Dermatology: Onychomycosis or Fungal Nail Infection (Nail Diseases Book 9)
Onychomycosis is an infection of the nail apparatus by dermatophytes, yeasts, or molds. The Hutchinson sign is often absent in in situ or early invasive melanoma Figure 2a Advanced melanoma is associated with ulcerations, hemorrhages, loss of parallelism of the bands, multiple colors, blurry borders, and marked invasion into the neighboring skin. Thicker tumors are more likely to infiltrate the bone as well Subungual melanomas can also be amelanotic, in which case they are harder to recognize clinically. Unfortunately, the mean delay from the onset of symptoms to surgery is 2.
It is treated with micrographically guided surgery 21 , Tinea unguium this is the plural form; if only one nail is affected, tinea unguis is caused exclusively by dermatophytes. Fungal infections of the nails are stigmatizing for the patient, causing difficulties in both personal and professional life Onychomycoses are found all over the world In Europe and the USA, their population-based prevalence is 4.
The prevalence increases with age and is highest in persons over age Men are more commonly affected than women, children markedly less so. Molds are found in Of all the dermatophytes isolated from patients with onychomycosis, T. Rarely isolated organisms include Epidermophyton floccosum and T. These are anthropophilic dermatophytes, i. Yeasts are emerging pathogens of onychomycosis that are now being more commonly diagnosed as the causative organisms of onychomycosis. Candida parapsilosis is the most common one, followed by C.
Molds, also called non-dermatophyte molds NDM , are also being increasingly diagnosed as the causative organisms of onychomycosis Scopulariopsis brevicaulis causes onychomycosis of the big toenails. Further mold pathogens include Onychocola canadensis e12 , Aspergillus fumigatus, Acremonium spp. Hendersonula toruloidea , Arthrographis kalrae, Chaetomium globosum as well as T.
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These infections can be transmitted within the family, e. Further sources of infection include swimming pools, bathhouses, saunas, sporting facilities, etc. Predisposing factors include prior nail trauma, advanced age slower nail growth, poorer limb circulation , vascular diseases, lymph edema, diabetes mellitus, immune compromise, tinea pedis, psoriasis vulgaris, psoriasis unguium, and hyperhidrosis.
Older persons often have multiple risk factors. Candida onychomycoses often affect immunosuppressed persons Onychomycosis is present in only about half of all pathological changes of the nails that visually suggest a fungal infection. The differential diagnosis includes a variety of non-infectious nail diseases. There is an autosomal dominant genetic predisposition to distal subungual onychomycosis due to T. Onychomycosis is present in only about half of all pathological changes of the nails that visually suggest a fungal infection e The differential diagnosis includes non-infectious nail diseases such as psoriasis unguium, lichen ruber, yellow nail syndrome, and tumors.
Toenails are affected much more often by onychomycosis than fingernails because of trauma shoes and underlying vascular diseases.
There is visible subungual hyperkeratosis of the markedly thickened nail plate, which is no longer transparent and manifests a yellowish-brown discoloration. In white superficial onychomycosis leukonychia trichophytica , a rarer condition, the fungal pathogens invade from the surface of the nail plate. This condition exclusively affects toenails. The most common pathogen is T. The mold Fusarium spp. In proximal subungual onychomycosis, the infection proceeds from the cuticle particularly in immunosuppressed patients.
The maximal variant of fungal disease of the nail is total dystrophic onychomycosis. In endonyx onychomycosis—caused in the tropics by T. Candida onychomycosis is generally associated with paronychia inflammation of the nail fold Onychomycosis should not be diagnosed on clinical grounds alone. The diagnosis should be based on mycological laboratory tests, including the demonstration of the fungal pathogen by culture of a specimen taken from the treatment-naive patient.
Onychomycosis has broad differential diagnosis and cannot be diagnosed on clinical grounds alone Figure 3. Mere inspection has the highest false-positive rate of any diagnostic method. Rather, the diagnosis should be based on mycological laboratory tests—either a potassium hydroxide preparation or an optical fluorescence preparation, along with growth of the pathogenic fungus in culture—in treatment-naive patients the diagnostic gold standard. The histologic demonstration of fungi causing nail infections by means of the periodic acid Schiff PAS reaction after a punch biopsy of the nails, or nail clippings, is likewise highly sensitive.
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Neither the native preparation nor the histologically examined specimen enables determination of the genus or species of the responsible fungus; culture alone enables identification down to the species level e15 , e There are also newer molecular-biological methods such as the polymerase chain reaction PCR for the direct demonstration of dermatophyte DNA in nail specimens. Used as a complement to conventional fungal culture, the direct demonstration of pathogenic fungi in nail tissue by PCR, multiple-fungus PCR for the simultaneous identification of for example 20 relevant types of fungus, or real-time PCR for the detection of dermatophyte DNA enable much faster, highly sensitive, and very specific diagnosis In vitro sensitivity testing, although a routine part of the work-up of bacterial infections, is not commonly done for fungi.
