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International Journal of Medical and Pharmaceutical
Case Reports
5(4): 1-4, 2015; Article no.IJMPCR.21498
ISSN: 2394-109X, NLM ID: 101648033
SCIENCEDOMAIN international
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A Rarely Seen Side Effect of Sulfasalazine:
Yellowish Colour in Toenails
Ibrahim Tekeoğlu1, Sinem Sağ1*, Ayhan Kamanli1, Mustafa Serdar Sağ1
and Teoman Erdem2
1
Department of Physical Medicine and Rehabilitation, Rheumatology, Faculty of Medicine,
Sakarya University, Sakarya, Turkey.
2
Department of Dermatology, Faculty of Medicine, Sakarya University, Sakarya, Turkey.
Authors’ contributions
This work was carried out in collaboration between all authors. Authors SS and IT wrote the draft of
the manuscript. Authors SS and MSS managed the literature searches. Authors IT and AK designed
the figures, managed literature searches and contributed to the correction of the draft. Author TE
provided the case, the figures and supervised the work. All authors read and approved the final
manuscript.
Article Information
DOI: 10.9734/IJMPCR/2015/21498
Editor(s):
(1) Jignesh G. Patel, Department of Pathology, University of Texas Medical Branch at Galveston, Texas, USA.
Reviewers:
(1) Ana Cláudia Correia Coelho, University of Trás-os-Montes and Alto Douro, Portugal.
(2) Joao de Magalhaes Avancini Ferreira Alves, University of Sao Paulo, Brazil.
(3) Chia-Li Yu, National Taiwan University Hospital, Taiwan.
Complete Peer review History: http://sciencedomain.org/review-history/11680
th
Case Study
Received 20 August 2015
Accepted 19th September 2015
th
Published 5 October 2015
ABSTRACT
Sulfasalazine (SLZ) was the slow acting medication most often used to treat patients with
ankylosing spondylitis whose symptoms were not adequately controlled with nonsteroidal antiinflammatory drugs, exercise, and rehabilitative therapies. Sulfasalazine is an older generation antirheumatic drug first synthesized in the 1940s as a combination of an antibiotic (sulfa pyridine) and
an nonsteroidal anti-inflammatory drug (5-aminosalicylic acid). Most patients can take sulfasalazine
with few side effects. In this study we present a rarely seen side effect of SLZ on a patient with
ankylosing spondylitis whose toenails turned gradually yellow in two years duration.
Keywords: Ankylosing spondylitis; sulfasalazine; yellowish toenails.
_____________________________________________________________________________________________________
*Corresponding author: E-mail: [email protected];
Tekeoğlu et al.; IJMPCR, 5(4): 1-4, 2015; Article no.IJMPCR.21498
skin reaction, hepatic toxicity were not seen. The
follow-ups showed that the toe nails of both feet
of the patient started to turn yellow within the
second year of the sulfasalazine treatment and
yellowness became more evident in the following
7 to 8 months. The reasons that can cause this
yellowness such as fungus eliminated with
Potassium hydroxide (KOH) examination and
culture after the consultation with dermatology
clinic. The patient declared that she did not use
any other medicine regularly. After the rheumatic
examination it was seen that there wasn’t any
symptom of inflammatory disease such as
collagen tissue disease. In the laboratory
examination ANA, ENA, anti-dsDNA, RF, and
anti-CCP values were negative. Urinary findings,
renal function values were normal. The chest
radiography was normal and the consultation
with pulmonology clinic proved that there wasn’t
any pathology in the lungs. The consultation with
cardiovascular surgery clinic examined the
arteriovenous system and lymph circulation and
there wasn’t any pathology. The yellowish colour
of toenails disapperared two months after the
patient stopped SLZ use.
1. INTRODUCTION
Ankylosing Spondylitis (AS) is characterized
by inflammatory back pain, asymmetrical
peripheral arthritis, enthesitis and extra-articular
features [1]. SLZ which is one of the conventional
Disease-Modifying
Anti-Rheumatic
Drugs
(DMARDs) is commonly recommended for the
treatment of peripheral spondyloarthropaty
(pSpA); however, there is no evidence for the
efficacy of this drug in the treatment of axial
disease [2].
The most common side effects of SLZ are
nausea and abdominal discomfort, which often
occur in up to a third of patients early in the
course of treatment.
Only about 10 percent of patients on this
medicine will get a skin rash or headache. Even
less commonly, patients taking this medication
for rheumatoid arthritis will get mouth sores,
itching or abnormalities of liver function [3].
Burning or skin damage from sunlight can also
be a problem. Some people will develop orange
colored urine, and even orange skin. This should
not cause alarm. It is usually harmless and goes
away after medication is stopped [3].
