Questionnaire survey of Healthcare Professionals on Taxane-Induced Nail Change in Japan

Questionnaire survey of Healthcare Professionals on Taxane-Induced Nail Change in Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Questionnaire survey of Healthcare Professionals on Taxane-Induced Nail Change in Japan Kazumasa Yamamoto, Yuko Tanabe, Kiyomi Nonogaki, Shogo Watanabe, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3931203/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Sep, 2024 Read the published version in Supportive Care in Cancer → Version 1 posted 11 You are reading this latest preprint version Abstract Purpose: Taxanes are widely used chemotherapeutic agents that frequently cause nail changes and have a significant impact on patients’ quality of life. Despite the prevalence of taxane-induced nail toxicity, limited data are available regarding evidence-based management strategies for the prevention or treatment of taxane-induced nail changes. Therefore, we aimed to disseminate a questionnaire survey to physicians, pharmacists, and nurses involved in oncology treatment to gain accurate insights into the prevention, treatment, and evaluation of nail changes in patients with cancer in Japan. Methods: Questions addressed prophylactic methods, evaluation practices, and treatment approaches for various nail disorders. Questionnaires were distributed on March 1, 2022, with a response deadline of December 1, 2022. Results: Of the 120 distributed questionnaires, 88 (73.3%) responses were deemed valid. The respondents included 69 physicians (32 oncologists, 26 breast surgeons, 6 dermatologists, 3 obstetricians/gynecologists, 1 gastroenterological surgeon, and 1 urologist), 9 pharmacists, and 10 nurses. Prophylactic measures included moisturizing (58.0%), protection (42.0%), cooling therapy (37.5%), and cleanliness (33.0%). Approximately 70% of the respondents used the Common Criteria for Adverse Events (CTCAE), while approximately 30% did not use a specific evaluation method. Opinions regarding treatment with antimicrobial or corticosteroid ointments varied; however, all severe cases were referred by dermatologists. Conclusion : This survey revealed that the management of chemotherapy-induced nail changes varies in clinical practice in Japan. These findings emphasize the need for standardized management strategies and further research. Taxanes chemotherapy Questionnaire Survey Nail change Gastric cancer Breast cancer Figures Figure 1 Figure 2 1. Introduction Taxanes are widely used chemotherapeutics in various treatment regimens for solid tumors. Nail changes frequently occur as adverse events of taxane use. Moreover, when accompanied by severe pain, detachment, or loss of nails, they can significantly limit daily activities and reduce quality of life [ 1 ]. Additionally, given the high visibility of b fingernails, even subtle changes in appearance, such as alterations in nail coloration, often lead to emotional stress. Therefore, nail changes rank highly as distressing among female patients with breast cancer [ 2 ]. Nail changes induced by taxanes are also highly prevalent [ 3 , 4 ]. A meta-analysis investigating taxane-induced nail changes revealed an all-grade incidence of 43.7% and 34.9% for paclitaxel and docetaxel, respectively [ 5 ]. Particularly, the relative risk of docetaxel-induced nail changes was 77.74 [ 5 ]. Moreover, the occurrence of nail changes strongly is correlated with the number of chemotherapy cycles and increases with increasing cumulative doses of taxanes [ 6 ]. Although the precise pathophysiology of the taxane-induced nail changes remains unclear, several mechanisms have been proposed. These include direct toxicity to the nail matrix and nail bed epithelium and neurogenic inflammation [ 7 – 9 ]. Taxane-induced nail changes have various manifestations which may involve alterations in the color of the nail matrix, the formation of lateral grooves on the nail surface, and even nail loss when the drug impacts the nail matrix. In case it affects the nail bed epithelium, it may result in nail exfoliation. Furthermore, taxanes may contribute to conditions such as paronychia when they affect the skin around the nail. Another potential consequence is hematoma formation beneath the nail, which is often accompanied by bleeding [ 9 ]. Despite the similarities between taxane-induced nail changes and their diverse manifestations, evidence-based preventive and treatment options remain limited. Patients are generally advised to avoid damaging or irritating their nails and to maintain regular nail care routines. Moreover, cooling therapy has recently been shown to be effective in preventing taxane-induced nail changes. Scotte et al. demonstrated a significant reduction in the incidence of nail damage when cooling gloves were used. Specifically, the incidence of nail avulsion, corresponding to grade 2 damage, was reduced to 0% with cooling gloves compared to 22% without them [ 10 ]. When nail changes occur, management is primarily focused on symptom control; however, there is no established treatment regimen. Infections are promptly treated with antimicrobial agents and strong topical steroids are commonly used to manage periungual inflammation. The Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 is commonly used in nail evaluations; however, it is inadequate to capture the range of nail changes and their effects on patients' quality of life. In Japan, various attempts have been made to intervene in chemotherapy-induced nail changes; however, no survey has been conducted to clarify the current status of these interventions, which are expected to vary across facilities. Therefore, we aimed to conduct a questionnaire survey of physicians, pharmacists, and nurses involved in oncology treatment to gain accurate insights into the prevention, treatment, and evaluation of nail changes in patients with cancer in Japan. 2. Methods Questionnaires were distributed to 120 healthcare professionals involved in oncology care across Japan via mail and responses were collected using return envelopes. The respondents were required to be healthcare professionals (physicians, nurses, and pharmacists) and treat cancers for which taxane therapy is approved in Japan. We selected hospitals, mainly those designated as basic hospitals for cancer treatment. Questionnaires were disseminated on March 1, 2022, with a response deadline of December 1, 2022. Approval for the publication of the results was obtained from the respondents. We collaborated with oncologists, dermatologists, oncology pharmacists, and oncology nurses to design the questionnaire to ensure the relevance and effectiveness of the survey. Table 1 outlines the specific content of the questionnaire. 3. Results 3.1 Professions of the Respondents Of the 120 questionnaires distributed, 88 (73.3%) received valid responses. The respondents consisted of 14 participants from five cancer hospitals, 37 participants from 32 university hospitals, and 37 participants from 14 general hospitals. The respondents included 69 physicians (78.4%), 10 nurses (11.4%), and 9 pharmacists (10.2%). Regarding physicians’ specialties, 32 (36.3%) were specialized in Medical Oncology, 26 (29.5%) in Breast Surgery, 6 (6.8%) in dermatology, and 5 (5.7%) in other fields (Table 2). 3.2 Prophylaxis Measures for Nail Changes Respondents reported various prophylactic measures to prevent nail changes. Moisturizing was implemented by 58.0% (n=51) of the participants, whereas protection measures were adopted by 42.0% (n=37) of them. Cooling therapy was used by 37.5% (n=33) of the respondents, followed by cleaning practices by 33.0% (n=29), and compression therapy by 15.9% (n=14) ( Fig.1 ). In the free-text column, the respondents noted additional prophylactic measures they employed, including the use of heparinoids, urea, camellia oil, and/or argan oil as moisturizers with gloves at bedtime. Additionally, respondents mentioned the use of nail polish and protective nail coats as protective measures. Some respondents also advised patients to use shoes with soft soles and thick socks and not cut the fingernails too close to the nail bed. 3.3 Evaluation Methods for Nail Changes In daily practice, 70.5% (n=62) of the respondents used the CTCAE to evaluate nail changes. However, 28.4% (n=25) of the participants did not have a specific method for evaluating nail changes, indicating potential variations in assessment approaches among healthcare professionals. Additionally, a small proportion (2.3%, n=2) of respondents used methods other than CTCAE for evaluation. They appeared to describe nail changes in patients’ medical records based on their observations without grading. Although the use of CTCAE as a standardized evaluation method is prevalent, these findings suggest that approximately 30% of the respondents do not have a specific assessment approach. 