A limited onychomycosis that does not involve the matrix often responds to topical treatment alone. On the other hand, matrix involvement—often recognizable from the so-called yellow streaks—should be treated with a systemic antimycotic drug, generally in combination with a topical one. The decision on the optimal type of treatment is also based on the number of affected fingernails or toenails, the extent of nail involvement, multimorbidity, drug interactions, and the identified pathogen Table 4.
For topical use, water-soluble ciclopiroxolamine nail varnish is more effective than amorolfin Confirmed dermatophyte infections should be treated with terbinafin, fluconazole, or itraconazole, while confirmed Candida spp. Either continuous or intermittent therapy is possible, depending on the preparation; terbinafin yields the highest response rate Persons with liver disease should only be given systemic antimycotic drugs for strict indications. Onychomycosis due to molds generally does not respond to systemic antimycotic treatment. In infections with Aspergillus species and Scopulariopsis brevicauli s, a trial of oral terbinafin may be successful.
The utility of laser treatment for onychomycosis is debated 38 — In infections with Aspergillus species and Scopulariopsis brevicaulis , a trial of oral terbinafin may be successful. Bacterial infections of the nails often arise out of acute or chronic paronychia, from which Staphylococcus aureus bacteria or streptococci can spread under the nail. Subungual bacterial infection can also be caused by Pseudomonas aeruginosa. Risk factors include repetitive minor trauma, working in damp conditions, onychotillomania compulsive nail-picking or nail-tearing , psoriasis, thumb-sucking, diabetes mellitus, and immunosuppression.
The greenish nail discoloration characteristic of Pseudomonas infection is probably caused by the diffusion of pyocyanin into the nail tissue, or else by bacterial invasion of the nail plate e Artificial fingernails are more heavily colonized than natural ones by both bacteria mainly Gramnegative bacilli and fungi mainly Candida spp.
There have not been any controlled clinical trials on the treatment of bacterial nail infections. There have been reports of the successful topical treatment of fingernail infections due to Pseudomonas aeruginosa and other Gram-negative bacteria with nadifloxacin e18 , e Ciprofloxacin is used for the systemic antibiotic treatment of Pseudomonas infections of the nails. Nail infections due to Staphylococcus aureus and Gram-negative bacteria, such as Klebsiella spp.
Wikiversity Journal of Medicine. See the following website: The EFN must be entered in the appropriate field in the cme. The end product of the nail organ is the nail plate. What structure is essential for horizontal nail growth? What manifestation is of greatest help in the differential diagnosis of rheumatoid arthritis from psoriatic arthritis? Hypoalbuminemia should be ruled out if which of the following manifestations is present?
Dermatoscopy, an optical technique, is particularly useful in the differential diagnosis of what type of nail abnormality? What type of fungus is the most common cause of onychomycosis in Germany and elsewhere in Europe? What diagnostic method is most likely to yield a false positive diagnosis of onychomycosis? Conflict of interest statement.
Nenoff owns Pfizer stock. Haroske state that they have no conflict of interest. National Center for Biotechnology Information , U. Journal List Dtsch Arztebl Int v. Published online Jul Uwe Wollina , Prof. Nenoff Find articles by Pietro Nenoff. Received Jan 8; Accepted Apr This article has been cited by other articles in PMC. Abstract Background Nail disorders can arise at any age.
Onychomycosis
Methods This review is based on publications and guidelines retrieved by a selective search in PubMed, including Cochrane reviews, meta-analyses, and AWMF guidelines. Results Nail disorders are a common reason for dermatologic consultation. Conclusion Evaluation of the nail organ is an important diagnostic instrument.
Open in a separate window. Components of the nail. Learning objectives This article aims to enable the reader to understand the anatomy of the nail organ,. Nail involvement in inflammatory dermatoses. Nail involvement in inflammatory skin diseases Nail involvement in psoriasis often points to the diagnosis. Table 1 Nail involvement in selected inflammatory dermatoses. Case presentation A year-old man presented with pain in one big toe with isolated yellowish thickening of the nail plate. Nail manifestations of internal diseases.
Nail symptoms in general medical disease Inspection of the nail organs is part of the routine physical examination in internal medicine Table 2. It can reveal a number of conditions: Table 2 Nail involvement in general medical diseases.
In the differential diagnosis of rheumatoid vs. Distal ischemia of the acral skin in scleroderma is a cause of acquired irreversible pterygium inversum unguis 1 , e8. Hourglass nails are a secondary phenomenon arising from clubbing of the fingers. Table 3 Drug-induced nail abnormalities. Drug Nail abnormality Vitamin A Dystrophy Anthracyclines and taxanes Painful photo- onycholysis, subungual abscesses, melanonychia EGFR inhibitors Paronychia, unguis incarnatus, granuloma telangiectaticum D-penicillamine, bucillamine Yellow nail syndrome Hydroxyurea Melanonychia brownish-black discoloration Indinavir, retinoids, chemotherapeutic drugs Onychomadesis, Beau-Reil lines mTOR inhibitors Dystrophy, yellow nail syndrome, distal onycholysis, paronychia Rituximab Multiple granulomata teleangiectatica Tetracyclines, retinoids, clofazimine, zidovudine, quinolones Photo-onycholysis, discoloration.
