
• Dryness
• Peeling
• Sensitivity to the sun
• Pain, swelling, redness and/or pus in the skin around the fingernails or toenails (an infection called paronychia)

Some common nail effects of chemotherapy are:

• Cracking
• Darkening
• Painful or sore cuticles

Chemotherapy medicines that can cause nail and skin changes include:

• Capecitabine (Xeloda)
• Docetaxel (Taxotere)
• Doxorubicin (Adriamycin)
• Liposomal doxorubicin HCI liposome injection (Doxil)
• Ixabepilone (Ixempra)
• Daunorubicin (Cerubidine, daunoxome)

Radiation therapy

Radiation therapy can cause skin reactions in the area receiving radiation and the skin surrounding it. In breast cancer, this is commonly the breast, chest, and underarm area. Radiation therapy can also be given to other parts of the body in people living with metastatic breast cancer.

Radiation therapy can cause a gradual, sunburn-like skin reaction on the area being treated. The skin may swell or puff. Because radiation affects nerve endings in the skin, it can cause skin to feel more sensitive to touch. Radiation can also make skin dry and itchy, cause it to peel, or cause darkening. Sometimes, people receiving radiation therapy develop sores that can become painful or infected.

Video: Skin care and scarring after breast cancer surgery and radiation therapy

In this interview, Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, speaks with breast surgical oncologist Monique Gary, DO, MSc, FACS, about ways to protect your skin before, during, and after treatment. Dr. Gary explains how doctors evaluate your skin before treatment and questions to ask. She also shares information on how to minimize keloids and hypertrophic scars, and about specific products, lotions, and supplements that strengthen skin, plus guidance to protect your sensitive skin in the summer sunshine.

Hormonal therapy

Hormonal therapies work against hormone receptor-positive breast cancers by disrupting how the body makes estrogen or the ways that estrogen helps cancer cells grow. Hormones in our bodies do many things, and one of them is contributing to our skin’s plumpness, hydration, and color. When hormonal therapy changes estrogen levels, there can be skin side effects. For example:

• The hormonal therapies tamoxifen and anastrozole (Arimidex) can sometimes cause a skin rash.
• Aromatase inhibitors including anastrozole, exemestane (Aromasin), and letrozole (Femara) can cause dry skin.

Targeted therapy

Targeted therapies are medicines that zero in on specific parts or actions of cancer cells to stop them from making cancer grow. Some of them target parts of cells involved in the growth or health of skin cells, which is why people taking them may see changes to the nails and skin.

Certain targeted therapies are known to cause skin and nail changes:

• Alpelisib (Piqray) can cause a rash; scaly skin; or red, itchy bumps.
• Everolimus (Afinitor) can cause a red, bumpy, dry, and sore rash, as well as cracked, dry, and itchy skin that may become scaly. It can also cause the skin to darken.
• Lapatinib (Tykerb) can cause an acne-like rash that cannot be treated with acne medication. The rash can be red, swollen, dry, crusty, and sore.
• Neratinib (Nerlynx) can cause a rash that is red and feels swollen, crusty, dry, and sore. The skin can also crack and itch.
• Palbociclib (Ibrance) can cause a rash.
• Pertuzumab (Perjeta) can cause the nails to darken, become brittle, or fall off. It can also cause a skin rash that appears as red, itchy bumps.
• Ribociclib (Kisqali) can sometimes cause an uncommon but severe skin side effect. If you develop a severe rash; red skin; flu-like symptoms; skin pain or burning; and/or lip, eye, or mouth blisters with or without a fever, you should contact your doctor right away.
• Sacituzumab govitecan (Trodelvy) can cause a rash; scaly skin; or red, itchy bumps.
• Tucatinib (Tukysa) can cause a skin reaction called hand-foot syndrome that involves tingling, redness, burning pain, itching, or swelling of the hands and feet, sometimes with blisters and peeling skin.
• Trastuzumab (Herceptin) can cause a rash.

Immunotherapy

Immunotherapy uses the body’s own immune system to destroy cancer cells. Immunotherapies approved to treat breast cancer include immune checkpoint inhibitors such as pembrolizumab (Keytruda). Immune checkpoint inhibitors don’t commonly cause skin side effects, but they can happen. These can include:

• Itchy or tight skin
• A burning sensation
• Rash
• Cracked or peeling skin
• Blisters
• Redness or other changes of color
• Areas of hair loss

Talking with your care team

Skin and nail treatment side effects can cause discomfort, and while many of them can be managed at home with the tips we provided earlier on this page, it’s important to report all side effects to your care team. If nail and skin issues become too uncomfortable, painful, or are getting in the way of everyday needs, your doctors may be able to offer advice or care. For example, they may be able to recommend pain or inflammation relievers, topical creams to help with rashes, or antibiotics to treat infections.

When you start treatment, or if you notice nail and skin changes, consider asking these questions:

• Can my treatment change my skin or nails?
• Can I prevent nail and skin side effects from happening? How?
• Can I continue my current nail routine during treatment?
• When can I expect changes to occur, and when do they get better/go away?
• What nail and skin problems should I call you about?
• Should I avoid any medications if I notice skin or nail changes?
• Can you recommend any products that help ease these side effects?
• Can I wear protective nail lacquer to help with side effects? Where do I get it?
• If I see skin changes, do I need to see my dermatologist?
• If I have nail side effects, how can I repair my nails after this treatment ends?