3.4 Is photography used to evaluate nail changes? Only 3.4% (n=3) of the participants photographed nail changes to obtain comprehensive records, even if the nail changes were mild. In total, 19.3% (n=17) and 15.9% (n=14) respondents reported capturing photographs of nail changes that were classified as moderate (CTCAE grade 2) and severe (CTCAE, grade 3), respectively. Additionally, 20.4% (n=18) of respondents reported that the photographs were taken in various situations that did not fall into the previous categories. Some respondents indicated that the dermatologists conducted the photography, while others took pictures when they felt that it was necessary for management purposes. Conversely, 40.9% of the respondents (n=36) reported that they did not take pictures of nail changes. 3.5 Impression of the duration of nail damage after taxanes Nearly half of the respondents reported that nail damage lasted six months to a year after taxane treatment was terminated and nearly 40% of the respondents reported that the damage lasted two to six months ( Fig. 2 ). 3.6 Treatment for nail changes The departments treating the nail changes and the corresponding treatments are summarized in Tables 3 and 4. For Beau's lines and nail ridging, more than 65% of respondents opted for observation, approximately 20% selected nail polishing, while the majority did not refer patients to dermatologists or plastic surgeons. For ingrown nails without granulation, 55.7% of respondents provided guidance on nail trimming, whereas 27.3% opted for follow-up observations. However, for ingrown toenails with granulation, 22.7% of respondents used steroid ointments and 35.2% resorted to surgical treatment in addition to providing nail-cutting instructions. Notably, 72.7% of the respondents referred patients to a dermatologist when granulation tissue was present. Regarding the question of whether they actively encourage or practice cutting ingrown toenails, 29% of respondents responded positively. Regarding discoloration, more than 60% of the participants were followed up, and approximately 12% used manicures as a treatment approach. Notably, for leukonychia, 77.3% of the respondents did not consider referral to a dermatologist or plastic surgeon necessary, however, 12.5% did, due to the possibility of cutaneous candidiasis as a differential diagnosis. In contrast, 28.4% of the patients were referred to a dermatologist for hyperpigmentation, a trend that was more common than for leukonychia. For onycholysis without pain, 52.3% of respondents indicated that follow-up was the preferred treatment, whereas 11.4% employed manicures, and 13.6% provided instructions for nail cutting. In such cases, most patients were not referred to a dermatologist or plastic surgeon. In contrast, when onycholysis was accompanied by pain or signs of infection, 51.1% of respondents opted for antimicrobial ointments, 27.3% prescribed oral antimicrobials, 17.0% selected surgical treatment, and 18.2% provided instructions for nail trimming. Over 80% of respondents referred patients to a dermatologist in these cases. For subungual hemorrhages, the treatment and departmental trends were similar to those observed for onycholysis, with patients experiencing subjective symptoms more likely to be seen by a dermatologist. For paronychia equivalent to CTCAE grade 1, 42.0% of the respondents prescribed steroid ointments, 33.0% prescribed antibacterial ointments, 21.6% prescribed oral antibacterial agents, and 53.4% referred patients to a dermatologist. In contrast, for paronychia equivalent to CTCAE grade 2, 40.9% of respondents prescribed steroids or antibacterial ointments, 26.1% prescribed oral antibacterial agents, and 17.0% resorted to surgical treatment. A dermatologist reported that 86.4% of patients with paronychia were referred to them. For pyogenic granulomas, in addition to antimicrobial ointments and oral antimicrobials, more than 40% of the patients opted for surgical treatment. Regarding referral, 89% of respondents indicated that they would not refer their patients to other facilities for nail changes. This may be due to the fact that many of the respondents in this survey are affiliated with large hospitals with dermatology departments. 4. Discussion This study was conducted to explore current management strategies for taxane-induced nail changes through a questionnaire survey among oncology healthcare professionals in Japan. Our results revealed a diversity of approaches and underscore the need for standardized interventions and additional research. Additionally, we observed that various attempts have been made to manage nail changes caused by anticancer drugs in Japan. The survey response rate was high (73.3 %), indicating a strong interest in nail changes among medical professionals involved in cancer treatment. Evidence-based management strategies for chemotherapy-induced nail changes are currently limited. Moisturizing was practiced by 60% of the respondents as a preventive method. Moreover, in recent years, the usefulness of cooling therapy has been examined and reported [11–14]; however, several issues, such as determining the optimal cooling temperature and duration of use, remain unresolved. No cooling devices have been approved by pharmaceutical regulatory bodies in Japan. Furthermore, practical issues, such as product availability, cost, and availability of facilities for preparing low-temperature cooling gloves, need to be addressed. Consequently, fewer than 40% of the respondents indicated that they had practiced cooling therapy. Additionally, the exact implementation of the cooling therapy in this study was not clearly elucidated. Most patients were referred to a dermatologist when presenting with symptoms concurrent with pain or signs of infection. Thus, it appears to be common practice for mild cases to be handled by various departments, while severe cases are typically managed by the dermatology department. However, there appears to be a difference in opinion regarding the use of steroid ointments alone versus combined with antibacterial agents in cases of paronychia. Several expert opinions support the use of steroid ointments for paronychia [15–17]. Additionally, the STEPP trial reported that the prophylactic application of steroid ointments at the time of anti-EGFR antibody use decreased the risk of developing paronychia [17]. However, the evidence regarding the use of taxanes remains inconclusive. Moreover, due to the lack of strong evidence supporting the use of ointments containing antimicrobials, which may contribute to bacterial resistance, they should be used with caution. Regarding the evaluation of nail changes, 70% respondents used CTCAE to assess nail disease, and 30% did not have a specific assessment method. The CTCAE for nails includes the assessment of nail infection, periungual inflammation, nail changes, discoloration, loss, and elevation, which may reflect that this alone does not provide a complete picture of the variety of nail changes. Therefore, the development of alternative measures may be required to assess nail changes in routine practice. The current findings provide valuable insights into the modalities used by Japanese healthcare providers to prevent, evaluate, and manage taxane-induced nail changes. However, the study has several limitations. Although the respondents were healthcare professionals practicing oncology, this was a small-scale study. Additionally, it is uncertain whether the, survey responses fully reflect the opinions of all Japanese healthcare professionals. The questionnaire was not anonymous and relied on respondents' self-reports, leading to the possibility of recall bias and social desirability bias. Moreover, the questionnaire was distributed to relatively large hospitals, such as those designated as base hospitals for cancer care treatment, which may not fully reflect the actual state of cancer care in Japan. However, we believe that it is appropriate to conduct surveys at these facilities to ensure quality and understand the actual status of daily cancer treatment. In conclusion, this study clarified the management of chemotherapy-induced nail changes in Japan and the challenges faced. We hope that mechanism-based interventions will be developed in the future along with the establishment of guidelines to address these issues. Declarations Funding None declared. Conflict of Interest None declared. Ethics approval This survey was not conducted on patients and was not subject to the "Ethical Guidelines for Medical and Health Research Involving Human Subjects" in Japan. The survey was conducted in compliance with the "Act on the Protection of Personal Information," taking into consideration the handling of personal and other information of the respondents and medical professionals. Informed consent Informed consent for survey participation was obtained from all survey respondents. Consent to publish Consent for publication was obtained from all survey respondents for consent to publish the results. Participants were assured that their responses would be kept confidential. Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Author Contributions Kazumasa Yamamoto and Yuko Tanabe developed the study conception. Kazumasa Yamamoto, Yuko Tanabe, Kiyomi Nonogaki, and Nobukazu Hayashi developed the questionnaire. Kazumasa Yamamoto and Kiyomi Nonogaki collected the questionnaires and tabulated the data. Kazumasa Yamamoto wrote the manuscript text and prepared all figures and tables. All authors reviewed the manuscript. Acknowledgments We are grateful to all respondents of this questionnaire: Sapporo City General Hospital (Keita Minami, Michio Nakamura, Satoko Sudo, Yukitoki Hayakashi, and Yumi Okawa); Hokkaido University Hospital (Kanako Hagio); Akita University Hospital (Kaori Terata); Tohoku University Hospital (Hiroshi Tada); Fukushima Medical University (Emi Tokuda); University of Tsukuba Hospital (Hiroko Bando); Jichi Medical University Hospital (Yumiko Iizuka and Michiko Harao); Gunma Prefectural Cancer Center (Kazuhiro Araki, Miho Yamazaki, and Yukiyoshi Fujita); Saitama Medical University International Medical Center (Maki Todo); National Cancer Center Hospital (Hironobu Hashimoto, Ryo Otsuka, and Shu Yazaki); St. Luke’s International Hospital (Jun Hashimoto); Toranomon Hospital (Aki Yoshida, Akiko Kishi, Kie Kasahara, Maki Okazaki, Mayumi Ogura, Megumi Kino, Mikiko Hiraoka, Shusuke Haruta, Takehiro Yamada, Yasuhiro Oda, Yukihiro Nakata, Yukiko Nagaoka, and Yuumi Miyaki); The Jikei University Hospital (Tadashi Uwagawa); The Institute of Medical Science, The University of Tokyo (Narikazu Boku); The University of Tokyo Hospital (Masahiko Tanabe, Mutsumi Yamagami, and Satoko Eguchi); Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital (Toshiyuki Ishiba); The Cancer Institute Hospital of JFCR (Makiko Ono, Mayu Yunokawa, Takahiro Kogawa, Toshimi Takano, and Yukinori Ozaki); NTT Medical Center Tokyo (Keita Uchino); Showa University Hospital (Hiroko Masuda and Hitomi Sakai); Japanese Red Cross Medical Center (Shingo Miyamoto); Tokyo Medical Center (Yasutaka Sukawa); Tokyo Medical University Hospital (Tomoyo Taito and Yoichi Koyama); Keio University Hospital (Aiko Nagayama); Center Hospital of the National Center for Global Health and Medicine (Akihiko Shimomura); Japanese Red Cross Musashino Hospital (Minoru Nakane); St. Marianna University Hospital (Yasuyuki Kojima); Yokohama Minami Kyousai Hospital (Koji Hashiguchi); Shonan Memorial Hospital (Kenichi Inoue); Chiba University Hospital (Chiharu Kiyohara); National Cancer Center Hospital East (Rurina Watanuki); IUHW Narita Hospital (Sasagu Kurozumi); Kameda Medical Center (Keiko Miyagawa); Hamamatsu University Hospital (Kei Koizumi); Aichi Cancer Center (Haruru Kotani, Kazuki Nozawa, and Kazunori Honda); Nagoya City University Hospital (Mitsuo Terada); Gifu University Hospital (Chiemi Hirose); Osaka Red Cross Hospital (Shigeru Tsuyuki); Kansai Medical University Hospital (Yuichiro Kikawa); Kindai University Hospital (Tsutomu Iwasa); Japanese Red Cross Kyoto Daiichi Hospital (Kota Asano); Kyoto University Hospital (Sayoko Ouchi); Nara Medical University Hospital (Yumi Yoshii); Wakayama Medical University Hospital (Hirokazu Tanino); Tottori University Hospital (Hisashi Suyama); Shimane University Hospital (Yukari Tsubata); Okayama University Hospital (Tadahiko Shien); Kawasaki Medical School Hospital (Naruto Taira); Hiroshima University Hospital (Kadoya Takayuki and Yuka Furuya); Ehime University Hospital (Akari Murakami); Kumamoto University Hospital (Hideaki Miyamoto and Yutaka Yamamoto); University of Miyazaki Hospital (Ayumu Hosokawa). 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Skin Appendage Disord 5:276–282. https://doi.org/10.1159/000497824 Lacouture ME, Mitchell EP, Piperdi B et al (2010) Skin toxicity evaluation protocol with panitumumab (STEPP), a phase II, open-label, randomized trial evaluating the impact of a pre-emptive skin treatment regimen on skin toxicities and quality of life in patients with metastatic colorectal cancer. J Clin Oncol 28:1351–1357. https://doi.org/10.1200/JCO.2008.21.7828 Tables Table 1 is available in the Supplementary Files section. Table 2 Professions of Respondents. n (%) Medical Oncologist 32 (36.4) Breast Surgeon 26 (30.0) Dermatologist 6 (6.8) Obstetricians and Gynecologists 3 (3.4) Digestive Surgeon 1 (1.1) Urologist 1 (1.1) Nurse 10 (11.4) Pharmacist 9 (10.2) Table 3 Department treating nail change, n (%). No referral to other departments Dermatology Plastic Surgery Other department Beau's line 75 (85.2) 2 (2.3) 0 (0) 0 (0) Nail ridging 57 (83.0) 5 (5.7) 0 (0) 0 (0) Ingrown nails without granulation 39 (44.3) 35 (39.8) 4 (4.5) 3 (3.4) Ingrown nails with granulation 11 (12.5) 64 (72.7) 9 (10.2) 1 (1.1) Leukonychia 68 (77.3) 11 (12.5) 0 (0) 0 (0) Hyperpigmentation 37 (55.7) 21 (28.4) 2 (2.3) 2 (2.3) Onycholysis without pain 63 (71.6) 17 (19.3) 0 (0) 1 (1.1) Onycholysis with pain or infection 15 (17.0) 72 (81.8) 2 (2.3) 1 (1.1) Subungual hemorrhage without pain or infection 68 (77.3) 5 (5.7) 1 (1.1) 1 (1.1) Subungual hemorrhage with pain or infection 14 (15.9) 69 (78.4) 4 (4.5) 1 (1.1) Hemorrhagic Onycholysis 17 (19.3) 65 (73.9) 4 (4.5) 1 (1.1) Paronychia (Grade1) 32 (36.4) 47 (53.4) 2 (2.3) 1 (1.1) Paronychia (Grade2) 9 (10.2) 76 (86.4) 4 (4.5) 2 (2.3) Pyogenic granuloma 6(6.8) 75 (85.2) 7 (8.0) 2 (2.3) Table 4 Treatment for nail changes, n (%). observation steroid ointment antibacterial ointment oral antibacterial surgical treatment nail polish nail trimming instructions Beau's line 63 (71.6) 2 (2.3) 0 (0) 0 (0) 0 (0) 15 (17.0) 4 (4.5) Nail ridging 58 (65.9) 5 (5.7) 1 (1.1) 0 (0) 1 (1.1) 19 (21.6) 10 (11.4) Ingrown nails without granulation 24 (27.3) 3 (3.4) 3 (3.4) 2 (2.3) 5 (5.7) 3 (3.4) 49 (55.7) Ingrown nails with granulation 3 (3.4) 20 (22.7) 11 (12.5) 10 (11.4) 31 (35.2) 1 (1.1) 40 (45.5) Leukonychia 63 (71.6) 1 (1.1) 2 (2.3) 0 (0) 0 (0) 12 (13.6) 4 (4.5) Hyperpigmentation 53 (60.2) 0 (0) 1 (1.1) 0 (0) 1 (1.1) 10 (11.4) 4 (4.5) Onycholysis without pain 46 (52.3) 4 (4.5) 3 (3.4) 0 (0) 2 (2.3) 10 (11.4) 12 (13.6) Onycholysis with pain or infection 3 (3.4) 9 (10.2) 45 (51.1) 24 (27.3) 15 (17.0) 4 (4.5) 16 (18.2) Subungual hemorrhage without pain or infection 61 (69.3) 0 (0) 1 (1.1) 0 (0) 0 (0) 2 (2.3) 3 (3.4) Subungual hemorrhage with pain or infection 4 (4.5) 5 (5.7) 45 (51.1) 30 (34.1) 12 (13.6) 0 (0) 6 (6.8) Hemorrhagic Onycholysis 19 (21.6) 2 (2.3) 18 (20.5) 7 (8.0) 19 (21.6) 0 (0) 7 (8.0) Paronychia（Grade1） 13 (14.8) 37 (42.0) 29 (33.0) 19 (21.6) 4 (4.5) 0 (0) 18 (20.5) Paronychia (Grade2) 1 (1.1) 36 (40.9) 36 (40.9) 23 (26.1) 15 (17.0) 0 (0) 15 (17.0) Pyogenic granuloma 2 (2.9) 16 (22.9) 36 (51.4) 29 (41.4) 28 (40.0) 0 (0) 14 (20.0) Additional Declarations No competing interests reported. Supplementary Files Table1.docx Cite Share Download PDF Status: Published Journal Publication published 10 Sep, 2024 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Reviews received at journal 02 Aug, 2024 Reviews received at journal 27 Jul, 2024 Reviewers agreed at journal 18 Jun, 2024 Reviewers agreed at journal 09 Jun, 2024 Reviewers agreed at journal 26 Mar, 2024 Reviewers agreed at journal 25 Mar, 2024 Reviewers invited by journal 09 Mar, 2024 Editor assigned by journal 09 Mar, 2024 Submission checks completed at journal 06 Feb, 2024 First submitted to journal 05 