Medications That Cause Leukonychia
Taxane chemotherapy agents (docetaxel and paclitaxel) are the primary medications causing true leukonychia, affecting the nail matrix as part of their broader nail toxicity profile. 1
Primary Causative Agents
Chemotherapy Drugs - Highest Risk
Taxanes are the most important drug class to recognize:
- Docetaxel and paclitaxel directly cause true leukonychia (white discoloration originating from the nail matrix itself) as part of their extensive nail toxicity syndrome 1
- These agents affect 34.9-43.7% of patients with various nail changes, with leukonychia being one manifestation alongside melanonychia, Beau's lines, and onychomadesis 1
- The mechanism involves direct cytotoxic damage to the nail matrix epithelium 1
Other chemotherapy agents with documented leukonychia:
- Cyclophosphamide, doxorubicin, and vincristine are the most frequently reported agents causing transverse leukonychia (white bands across the nail) 2
- Capecitabine, etoposide, cytarabine can cause milder nail changes that may include leukonychia 1
Additional Drug Classes
Other medications associated with leukonychia include:
- Fluorouracil and other antimetabolites used in cancer treatment 3
- Retinoids (systemic) can affect nail plate appearance 3, 4
- Anthracyclines as a drug class cause various nail abnormalities 3
Clinical Context and Differentiation
Important distinction - apparent vs. true leukonychia:
- The white discoloration in onycholysis (nail plate separation) represents apparent leukonychia where the detached nail becomes opaque and can appear white, black, or brown-red 1
- True leukonychia originates from the nail matrix and represents actual white nail plate formation 1
- Both can occur with taxane therapy, making clinical examination critical 1
Timing and Pattern Recognition
Key clinical features to anticipate:
- Nail changes appear several weeks after treatment initiation due to slow nail plate growth rate 1
- Changes are dose-related and cumulative, increasing with number of treatment cycles 1
- Fingernails are more commonly affected than toenails, though involvement may be diffuse 1
- Multiple or all nails are typically involved with drug-induced changes, distinguishing this from localized trauma 4
Critical Clinical Pitfall
The most important caveat: When you see white nails in a patient on taxanes, determine whether this is true leukonychia (matrix involvement) or apparent leukonychia from onycholysis 1. This distinction matters because onycholysis requires urgent intervention to prevent permanent nail bed keratinization, while true leukonychia is primarily cosmetic and self-limited after drug discontinuation 1, 5.