Onychomycosis


Article Author:
Myron Bodman


Article Editor:
Karthik Krishnamurthy


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


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Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/8/2019 2:01:27 PM

Introduction

Onychomycosis is a fungal infection of the nail unit. When onychomycosis is caused by dermatophytes, it is called tinea unguium. The term onychomycosis encompasses not only the dermatophytes but the yeasts and saprophytic molds infections as well. An abnormal nail that is not caused by a fungal infection is a type of dystrophic nail. Onychomycosis can infect both fingernails and toenails, but onychomycosis of the toenail is much more prevalent. The disease burden, clinical types, staging, diagnosis, and management of toenail onychomycosis will be discussed.[1][2][3]

Etiology

The most frequent cause of onychomycosis is Trichophyton rubrum, but other dermatophytes including Trichophyton mentagrophytes and Epidermophyton floccossum can be caused as well. The dermatophytes are identified in 90% of the toenail and 50% of finger nail onychomycosis. Candida albicans accounts for 2% of onychomycosis, occurring especially in finger nails. Nondermatophytic mold onychomycosis is primarily cultured from toenails. Examples of these saprophytic molds include Fusarium, Aspergillus, Acremonium, Scytalidium and Sciopulariopsis brevicaulis. They account for about 8% of the nail infections.[4]

Epidemiology

Onychomycosis is a common infection that is increasing in incidence. In the United States, Trichophyton rubrum was initially thought to be a culture contaminant, but since the advent of international travel to Asia, T. rubrum has become the dominant causative organism in the United States. At least half of abnormal toenails are mycotic. Prevalence estimates range from 1% to 8%, and the incidence is increasing. It has been reported that patients are genetically susceptible to dermatophyte infections in an autosomal dominant pattern. Risk factors include aging, diabetes, tinea pedis, psoriasis, immunodeficiency and living with family members who have onychomycosis. [5][6]

Pathophysiology

Causative organisms can be cultured from hotel carpets, public showers and pool decks. In most cases, onychomycosis is preceded by an asymptomatic, dry hyperkeratotic tinea pedis. Over time, the dark, warm, moist environment of shoes and micro-traumatic pressure on the nail unit compromise and break the hyponychial seal, allowing penetration of the dermatophyte into the nail bed. Repeated exposure to water in wet work compromises fingernails. Dermatophytes only live on the keratin of dead corneocytes in skin, nails, and hair. In the foot, the dermatophytes produce keratinases that begin the infection between the lesser toes, spread to the hyperkeratotic sole, and gradually extend to the distal hyponychial space of micro-traumatized nail units. Once the distal nail hyponychium is breached, the dermatophytes infect the nail bed, spreading proximally as onycholysis and subungual hyperkeratosis. [7][8]

The primary site of the infection is the nail bed where the acute infection occurs with a low-grade inflammatory response and progresses to a chronic phase of the nail bed infection as total dystrophic onychomycosis. Histologically, the acute lesion of onychomycosis manifests as spongiosis, acanthosis, papillomatosis with edema, and hyperkeratosis. These signs resemble the pathology of psoriasis. As in most infection, a dense inflammatory infiltrate develops. Onychomycosis does infect viable nail matrix. Onychomycosis secondarily damages the nail matrix as the nail bed becomes hyperkeratotic and thickened in an effort to shed the fungal infection. The dermatophyte also invades the overlying nail plate, detaching and distorting it over time. The nail plate becomes elevated and misaligned as the infection enters the chronic total dystrophic clinical stage of onychomycosis (TDO). At this chronic stage of the infection, there are large amounts of compact hyperkeratosis, hypergranulosis, acanthosis, and papillomatosis with sparse perivascular infiltrate. Dermatophytosis and subungual seromas can occur. Zaikovska et al. found high levels of cytokines interleukin-6- and interleukin-10-positive cells in the nail bed as well as the bloodstream in onychomycosis. A significant amount of fibers containing human beta defensin-2 were found in the bed and plate of the mycotic nails. 

History and Physical

The duration, progression, and success of previous treatments are all important aspects of the evaluation of a patient with nail disease. In addition, in suspected onychomycosis, the medication history is important to assess the potential impact of systemic antifungals with current medications. A history of hepatitis or travel to areas where hepatitis is endemic is an important aspect in considering appropriate tests to order in the laboratory workup. Alcohol usage should be chronicled. Recreational activities can predispose patients to recurrence or re-infection. Tinea manum, cruris or psoriasis often accompany onychomycosis. The focused cutaneous examination should include special attention to the hands and feet and scalp.

Pedal onychomycosis often presents as one or more thickened, discolored toenails. Usually, one or both great toenails are affected. Most cases have concurrent mild, dry, hyperkeratotic tinea pedis that patients often mistake for simple xerosis. Baseline images of the target nail and measuring the extent of the infection are important to predict the duration of treatment and evaluate therapeutic progress in an infection that can take 12 months to clear. Estimate toenail growth at approximately one millimeter per month and measure the infected area of the nail unit to estimate the duration of the treatment. Keep in mind that fingernails grow faster than toenails, and aging and peripheral vascular insufficiency slow growth rates. 