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Tanabe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYNCCCgke++MNQIaBBbFaztjIMZw5ANIiQaQOxrY0Y4YbCSAmEVoMbuSYSfOwHU5snPn86oYfBRIM/O3dCURo4Tmc2CydU3azB+gwiTNnNxChReJwYpt0TtoNHqAWA4lcYrQYHE7skTyTdvMP8VoS0owlJNiP3SbKFskzz4ot5xywkTPgyWG7LWMgwUPQL3zHkzfeePtPgseA/fizm2/+2Mjxt/fi16JwAM7kMQCTeJWDgHwDnMn+gKDqUTAKRsEoGJkAADnxRsf2d24XAAAAAElFTkSuQmCC","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yuko","middleName":"","lastName":"Tanabe","suffix":""},{"id":271304618,"identity":"9fc1bca2-77ec-4847-921b-2945a463e635","order_by":2,"name":"Kiyomi Nonogaki","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kiyomi","middleName":"","lastName":"Nonogaki","suffix":""},{"id":271304619,"identity":"ad6a9c7f-deb8-4384-9401-0d54a27c7ea1","order_by":3,"name":"Shogo Watanabe","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shogo","middleName":"","lastName":"Watanabe","suffix":""},{"id":271304620,"identity":"7c181c3d-ae17-4c7d-80f2-a1d4a508efd5","order_by":4,"name":"Kohji Takemura","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kohji","middleName":"","lastName":"Takemura","suffix":""},{"id":271304621,"identity":"e85bfd63-dddc-43f2-ab90-a88c7a95c141","order_by":5,"name":"Taro Yamanaka","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Taro","middleName":"","lastName":"Yamanaka","suffix":""},{"id":271304622,"identity":"b044dcf8-b456-4b59-9f73-3840a2a74d76","order_by":6,"name":"Rika Kizawa","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rika","middleName":"","lastName":"Kizawa","suffix":""},{"id":271304623,"identity":"f5d301ff-d04a-4ab9-9fbc-11fc0e05e1b9","order_by":7,"name":"Takeshi Yamaguchi","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":271304624,"identity":"70065e9c-fea5-4ffd-a450-8e78795debd3","order_by":8,"name":"Koichi Suyama","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Koichi","middleName":"","lastName":"Suyama","suffix":""},{"id":271304625,"identity":"ee71e703-333d-450c-8749-cb9caed13318","order_by":9,"name":"Nobukazu Hayashi","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nobukazu","middleName":"","lastName":"Hayashi","suffix":""},{"id":271304626,"identity":"4ff5fed5-2598-41f0-80bc-6be89377a606","order_by":10,"name":"Yuji Miura","email":"","orcid":"","institution":"Toranomon Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Miura","suffix":""}],"badges":[],"createdAt":"2024-02-05 14:29:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3931203/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3931203/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-024-08858-9","type":"published","date":"2024-09-10T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50818483,"identity":"5d9bbe7b-0078-45b8-8b93-8d55b5fcc348","added_by":"auto","created_at":"2024-02-07 20:18:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45121,"visible":true,"origin":"","legend":"\u003cp\u003eProphylaxis for nail changes (%).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3931203/v1/40aeb60a1a174c9aaa1424b0.jpg"},{"id":50818484,"identity":"d8085549-4c9d-44f4-9d36-fb069b1eb8ce","added_by":"auto","created_at":"2024-02-07 20:18:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35211,"visible":true,"origin":"","legend":"\u003cp\u003eImpression of the duration of nail damage after taxane treatment (%).\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3931203/v1/50a2b90d399d46d6acc76a3a.jpg"},{"id":64619582,"identity":"612a9412-f406-4350-a101-943b8a69fcf6","added_by":"auto","created_at":"2024-09-16 16:16:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":604650,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3931203/v1/0a16281a-cde7-4a61-b479-013f0fb2ef03.pdf"},{"id":50818482,"identity":"d8d2dab1-69e7-43e1-8c59-f6b099020a93","added_by":"auto","created_at":"2024-02-07 20:18:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16364,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3931203/v1/3859a02ee28af2c143f6a705.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Questionnaire survey of Healthcare Professionals on Taxane-Induced Nail Change in Japan","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eTaxanes are widely used chemotherapeutics in various treatment regimens for solid tumors. Nail changes frequently occur as adverse events of taxane use. Moreover, when accompanied by severe pain, detachment, or loss of nails, they can significantly limit daily activities and reduce quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, given the high visibility of b fingernails, even subtle changes in appearance, such as alterations in nail coloration, often lead to emotional stress. Therefore, nail changes rank highly as distressing among female patients with breast cancer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNail changes induced by taxanes are also highly prevalent [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A meta-analysis investigating taxane-induced nail changes revealed an all-grade incidence of 43.7% and 34.9% for paclitaxel and docetaxel, respectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Particularly, the relative risk of docetaxel-induced nail changes was 77.74 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Moreover, the occurrence of nail changes strongly is correlated with the number of chemotherapy cycles and increases with increasing cumulative doses of taxanes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough the precise pathophysiology of the taxane-induced nail changes remains unclear, several mechanisms have been proposed. These include direct toxicity to the nail matrix and nail bed epithelium and neurogenic inflammation [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Taxane-induced nail changes have various manifestations which may involve alterations in the color of the nail matrix, the formation of lateral grooves on the nail surface, and even nail loss when the drug impacts the nail matrix. In case it affects the nail bed epithelium, it may result in nail exfoliation. Furthermore, taxanes may contribute to conditions such as paronychia when they affect the skin around the nail. Another potential consequence is hematoma formation beneath the nail, which is often accompanied by bleeding [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the similarities between taxane-induced nail changes and their diverse manifestations, evidence-based preventive and treatment options remain limited. Patients are generally advised to avoid damaging or irritating their nails and to maintain regular nail care routines. Moreover, cooling therapy has recently been shown to be effective in preventing taxane-induced nail changes. Scotte et al. demonstrated a significant reduction in the incidence of nail damage when cooling gloves were used. Specifically, the incidence of nail avulsion, corresponding to grade 2 damage, was reduced to 0% with cooling gloves compared to 22% without them [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhen nail changes occur, management is primarily focused on symptom control; however, there is no established treatment regimen. Infections are promptly treated with antimicrobial agents and strong topical steroids are commonly used to manage periungual inflammation. The Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 is commonly used in nail evaluations; however, it is inadequate to capture the range of nail changes and their effects on patients' quality of life.\u003c/p\u003e\u003cp\u003eIn Japan, various attempts have been made to intervene in chemotherapy-induced nail changes; however, no survey has been conducted to clarify the current status of these interventions, which are expected to vary across facilities. Therefore, we aimed to conduct a questionnaire survey of physicians, pharmacists, and nurses involved in oncology treatment to gain accurate insights into the prevention, treatment, and evaluation of nail changes in patients with cancer in Japan.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eQuestionnaires were distributed to 120 healthcare professionals involved in oncology care across Japan via mail and responses were collected using return envelopes. The respondents were required to be healthcare professionals (physicians, nurses, and pharmacists) and treat cancers for which taxane therapy is approved in Japan. We selected hospitals, mainly those designated as basic hospitals for cancer treatment. Questionnaires were disseminated on March 1, 2022, with a response deadline of December 1, 2022. Approval for the publication of the results was obtained from the respondents.