Subungual and periungual tumors Warts due to HPV are the most common type of benign growth affecting the nails. Subungual and periungual tumors. Common malignancies of the nails. Case illustration A year-old woman presented to a dermatologist with progressive onychomadesis of the left thumbnail.
Nail dystrophy of uncertain type. Infectious diseases of the nails Onychomycosis is an infection of the nail apparatus by dermatophytes, yeasts, or molds. Non-infectious causes of nail disease. Onychomycoses a Distal-lateral subungual onychomycosis due to T. There is visible subungual hyperkeratosis of the markedly thickened nail plate, which is no longer transparent and manifests a yellowish-brown discoloration c White superficial onychomycosis leuconychia trichophytica in a year-old man d Total dystrophic onychomycosis of the fingernails due to C.
The diagnosis of onychomycosis. Diagnostic evaluation Onychomycosis has broad differential diagnosis and cannot be diagnosed on clinical grounds alone Figure 3. Table 4 The treatment of onychomycosis usual duration: Bacterial infections of the nails Bacterial infections of the nails often arise out of acute or chronic paronychia, from which Staphylococcus aureus bacteria or streptococci can spread under the nail.
The state of the evidence. Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate. Footnotes Conflict of interest statement Dr. Anatomy of the nail unit and the nail biopsy.
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Congenital aberrant hyponychium vs. J Eur Acad Dermatol Venereol. Nail biology and nail science. Int J Cosmet Sci. Growth rate of human fingernails and toenails in healthy American young adults. Nail psoriasis in Germany: Hand dermatitis and nail disorders of the workplace. Clin Occup Environ Med. Uter W, Geier J. Contact allergy to acrylates and methacrylates in consumers and nail artists—data of the Information Network of Departments of Dermatology, Gagnon AL, Desai T.
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Sauer's Manual of Skin Diseases 10 ed. The latter gives rise to a dense superficial connective-tissue lamina enveloping the nail matrix e1. When the reaction is localized to the nails possible reactions include: In some cases of suspected nail fungus there is actually no fungal infection, but only nail deformity. In conclusion the authors say that terbinafine has a relatively benign adverse effect profile, with liver damage very rare, so it makes more sense cost-wise for the dermatologist to prescribe the treatment without doing the PAS test.
Nail toxicities induced by systemic anticancer treatments. Piraccini BM, Alessandrini A. Topical treatments for cutaneous warts. Patients should address specific medical concerns with their physicians. Nail plate changes Technique: Obtaining Nail specimens Labs: Miscellaneous Differential Diagnosis Management: Less effective agents generally avoid these for Onychomycosis Prognosis Complications References Extra: Related Bing Images Extra: Definition Fungal infection affecting the Toenail or Fingernail.
Epidemiology Prevalence Gene ral population: Age over 60 years: Pathophysiology Person to person transmission Toenail s are more commonly affected than Fingernail s Decreased blood supply and slower growth compared with Fingernail s Dark, moist environment. Types Distal Subungual most common Affects distal and lateral Toenail s and Fingernail s Starts distally at Hyponychium and spreads into nail plate and nail bed Associated with hyperkeratosis with secondary Onycholysis and ultimately Dystrophic Nail s with yellow or brown discoloration Acquired through break in skin at nail undersurface e.
Trichophyton mentagrophytes Typically white but sometimes black powdery patches forming horizontal nail lines Endonyx Subungual rare subtype of distal subungual Etiologies Trichophyton soudanense Trichophyton violaceum Direct infection of full nail thickness without affecting nail bed May affect entire Toenail s Starts as opaque, well demarcated milky-white spots Spots coalesce to involve entire nail Associated findings Lamellar splitting and nail indentations No hyperkeratosis or Onycholysis Proximal Subungual least common Most common etiology: Trichophyton rubrum Affects proximal Fingernail s and Toenail s Fungi invade proximal nail fold to enter nail Hyperkeratosis and debris form under proximal nail resulting in Onycholysis that spreads gradually from proximal to distal nail Predisposing factors Immunocompromised status e.
HIV Infection or AIDS Local Trauma may also result in similar presentation Candida Onychomycosis rare Associated with Chronic Paronychia Candida More common in immunocompromised state Total dystrophic Onychomycosis Total nail plate destruction from above types especially distal subungual Associated with long-term infection that thickens the nail and ultimately destroys the nail structure. Nail plate changes Discoloration white or yellow Opacification Distribution based on type see above. Subungual debris scraping Test Sensitivity: Periodic acid schiff stain effective, but expensive and not widely available Test Sensitivity: General Measures Keep feet dry Wear cotton socks and change times per day Wear shoes that are breathable Reduce fungus exposure Wear foot protection in shared showers locker room Treat Tinea Pedis Consider nail removal in severe Onycholysis Optimize chronic disease management Diabetes Mellitus Tobacco Cessation Cosmetic procedures Laser Therapy e.
PinPointe Treats only the cosmetic appearance of the nail not the fungal infection Antifungal Medications Consider Topical Antifungal to treat periungual fungus as adjunct to those below Consider longer Antifungal course in some patients Slow Nail Growth Extensive nail plate involvement Diminished blood supply Peripheral Vascular Disease Diabetes Mellitus.