3. DISCUSSION
This is a rare case we present since the colour
change in the toenails of our patient in last two
years considered to the use of SLZ after
diagnosis of AS .
We aimed to present one of the rarest side
effects of sulfasalazine in one of our patients,
who has been diagnosed with AS and whose
toenails started to turn yellow gradually on the
second year of sulfasalazine treatment.
The yellow discoloration toe nails can have many
reasons. It is generally seen after a fungal
infection on the toe nails. Besides, it can be seen
as the side effect of some medicines or it can be
one of the symptoms of a systematic illness.
2. CASE
A 40-year-old female patient. She has a medical
history of inflammatory lumbar pain and
suspicious arthritis on her wrists for more than 3
years and a rheumatic medical history of
inflammatory back pain on the lumbar and gluteal
area for about 4 years. On her examination
Mennel and Gaenslen sacroiliac compression
tests for the right sacroiliac joint was positive. A
Phase 3 sacroiliitis on the right was seen on the
pelvis graph of the patient whose peripheral
active arthritis couldn’t be identified. When an
active sacroiliitis were seen on the right side in
the sacroiliac MRI, and HLA B-27 positivity,
the patient was diagnosed with ankylosing
spondylitis according to Modified New York
Criteria and a treatment of nonsteroid antiinflammatory and sulfasalazine 500 mg,
gradually increased 2 gr a day [4]. Any other side
effects such as gastrointestınal upset, allergic
Onychomycosis of the patient whose toe nails in
both feet turn yellow was discussed with the
dermatology clinic. In the dermatologic
examination all the pathologies such as fungus
were eliminated.
Some drugs that are used in various treatments
can have side effects that can cause yellowness
on the toe nails. Tetracyclines may produce a
yellow fluorescence of the lunulae or a yellow
discoloration of the entire nail plate [5]. Having
been asked, our patient mentioned that she
wasn’t using any antibiotic before the yellowness
and she wasn’t using any other medicine
regularly either.
Yellow nails cannot be seen alone, it can be one
of the components of a syndrome. Yellow nail
2
Tekeoğlu et al.; IJMPCR, 5(4): 1-4, 2015; Article no.IJMPCR.21498
syndrome (YNS) is a rare disorder of unknown
cause characterized by the classic triad of yellow
and thickened nails, lymphedema, and
respiratory manifestations. According to an
analysis of 97 YNS patients reported by Nordkild
et al. [6], 89% had yellow nails, 80% had
lymphedema, and 36% had lung disease. We
examined the yellow nail syndrome in the
differential diagnosis of our patient. Since the
patient didn’t have any other symptoms, yellow
nail syndrome wasn’t considered for her.
In some of the rheumatic diseases, especially in
the collagen tissue diseases nails changes are
seen frequently. Change of nail color is not an
expected symptom in diseases except psoriatic
arthritis in spondyloarthropathies. However,
some of the medicines used for the treatment of
these diseases can implicitly cause some lesions
on the nails.
The series of Sfikakis et al. [10] which includes 5
cases receiving anti-TNF treatment; two
rheumatoid arthritis, two Behçet's syndrome and
one ankylosing spondylitis; put forth that three
patients developing psoriasis after anti-TNF
treatment also had onycholysis and yellow
discoloration. Any biologic agents has not been
used for the treatment of this patient.
Smoking has been linked to many skin conditions
for more than 150 years and evidence exists that
skin involvement might be a conspicuous marker
of other tobacco-related disease [7]. The yellow
rounded digit and harlequin nail signs are two
other simple clinical signs which aid the
diagnosis of health conditions [8,9]. Our patient
was smoking a package weekly. Since the
yellowness was seen only on the toe nails and
since the toes weren’t yellow, the color change
cannot be associated with smoking (Figs.1-2).
Some people will develop orange colored urine
and even orange skin while they are on
sulfasalazine treatment. This should not cause
any alarm. It is usually harmless and goes away
after medication is over.
We haven’t seen any studies or any case reports
in the literature indicating that sulfasalazine
causes nail discoloration. In our case, the
discoloration of the nail which may be associated
with taking sulfasalazine is first case. However,
there has been a regression in the discoloration
on the nails for two months since the patient
freely wanted to stop taking sulfasalazine.
4. CONCLUSION
As a result, sulfasalazine is a medicine which is
used frequently in some phases of spondyloarthropathy. However, it is important to be
conscious of the rare side effects besides the
well-known ones. Further studies both on the
effectiveness and the side effects of spondyloarthropathy diseases will enhance the awareness
of the rare side effects.
CONSENT
Consent was obtained from the patient prior to
manuscript submission.
COMPETING INTERESTS
Authors have
interests exist.
declared
that
no
competing
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Figs. 1-2. Our patient yellowish colour of
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© 2015 Tekeoğlu et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
http://sciencedomain.org/review-history/11680
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