\u003c/p\u003e\n\u003cp\u003eWe collaborated with oncologists, dermatologists, oncology pharmacists, and oncology nurses to design the questionnaire to ensure the relevance and effectiveness of the survey. Table 1 outlines the specific content of the questionnaire.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.1 Professions of the Respondents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 120 questionnaires distributed, 88 (73.3%) received valid responses. The respondents consisted of 14 participants from five cancer hospitals, 37 participants from 32 university hospitals, and 37 participants from 14 general hospitals. The respondents included 69 physicians (78.4%), 10 nurses (11.4%), and 9 pharmacists (10.2%). Regarding physicians\u0026rsquo; specialties, 32 (36.3%) were specialized in Medical Oncology, 26 (29.5%) in Breast Surgery, 6 (6.8%) in dermatology, and 5 (5.7%) in other fields (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.2 Prophylaxis Measures for Nail Changes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents reported various prophylactic measures to prevent nail changes. Moisturizing was implemented by 58.0% (n=51) of the participants, whereas protection measures were adopted by 42.0% (n=37) of them. Cooling therapy was used by 37.5% (n=33) of the respondents, followed by cleaning practices by 33.0% (n=29), and compression therapy by 15.9% (n=14) (\u003cstrong\u003eFig.1\u003c/strong\u003e). In the free-text column, the respondents noted additional prophylactic measures they employed, including the use of heparinoids, urea, camellia oil, and/or argan oil as moisturizers with gloves at bedtime. Additionally, respondents mentioned the use of nail polish and protective nail coats as protective measures. Some respondents also advised patients to use shoes with soft soles and thick socks and not cut the fingernails too close to the nail bed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.3 Evaluation Methods for Nail Changes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn daily practice, 70.5% (n=62) of the respondents used the CTCAE to evaluate nail changes. However, 28.4% (n=25) of the participants did not have a specific method for evaluating nail changes, indicating potential variations in assessment approaches among healthcare professionals. Additionally, a small proportion (2.3%, n=2) of respondents used methods other than CTCAE for evaluation. They appeared to describe nail changes in patients\u0026rsquo; medical records based on their observations without grading. Although the use of CTCAE as a standardized evaluation method is prevalent, these findings suggest that approximately 30% of the respondents do not have a specific assessment approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.4 Is photography used to evaluate nail changes?\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 3.4% (n=3) of the participants photographed nail changes to obtain comprehensive records, even if the nail changes were mild. In total, 19.3% (n=17) and 15.9% (n=14) respondents reported capturing photographs of nail changes that were classified as moderate (CTCAE grade 2) and severe (CTCAE, grade 3), respectively. Additionally, 20.4% (n=18) of respondents reported that the photographs were taken in various situations that did not fall into the previous categories. Some respondents indicated that the dermatologists conducted the photography, while others took pictures when they felt that it was necessary for management purposes. Conversely, 40.9% of the respondents (n=36) reported that they did not take pictures of nail changes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.5 Impression of the duration of nail damage after taxanes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly half of the respondents reported that nail damage lasted six months to a year after taxane treatment was terminated and nearly 40% of the respondents reported that the damage lasted two to six months (\u003cstrong\u003eFig. 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.6 Treatment for nail changes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe departments treating the nail changes\u0026nbsp;and the corresponding treatments\u0026nbsp;are summarized in Tables 3 and 4.\u0026nbsp;For Beau\u0026apos;s lines and nail ridging, more than 65% of respondents opted for observation, approximately 20% selected nail polishing, while the majority did not refer patients to dermatologists or plastic surgeons. For ingrown nails without granulation, 55.7% of respondents provided guidance on nail trimming, whereas 27.3% opted for follow-up observations. However, for ingrown toenails with granulation, 22.7% of respondents used steroid ointments and 35.2% resorted to surgical treatment in addition to providing nail-cutting instructions. Notably, 72.7% of the respondents referred patients to a dermatologist when granulation tissue was present. Regarding the question of whether they actively encourage or practice cutting ingrown toenails, 29% of respondents responded positively.\u003c/p\u003e\n\u003cp\u003eRegarding discoloration, more than 60% of the participants were followed up, and approximately 12% used manicures as a treatment approach. Notably, for leukonychia, 77.3% of the respondents did not consider referral to a dermatologist or plastic surgeon necessary, however, 12.5% did, due to the possibility of cutaneous candidiasis as a differential diagnosis. In contrast, 28.4% of the patients were referred to a dermatologist for hyperpigmentation, a trend that was more common than for leukonychia. For onycholysis without pain, 52.3% of respondents indicated that follow-up was the preferred treatment, whereas 11.4% employed manicures, and 13.6% provided instructions for nail cutting. In such cases, most patients were not referred to a dermatologist or plastic surgeon. In contrast, when onycholysis was accompanied by pain or signs of infection, 51.1% of respondents opted for antimicrobial ointments, 27.3% prescribed oral antimicrobials, 17.0% selected surgical treatment, and 18.2% provided instructions for nail trimming. Over 80% of respondents referred patients to a dermatologist in these cases. For subungual hemorrhages, the treatment and departmental trends were similar to those observed for onycholysis, with patients experiencing subjective symptoms more likely to be seen by a dermatologist. For paronychia equivalent to CTCAE grade 1, 42.0% of the respondents prescribed steroid ointments, 33.0% prescribed antibacterial ointments, 21.6% prescribed oral antibacterial agents, and 53.4% referred patients to a dermatologist. In contrast, for paronychia equivalent to CTCAE grade 2, 40.9% of respondents prescribed steroids or antibacterial ointments, 26.1% prescribed oral antibacterial agents, and 17.0% resorted to surgical treatment. A dermatologist reported that 86.4% of patients with paronychia were referred to them. For pyogenic granulomas, in addition to antimicrobial ointments and oral antimicrobials, more than 40% of the patients opted for surgical treatment.\u003c/p\u003e\n\u003cp\u003eRegarding referral, 89% of respondents indicated that they would not refer their patients to other facilities for nail changes. This may be due to the fact that many of the respondents in this survey are affiliated with large hospitals with dermatology departments. \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study was conducted to explore current management strategies for taxane-induced nail changes through a questionnaire survey among oncology healthcare professionals in Japan. Our results revealed a diversity of approaches and underscore the need for standardized interventions and additional research. Additionally, we observed that various attempts have been made to manage nail changes caused by anticancer drugs in Japan. The survey response rate was high (73.3 %), indicating a strong interest in nail changes among medical professionals involved in cancer treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvidence-based management strategies for chemotherapy-induced nail changes are currently limited. Moisturizing was practiced by 60% of the respondents as a preventive method. Moreover, in recent years, the usefulness of cooling therapy has been examined and reported [11\u0026ndash;14]; however, several issues, such as determining the optimal cooling temperature and duration of use, remain unresolved. No cooling devices have been approved by pharmaceutical regulatory bodies in Japan. Furthermore, practical issues, such as product availability, cost, and availability of facilities for preparing low-temperature cooling gloves, need to be addressed. Consequently, fewer than 40% of the respondents indicated that they had practiced cooling therapy. Additionally, the exact implementation of the cooling therapy in this study was not clearly elucidated.