Onychomycosis Classification and external resources
A toenail affected by onychomycosis
ICD-10 B35.1 ICD-9 110.1 DiseasesDB 13125 MedlinePlus 001330 eMedicine derm/300 MeSH D014009
Onychomycosis (also known as "dermatophytic onychomycosis," "ringworm of the nail," and "tinea unguium") means fungal infection of the nail. It is the most common disease of the nails and constitutes about a half of all nail abnormalities.
This condition may affect toenails or fingernails, but toenail infections are particularly common. The prevalence of onychomycosis is about 6-8% in the adult population.
There are four classic types of onychomycosis:
- Distal subungual onychomycosis is the most common form of tinea unguium, and is usually caused by Trichophyton rubrum, which invades the nail bed and the underside of the nail plate.
- White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. It accounts for only 10 percent of onychomycosis cases. In some cases, WSO is a misdiagnosis of "keratin granulations" which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.
- Proximal subungual onychomycosis is fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people, but is found more commonly when the patient is immunocompromised.
- Candidal onychomycosis is Candida species invasion of the fingernails, usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.
Signs and symptoms
The nail plate can have a thickened, yellow, or cloudy appearance. The nails can become rough and crumbly, or can separate from the nail bed. There is usually no pain or other bodily symptoms, unless the disease is severe.
Dermatophytids are fungus-free skin lesions that sometimes form as a result of a fungus infection in another part of the body. This could take the form of a rash or itch in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction to the fungus. People with onychomycosis may experience significant psychosocial problems due to the appearance of the nail. This is particularly increased when fingernails are affected.
The causative pathogens of onychomycosis include dermatophytes, Candida, and nondermatophytic molds. Dermatophytes are the fungi most commonly responsible for onychomycosis in the temperate western countries; while Candida and nondermatophytic molds are more frequently involved in the tropics and subtropics with a hot and humid climate.
Trichophyton rubrum is the most common dermatophyte involved in onychomycosis. Other dermatophytes that may be involved are T. interdigitale, Epidermophyton floccosum, T. violaceum, Microsporum gypseum, T. tonsurans, T. soudanense (considered by some to be an African variant of T. rubrum rather than a full-fledged separate species) and the cattle ringworm fungus T. verrucosum. A common outdated name that may still be reported by medical laboratories is Trichophyton mentagrophytes for T. interdigitale. The name T. mentagrophytes is now restricted to the agent of favus skin infection of the mouse; though this fungus may be transmitted from mice and their danders to humans, it generally infects skin and not nails.
Other causative pathogens include Candida and nondermatophytic molds, in particular members of the mold generation Scytalidium (name recently changed to Neoscytalidium), Scopulariopsis, and Aspergillus. Candida spp. mainly cause fingernail onychomycosis in people whose hands are often submerged in water. Scytalidium mainly affects people in the tropics, though it persists if they later move to areas of temperate climate.
Other molds more commonly affect people older than 60 years, and their presence in the nail reflects a slight weakening in the nail's ability to defend itself against fungal invasion.
Risk factors for onychomycosis include family history, increasing age, poor health, prior trauma, warm climate, participation in fitness activities, immunosuppression (e.g., HIV, drug induced), communal bathing, and occlusive footwear.
To avoid misdiagnosis as nail psoriasis, lichen planus, contact dermatitis, trauma, nail bed tumor or yellow nail syndrome, laboratory confirmation may be necessary. The three main approaches are potassium hydroxide smear, culture and histology. This involves microscopic examination and culture of nail scrapings or clippings. Recent results indicate the most sensitive diagnostic approaches are direct smear combined with histological examination, and nail plate biopsy using periodic acid-Schiff stain. To reliably identify nondermatophyte molds, several samples may be necessary.
Treatment of onychomycosis is challenging because the infection is embedded within the nail and is difficult to reach. As a result, full removal of symptoms is very slow and may take a year or more.
Most treatments are either systemic antifungal medications, such as terbinafine and itraconazole, or topical, such as nail paints containing ciclopirox or amorolfine. There is also evidence for combining systemic and topical treatments.
For superficial white onychomycosis, systemic rather than topical antifungal therapy is advised.
In July 2007, a meta-study reported on clinical trials for topical treatments of fungal nail infections. The study included six randomised, controlled trials dating up to March 2005. The main findings are:
- There is some evidence ciclopiroxolamine and butenafine are both effective, but both need to be applied daily for prolonged periods (at least 1 year).
- There is evidence topical ciclopiroxolamine has poor cure rates, and that amorolfine might be substantially more effective.
- Further research into the effectiveness of antifungal agents for nail infections is required.
A 2002 study compared the efficacy and safety of terbinafine in comparison to placebo, itraconazole and griseofulvin in treating fungal infections of the nails. The main findings were for reduced fungus, terbinafine was found to be significantly better than itraconazole and griseofulvin, and terbinafine was better tolerated than itraconazole.