\u003c/p\u003e\n\u003cp\u003eMost patients were referred to a dermatologist when presenting with symptoms concurrent with pain or signs of infection. Thus, it appears to be common practice for mild cases to be handled by various departments, while severe cases are typically managed by the dermatology department. However, there appears to be a difference in opinion regarding the use of steroid ointments alone versus combined with antibacterial agents in cases of paronychia. Several expert opinions support the use of steroid ointments for paronychia\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[15\u0026ndash;17]. Additionally, the STEPP trial reported that the prophylactic application of steroid ointments at the time of anti-EGFR antibody use decreased the risk of developing paronychia [17]. However, the evidence regarding the use of taxanes remains inconclusive. Moreover, due to the lack of strong evidence supporting the use of ointments containing antimicrobials, which may contribute to bacterial resistance, they should be used with caution.\u003c/p\u003e\n\u003cp\u003eRegarding the evaluation of nail changes, 70% respondents used CTCAE to assess nail disease, and 30% did not have a specific assessment method. The CTCAE for nails includes the assessment of nail infection, periungual inflammation, nail changes, discoloration, loss, and elevation, which may reflect that this alone does not provide a complete picture of the variety of nail changes. Therefore, the development of alternative measures may be required to assess nail changes in routine practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current findings provide valuable insights into the modalities used by Japanese healthcare providers to prevent, evaluate, and manage taxane-induced nail changes. However, the study has several limitations. Although the respondents were healthcare professionals practicing oncology, this was a small-scale study. Additionally, it is uncertain whether the, survey responses fully reflect the opinions of all Japanese healthcare professionals. The questionnaire was not anonymous and relied on respondents\u0026apos; self-reports, leading to the possibility of recall bias and social desirability bias. Moreover, the questionnaire was distributed to relatively large hospitals, such as those designated as base hospitals for cancer care treatment, which may not fully reflect the actual state of cancer care in Japan. However, we believe that it is appropriate to conduct surveys at these facilities to ensure quality and understand the actual status of daily cancer treatment.\u003c/p\u003e\n\u003cp\u003eIn conclusion, this study clarified the management of chemotherapy-induced nail changes in Japan and the challenges faced. We hope that mechanism-based interventions will be developed in the future along with the establishment of guidelines to address these issues.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of Interest\u003c/em\u003e\u003c/strong\u003e None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e \u003c/em\u003e\u003c/strong\u003eThis survey was not conducted on patients and was not subject to the \u0026quot;Ethical Guidelines for Medical and Health Research Involving Human Subjects\u0026quot; in Japan.\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe survey was conducted in compliance with the \u0026quot;Act on the Protection of Personal Information,\u0026quot; taking into consideration the handling of personal and other information of the respondents and medical professionals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInformed consent\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eInformed consent for survey participation was obtained from all survey respondents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to publish\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e \u003c/em\u003e\u003c/strong\u003e Consent for publication was obtained from all survey respondents\u0026nbsp;for consent to publish the results.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eParticipants were assured that their responses would be kept confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData availability statement\u003c/em\u003e\u003c/strong\u003e The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKazumasa Yamamoto and Yuko Tanabe developed the study conception. \u0026nbsp;Kazumasa Yamamoto, Yuko Tanabe, Kiyomi Nonogaki, and Nobukazu Hayashi developed the questionnaire. Kazumasa Yamamoto and Kiyomi Nonogaki collected the questionnaires and tabulated the data. Kazumasa Yamamoto wrote the manuscript text and prepared all figures and tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cstrong\u003e \u003c/strong\u003eWe are grateful to all respondents of this questionnaire: Sapporo City General Hospital (Keita Minami, Michio Nakamura, Satoko Sudo, Yukitoki Hayakashi, and Yumi Okawa); Hokkaido University Hospital (Kanako Hagio); Akita University Hospital (Kaori Terata); Tohoku University Hospital (Hiroshi Tada); Fukushima Medical University (Emi Tokuda); University of Tsukuba Hospital (Hiroko Bando); Jichi Medical University Hospital (Yumiko Iizuka and Michiko Harao); Gunma Prefectural Cancer Center (Kazuhiro Araki, Miho Yamazaki, and Yukiyoshi Fujita); Saitama Medical University International Medical Center (Maki Todo); National Cancer Center Hospital (Hironobu Hashimoto, Ryo Otsuka, and Shu Yazaki); St. Luke\u0026rsquo;s International Hospital (Jun Hashimoto); Toranomon Hospital (Aki Yoshida, Akiko Kishi, Kie Kasahara, Maki Okazaki, Mayumi Ogura, Megumi Kino, Mikiko Hiraoka, Shusuke Haruta, Takehiro Yamada, Yasuhiro Oda, Yukihiro Nakata, Yukiko Nagaoka, and Yuumi Miyaki); The Jikei University Hospital (Tadashi Uwagawa); The Institute of Medical Science, The University of Tokyo (Narikazu Boku); The University of Tokyo Hospital (Masahiko Tanabe, Mutsumi Yamagami, and Satoko Eguchi); Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital (Toshiyuki Ishiba); The Cancer Institute Hospital of JFCR (Makiko Ono, Mayu Yunokawa, Takahiro Kogawa, Toshimi Takano, and Yukinori Ozaki); NTT Medical Center Tokyo (Keita Uchino); Showa University Hospital (Hiroko Masuda and Hitomi Sakai); Japanese Red Cross Medical Center (Shingo Miyamoto); Tokyo Medical Center (Yasutaka Sukawa); Tokyo Medical University Hospital (Tomoyo Taito and Yoichi Koyama); Keio University Hospital (Aiko Nagayama); Center Hospital of the National Center for Global Health and Medicine (Akihiko Shimomura); Japanese Red Cross Musashino Hospital (Minoru Nakane); St. Marianna University Hospital (Yasuyuki Kojima); Yokohama Minami Kyousai Hospital (Koji Hashiguchi); Shonan Memorial Hospital (Kenichi Inoue); Chiba University Hospital (Chiharu Kiyohara); National Cancer Center Hospital East (Rurina Watanuki); IUHW Narita Hospital (Sasagu Kurozumi); Kameda Medical Center (Keiko Miyagawa); Hamamatsu University Hospital (Kei Koizumi); Aichi Cancer Center (Haruru Kotani, Kazuki Nozawa, and Kazunori Honda); Nagoya City University Hospital (Mitsuo Terada); Gifu University Hospital (Chiemi Hirose); Osaka Red Cross Hospital (Shigeru Tsuyuki); Kansai Medical University Hospital (Yuichiro Kikawa); Kindai University Hospital (Tsutomu Iwasa); Japanese Red Cross Kyoto Daiichi Hospital (Kota Asano); Kyoto University Hospital (Sayoko Ouchi); Nara Medical University Hospital (Yumi Yoshii); Wakayama Medical University Hospital (Hirokazu Tanino); Tottori University Hospital (Hisashi Suyama); Shimane University Hospital (Yukari Tsubata); Okayama University Hospital (Tadahiko Shien); Kawasaki Medical School Hospital (Naruto Taira); Hiroshima University Hospital (Kadoya Takayuki and Yuka Furuya); Ehime University Hospital (Akari Murakami); Kumamoto University Hospital (Hideaki Miyamoto and Yutaka Yamamoto); University of Miyazaki Hospital (Ayumu Hosokawa).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMorrison A, Marshall-McKenna RM, McFadyen AK et al (2022) A randomised controlled trial of interventions for taxane-induced nail toxicity in women with early breast cancer. Sci Rep 12:11575. https://doi.org/10.1038/s41598-022-13327-6\u003c/li\u003e\n\u003cli\u003eNozawa K, Shimizu C, Kakimoto M et al (2013) Quantitative assessment of appearance changes and related distress in cancer patients. Psychooncology 22:2140\u0026ndash;2147. https://doi.org/10.1002/pon.3268\u003c/li\u003e\n\u003cli\u003eMiller KK, Gorcey L, McLellan BN (2014) Chemotherapy-induced hand-foot syndrome and nail changes: a review of clinical presentation, etiology, pathogenesis, and management. J Am Acad Dermatol 71:787\u0026ndash;794. https://doi.org/10.1016/j.jaad.2014.03.019\u003c/li\u003e\n\u003cli\u003eMinisini AM, Tosti A, Sobrero AF et al (2003) Taxane-induced nail changes: incidence, clinical presentation and outcome. Ann Oncol 14:333\u0026ndash;337. https://doi.org/10.1093/annonc/mdg050\u003c/li\u003e\n\u003cli\u003eCapriotti K, Capriotti JA, Lessin S et al (2015) The risk of nail changes with taxane chemotherapy: a systematic review of the literature and meta-analysis. Br J Dermatol 173:842\u0026ndash;845. https://doi.org/10.1111/bjd.13743\u003c/li\u003e\n\u003cli\u003eGilbar P, Hain A, Peereboom VM (2009) Nail toxicity induced by cancer chemotherapy. J Oncol Pharm Pract 15:143\u0026ndash;155. https://doi.org/10.1177/1078155208100450\u003c/li\u003e\n\u003cli\u003eWasner G, Hilpert F, Baron R, Pfisterer J (2001) Clinical picture: nail changes secondary to docetaxel. Lancet 357:910. https://doi.org/10.1016/s0140-6736(00)04210-0\u003c/li\u003e\n\u003cli\u003eBattegay EJ (1995) Angiogenesis: mechanistic insights, neovascular diseases, and therapeutic prospects. J Mol Med (Berl) 73:333\u0026ndash;346. https://doi.org/10.1007/BF00192885\u003c/li\u003e\n\u003cli\u003eSibaud V, Leb\u0026oelig;uf NR, Roche H et al (2016) Dermatological adverse events with taxane chemotherapy. Eur J Dermatol 26:427\u0026ndash;443. https://doi.org/10.1684/ejd.2016.2833\u003c/li\u003e\n\u003cli\u003eScott\u0026eacute; F, Tourani JM, Banu E et al (2005) Multicenter study of a frozen glove to prevent docetaxel-induced onycholysis and cutaneous toxicity of the hand. J Clin Oncol 23:4424\u0026ndash;4429. https://doi.org/10.1200/JCO.2005.15.651\u003c/li\u003e\n\u003cli\u003eScott\u0026eacute; F, Banu E, Medioni J et al (2008) Matched case-control phase 2 study to evaluate the use of a frozen sock to prevent docetaxel-induced onycholysis and cutaneous toxicity of the foot. Cancer 112:1625\u0026ndash;1631. https://doi.org/10.1002/cncr.23333\u003c/li\u003e\n\u003cli\u003eCan G, Aydiner A, Cavdar I (2012) Taxane-induced nail changes: predictors and efficacy of the use of frozen gloves and socks in the prevention of nail toxicity. Eur J Oncol Nurs 16:270\u0026ndash;275. https://doi.org/10.1016/j.ejon.2011.06.007\u003c/li\u003e\n\u003cli\u003eMcCarthy AL, Shaban RZ, Gillespie K, Vick J (2014) Cryotherapy for docetaxel-induced hand and nail toxicity: randomised control trial. Support Care Cancer 22:1375\u0026ndash;1383. https://doi.org/10.1007/s00520-013-2095-x\u003c/li\u003e\n\u003cli\u003eKiyohara Y, Yamazaki N, Kishi A (2013) Erlotinib-related skin toxicities: treatment strategies in patients with metastatic non-small cell lung cancer. J Am Acad Dermatol 69:463\u0026ndash;472. https://doi.org/10.1016/j.jaad.2013.02.025\u003c/li\u003e\n\u003cli\u003eWnorowski AM, de Souza AD, Chachoua A, Cohen DE (2012) The management of EGFR inhibitor adverse events: a case series and treatment paradigm. Int J Dermatol 51:223\u0026ndash;232. https://doi.org/10.1111/j.1365-4632.2011.05082.x\u003c/li\u003e\n\u003cli\u003eAlessandrini A, Starace M, Cer\u0026egrave; G, Brandi N, Piraccini BM (2019) Management and outcome of taxane-induced nail side effects: experience of 79 patients from a single centre. Skin Appendage Disord 5:276\u0026ndash;282. https://doi.org/10.1159/000497824\u003c/li\u003e\n\u003cli\u003eLacouture ME, Mitchell EP, Piperdi B et al (2010) Skin toxicity evaluation protocol with panitumumab (STEPP), a phase II, open-label, randomized trial evaluating the impact of a pre-emptive skin treatment regimen on skin toxicities and quality of life in patients with metastatic colorectal cancer. J Clin Oncol 28:1351\u0026ndash;1357. https://doi.org/10.1200/JCO.2008.21.7828\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 is available in the Supplementary Files section.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Professions of Respondents.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eMedical Oncologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e32 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eBreast Surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e26 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eDermatologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e 6 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eObstetricians and Gynecologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e 3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eDigestive Surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e 1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eUrologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e 1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.61616161616162%\" valign=\"top\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" valign=\"top\"\u003e\n \u003cp\u003e 9 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Department treating nail change, n (%).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003eNo referral to\u003c/p\u003e\n \u003cp\u003eother departments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003eDermatology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003ePlastic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003eOther department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eBeau\u0026apos;s line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e75 (85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eNail ridging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e57 (83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eIngrown nails without granulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e39 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e35 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eIngrown nails with granulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e11 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e64 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e9 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eLeukonychia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e68 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e11 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eHyperpigmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e37 (55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eOnycholysis without pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e63 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e17 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eOnycholysis with pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e72 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eSubungual hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewithout pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e68 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eSubungual hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewith pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e14 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e69 (78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eHemorrhagic Onycholysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e17 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e65 (73.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eParonychia (Grade1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e32 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e47 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\"\u003e\n \u003cp\u003eParonychia (Grade2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e9 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e76 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003ePyogenic granuloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.587628865979383%\" valign=\"top\"\u003e\n \u003cp\u003e6(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e75 (85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\" valign=\"top\"\u003e\n \u003cp\u003e7 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.52577319587629%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Treatment for nail changes, n (%).