- A small study in 2004 showed ciclopirox nail paint was more effective when combined with topical urea cream.
- A study of 504 patients in 2007 found aggressive debridement of the nail, combined with oral terbinafine, significantly reduced symptom frequency over terbinafine alone.
- A 2007 randomised clinical trial with 249 patients showed a combination of amorolfine nail lacquer and oral terbinafine enhanced clinical efficacy and is more cost-effective than terbinafine alone.
A Noveon-type laser, already in use by physicians for some types of cataract surgery, is used by some podiatrists, although the only scientific study on its efficacy, while showing positive results, included far too few test subjects for the laser to be proven generally effective.
Light Age, Inc. has approval to market a Nd:YAG laser for onychomycosis treatment.
As with many diseases, there are also some scientifically unverified folk or alternative medicine remedies.
- Australian tea tree oil has been tested, but there is insufficient information to make recommendations for its use for onychomycosis.
- Grapefruit seed extract as a natural antimicrobial is not demonstrated. Its effectiveness is scientifically unverified. Multiple studies indicate the universal antimicrobial activity is due to contamination with synthetic preservatives that were unlikely to be made from the seeds of the grapefruit.
- Snakeroot leaf extract has, in studies, shown ability to treat superficial onychomycosis, although the results show it is less effective, and equal to conventional drugs ciclopirox and ketaconazole, respectively.
A 2003 survey of diseases of the foot in 16 European countries found onychomycosis to be the most frequent fungal foot infection and estimates its prevalence at 27%. Prevalence was observed to increase with age. In Canada, the prevalence was estimated to be 6.48%. Onychomycosis affects approximately one-third of diabetics and is 56% more frequent in people suffering from psoriasis.
Most drug development activities are focused on the discovery of new antifungals and novel delivery methods to promote access of existing antifungal drugs into the infected nail plate. Active clinical trials investigating onychomycosis:
- A topical treatment, AN2690, is being developed by Anacor Pharmaceuticals. It is active against Trichophyton species.
- A medicinal nail lacquer, MycoVa from Apricus Biosciences, contains terbinafine as the active ingredient and a permeation enhancer DDAIP which facilitates the delivery of the drug into the nail bed where the fungus resides.
- A comparison of delivery methods for itraconzole
- Safety and tolerability of topical terbinafine
- Laser-based treatments
- Topical IDP-108
- Bifonazole cream application after nail ablation with urea paste
- Posaconazole, taken orally.
- A topical treatment, NB-002, is being developed by NanoBio Corporation. It has completed Phase II trials.
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Diseases of the skin and appendages by morphology GrowthsPigmentedDermal and
PurpuraMacularthrombocytopenic purpura · actinic purpuraPapularIndurated
Infectious diseases · Mycoses and Mesomycetozoea (B35–B49, 110–118) Superficial and
endothrix)=hairBy locationTinea barbae/Tinea capitis (Kerion) · Tinea corporis (Ringworm, Dermatophytid) · Tinea cruris · Tinea manuum · Tinea pedis (Athlete's foot) · Tinea unguium/Onychomycosis (White superficial onychomycosis · Distal subungual onychomycosis · Proximal subungual onychomycosis)
Tinea corporis gladiatorum · Tinea faciei · Tinea imbricata · Tinea incognito · FavusBy organismOtherHortaea werneckii (Tinea nigra) · Piedraia hortae (Black piedra)
(yeast+mold)Coccidioides immitis/Coccidioides posadasii (Coccidioidomycosis, Disseminated coccidioidomycosis, Primary cutaneous coccidioidomycosis. Primary pulmonary coccidioidomycosis) · Histoplasma capsulatum (Histoplasmosis, Primary cutaneous histoplasmosis, Primary pulmonary histoplasmosis, Progressive disseminated histoplasmosis) · Histoplasma duboisii (African histoplasmosis) · Lacazia loboi (Lobomycosis) · Paracoccidioides brasiliensis (Paracoccidioidomycosis)OtherYeast-likeCandida albicans (Candidiasis, Oral, Esophageal, Vulvovaginal, Chronic mucocutaneous, Antibiotic candidiasis, Candidal intertrigo, Candidal onychomycosis, Candidal paronychia, Candidid, Diaper candidiasis, Congenital cutaneous candidiasis, Perianal candidiasis, Systemic candidiasis, Erosio interdigitalis blastomycetica) · C. glabrata · C. tropicalis · C. lusitaniae · Pneumocystis jirovecii (Pneumocystosis, Pneumocystis pneumonia)Mold-likeAspergillus (Aspergillosis, Aspergilloma, Allergic bronchopulmonary aspergillosis, Primary cutaneous aspergillosis) · Exophiala jeanselmei (Eumycetoma) · Fonsecaea pedrosoi/Fonsecaea compacta/Phialophora verrucosa (Chromoblastomycosis) · Geotrichum candidum (Geotrichosis) · Pseudallescheria boydii (Allescheriasis)Entomophthorales