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"130%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003eobservation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003esteroid ointment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003eantibacterial ointment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003eoral antibacterial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003esurgical treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003enail\u0026nbsp;\u003c/p\u003e\n \u003cp\u003epolish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003enail trimming instructions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eBeau\u0026apos;s line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e63 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003eNail ridging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e58 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e19 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eIngrown nails without granulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e24 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e49 (55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eIngrown nails with granulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e20 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e11 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e31 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e40 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eLeukonychia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e63 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e12 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003eHyperpigmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e53 (60.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eOnycholysis without pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e46 (52.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e12 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eOnycholysis with pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e9 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e45 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e24 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e16 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003eSubungual hemorrhage\u003c/p\u003e\n \u003cp\u003ewithout pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e61 (69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003eSubungual hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewith pain or infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e45 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e30 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e12 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e6 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003eHemorrhagic Onycholysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e19 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e18 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e7 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e19 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e7 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eParonychia（Grade1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e13 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e37 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e29 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e19 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e18 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\"\u003e\n \u003cp\u003eParonychia (Grade2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e36 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e36 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e23 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.649484536082475%\" valign=\"top\"\u003e\n \u003cp\u003ePyogenic granuloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e16 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e36 (51.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e29 (41.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e28 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e14 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Taxanes, chemotherapy, Questionnaire Survey, Nail change, Gastric cancer, Breast cancer","lastPublishedDoi":"10.21203/rs.3.rs-3931203/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3931203/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/em\u003e Taxanes are widely used chemotherapeutic agents that frequently cause nail changes and have a significant impact on patients’ quality of life. Despite the prevalence of taxane-induced nail toxicity, limited data are available regarding evidence-based management strategies for the prevention or treatment of taxane-induced nail changes. Therefore, we aimed to disseminate a questionnaire survey to physicians, pharmacists, and nurses involved in oncology treatment to gain accurate insights into the prevention, treatment, and evaluation of nail changes in patients with cancer in Japan.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e Questions addressed prophylactic methods, evaluation practices, and treatment approaches for various nail disorders. Questionnaires were distributed on March 1, 2022, with a response deadline of December 1, 2022.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e Of the 120 distributed questionnaires, 88 (73.3%) responses were deemed valid. The respondents included 69 physicians (32 oncologists, 26 breast surgeons, 6 dermatologists, 3 obstetricians/gynecologists, 1 gastroenterological surgeon, and 1 urologist), 9 pharmacists, and 10 nurses. Prophylactic measures included moisturizing (58.0%), protection (42.0%), cooling therapy (37.5%), and cleanliness (33.0%). Approximately 70% of the respondents used the Common Criteria for Adverse Events (CTCAE), while approximately 30% did not use a specific evaluation method. Opinions regarding treatment with antimicrobial or corticosteroid ointments varied; however, all severe cases were referred by dermatologists.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e: This survey revealed that the management of chemotherapy-induced nail changes varies in clinical practice in Japan. These findings emphasize the need for standardized management strategies and further research.\u003c/p\u003e","manuscriptTitle":"Questionnaire survey of Healthcare Professionals on Taxane-Induced Nail Change in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-07 20:18:04","doi":"10.21203/rs.3.rs-3931203/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T21:35:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T18:44:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-27T17:32:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244037094148299009400385009071634727687","date":"2024-06-18T15:55:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1560259667987710832435578861646247233","date":"2024-06-10T02:07:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9f5cc8f4-e8cb-4f36-a0cf-6cc4aa6773cb","date":"2024-03-26T05:36:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40869c93-10f4-4e34-acbb-99ebe49612ba","date":"2024-03-25T09:45:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-09T15:26:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-09T15:22:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-06T09:12:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-02-05T14:20:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3f93f5cf-1c5d-4dfc-9f67-1f463417b24f","owner":[],"postedDate":"February 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T16:09:47+00:00","versionOfRecord":{"articleIdentity":"rs-3931203","link":"https://doi.org/10.1007/s00520-024-08858-9","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2024-09-10 15:58:15","publishedOnDateReadable":"September 10th, 2024"},"versionCreatedAt":"2024-02-07 20:18:04","video":"","vorDoi":"10.1007/s00520-024-08858-9","vorDoiUrl":"https://doi.org/10.1007/s00520-024-08858-9","workflowStages":[]},"version":"v1","identity":"rs-3931203","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3931203","identity":"rs-3931203","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}