(Entomophthoramycosis)Enterocytozoon bieneusi/Encephalitozoon intestinalis
Mesomycetozoea Ungrouped Disorders of skin appendages (L60–L75, 703–706) Nailbehavior: Onychotillomania · Onychophagiaother: Ingrown nail · Anonychiaungrouped: Paronychia (Acute paronychia, Chronic paronychia ) · Chevron nail · Congenital onychodysplasia of the index fingers · Green nails · Half and half nails · Hangnail · Hapalonychia · Hook nail · Lichen planus of the nails · Longitudinal erythronychia · Malalignment of the nail plate · Median nail dystrophy · Mees' lines · Melanonychia · Muehrcke's lines · Nail–patella syndrome · Onychoatrophy · Onychocryptosis · Onycholysis · Onychomadesis · Onychomatricoma · Onychomycosis · Onychophosis · Onychoptosis defluvium · Onychorrhexis · Onychoschizia · Platonychia · Pincer nails · Plummer's nail · Psoriatic nails · Pterygium inversum unguis · Pterygium unguis · Purpura of the nail bed · Racquet nail · Red lunulae · Shell nail syndrome · Splinter hemorrhage · Spotted lunulae · Staining of the nail plate · Stippled nails · Subungual hematoma · Terry's nails · Twenty-nail dystrophy Hairnoncicatricial alopecia: Alopecia/Alopecia areata (Alopecia totalis, Alopecia universalis, Ophiasis)
Androgenic alopecia (male-pattern baldness) · Hypotrichosis · Telogen effluvium · Traction alopecia · Lichen planopilaris · Trichorrhexis nodosa · Alopecia neoplastica · Anagen effluvium · Alopecia mucinosacicatricial alopecia: Pseudopelade of Brocq · Central centrifugal cicatricial alopecia · Pressure alopecia · Traumatic alopecia · Tumor alopecia · Hot comb alopecia · Perifolliculitis capitis abscedens et suffodiens · Graham-Little syndrome · Folliculitis decalvansungrouped: Triangular alopecia · Frontal fibrosing alopecia · Marie Unna hereditary hypotrichosisHirsutism · Acquired generalized hypertrichosis · Generalized congenital hypertrichosis · Localized acquired hypertrichosis · Localized congenital hypertrichosis · Patterned acquired hypertrichosis · Prepubertal hypertrichosis · X-linked hypertrichosisAcneAcne vulgaris · Acne conglobata · Acne miliaris necrotica · Tropical acne · Infantile acne/Neonatal acne · Excoriated acne · Acne fulminans · Acne medicamentosa (e.g., steroid acne) · Halogen acne (Iododerma, Bromoderma, Chloracne) · Oil acne · Tar acne · Acne cosmetica · Occupational acne · Acne aestivalis · Acne keloidalis nuchae · Acne mechanica · Acne with facial edema · Pomade acne · Acne necrotica · Blackhead · Lupus miliaris disseminatus facieiPerioral dermatitis (Granulomatous perioral dermatitis) · Phymatous rosacea (Rhinophyma, Blepharophyma, Gnathophyma, Metophyma, Otophyma) · Papulopustular rosacea · Lupoid rosacea · Erythrotelangiectatic rosacea · Glandular rosacea · Gram-negative rosacea · Steroid rosacea · Ocular rosacea · Persistent edema of rosacea · Rosacea conglobata · variants (Periorificial dermatitis, Pyoderma faciale)UngroupedGranulomatous facial dermatitis · Idiopathic facial aseptic granuloma · Periorbital dermatitis · SAPHO syndromeFollicular cystsUngroupedAcrokeratosis paraneoplastica of Bazex · Acroosteolysis · Bubble hair deformity · Disseminate and recurrent infundibulofolliculitis · Erosive pustular dermatitis of the scalp · Erythromelanosis follicularis faciei et colli · Hair casts · Hair follicle nevus · Intermittent hair–follicle dystrophy · Keratosis pilaris atropicans · Kinking hair · Koenen's tumor · Lichen planopilaris · Lichen spinulosus · Loose anagen syndrome · Menkes kinky hair syndrome · Monilethrix · Parakeratosis pustulosa · Pili (Pili annulati · Pili bifurcati · Pili multigemini · Pili pseudoannulati · Pili torti) · Pityriasis amiantacea · Plica neuropathica · Poliosis · Rubinstein–Taybi syndrome · Setleis syndrome · Traumatic anserine folliculosis · Trichomegaly · Trichomycosis axillaris · Trichorrhexis (Trichorrhexis invaginata · Trichorrhexis nodosa) · Trichostasis spinulosa · Uncombable hair syndrome · Wooly hair · Wooly hair nevus
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