Evaluation

Determining the severity and clinical stage of the infection helps guide therapy and improves outcomes. The most common clinical subtype of onychomycosis is distal lateral subungual onychomycosis(DSLO). It presents as partial distal onycholysis with subungual hyperkeratosis or crumbling. Much less common is white superficial onychomycosis (WSO) which appears as white chalky deposits on the surface of the affected nail plate. It can be easily scrapped away with a currette or rotary burr. The rarest subtype is proximal subungual onychomycosis (PSO) which develops overlying the nail matrix. It has been associated with acquired immunodeficiency syndrome (AIDS) and may be hematogenously spread. In the endonyx subtype, the interior of the nail plate is infected first, and the key feature of subungual hyperkeratosis of the nail bed is not evident. Total dystrophic onychomycosis (TDO) refers to the most advanced form of all sub-types. TDO is a later severe stage of the chronic subungual dermatophyte infection that may take 10 to 15 years to develop. There is significant subungual hyperkeratosis and destruction of abnormal nail plate and ridging of the nail bed. It not only is the most difficult stage to clear but also the type with the highest risk of developing subungual ulceration, secondary bacterial infection, and precipitating gangrene in patients with impaired peripheral circulation.[9][10][11]

It is important to know that almost half of abnormal appearing toenails are not actually mycotic, so mycological testing is important to establish an accurate diagnosis. This is especially important if systemic therapy is planned. The traditional potassium hydroxide (KOH) wet mount preparation of subungual debris is only 60% sensitive but cannot identify the species. However, if the KOH is positive it can separate dermatophytes from saprophytes. Currently, the most sensitive test (95%) is a pathologist interpreted nail clip biopsy that has been stained with periodic acid-Schiff (PAS) plus Grocott methenamine silver. Today, a mycologist is required to interpret fungal culture testing. Fungal cultures are very specific but not very sensitive (60%). Fungal cultures grow slowly, adding weeks and cost to the workup.

Fungal culture or PCR are required to speciate the cause of the infection. They are useful to help determine the source of the infection in atypical cases or when one suspects a primary saprophytic infection. To confirm this suspicion, two subsequent cultures of the same saprophytic mold should be obtained before concluding that the saprophyte is the primary pathogen and not a contaminant. PCR improves the species-specific detection of dermatophytes 20% over fungal cultures alone. 

Dermoscopy can clinically diagnoses onychomycosis. It also can readily differentiate between onychomycosis and nail dystrophy. The presence of subungual short spikes and longitudinal striae indicates onychomycosis while transverse onycholysis is consistent with microtraumatic nail dystrophy. 

Treatment / Management

The most effective treatments for onychomycosis are systemic antifungals. Due to an increased risk of subungual ulceration, one also should consider oral antifungal therapy in moderate to severe disease, especially in patients with diabetes mellitus. Combination therapy with topical agents, periodic debridement or chemical nail avulsion, may produce better results than systemic medication alone. For mild to moderate cases and in patients who prefer to avoid systemic antifungals, the newer topical antifungal therapies have improved cure rates. Meta-analyses have shown the mycological cure rate for terbinafine is 76%, itraconazole pulse dosing is 63%, and fluconazole is 48% effective while topical therapy mycological cure rates are 55% for efinaconazole and 36% for tavaborole or ciclopirox.[7][12][13]

The complete cure rate is defined as both negative mycology and 100% clear nail is the gold standard for comparing efficacies. However, it is a very stringent criteria as residual nail dystrophy from chronic infection may scar the nail plate and not allow some results to be considered completely clear even though there may be a significant clinical improvement. On the other hand, the nail unit may be 100% clear, but the post treatment fungal culture may detect fungal colonization. The complete cure rate for systemic terbinafine is 38%. 

Oral therapy is the most effective therapy for severe onychomycosis, but for some patients, it is medically inappropriate. Additionally, many patients have a strong personal preference for a non-systemic approach. Topical therapy would seem to be a good solution to the problem if the efficacy rates were better. Many over the counter and prescription products are available, hinting that there is no clearly effective topical choice. The evidence concludes that complete cure rates for FDA-approved topical therapies have recently improved from 8.5% for ciclopirox lacquer to 18% for an efinaconazole solution. The tavaborole solution has a complete cure rate of 9.1% in mild to moderate distal subungual onychomycosis.

It is important to carefully review the patient history for alcohol abuse and hepatitis. Ordering alanine aminotransferase and aspartate aminotransferase hepatic function tests before the beginning of continuous therapy establishes a baseline. If there is a history of living overseas where hepatitis is endemic, one can add a hepatitis antigen screening panel to the workup. Follow-up hepatic function tests at five weeks serve to detect the less than 2% of idiosyncratic reactions. If the follow-up tests are significantly elevated, one can stop the drug and retest.

Additionally, concurrent medications may preclude the use of oral antifungals. Terbinafine may alter the metabolism of a number of drugs, so monitoring is appropriate. Concerns regarding drug-to-drug interactions with statin therapy and systemic antifungal therapy are actually with the azole class of antifungals and not terbinafine. It might be best to avoid systemic therapy in patients on psychotropic medications. Terbinafine carries a contraindication for concurrent use with the phenothiazines and pimozide for increased risk of QT prolongation. Gupta reports one can use terbinafine safely in children as well as the elderly. However, clinicians should always exercise caution in patients with polypharmacy major. It may be best to use an alternative therapy or periodic debridement alone to control symptoms in these cases to avoid adverse drug reactions in patients with an essentially benign disease. 

Differential Diagnosis

  • Yellow nail syndrome
  • Drug reaction
  • Hypothyroidism
  • Nail malignancy
  • Psoriatic nail
  • Contact dermatitis

Complications

Risk of infections are usually higher in diabetics and include the following: 

  • Cellulitis
  • Sepsis
  • Osteomyelitis
  • Tissue damage
  • Loss of nail

Pearls and Other Issues

To control symptoms and reduce the risks of subungual ulceration and secondary bacterial infection, clinicians can use periodic debridement to successfully manage severe onychomycosis in patients who elect to avoid systemic therapy or are unable to apply topical antifungals. In addition, many patients are reluctant to accept the potential risk of idiosyncratic hepatic reaction that may occur during 90 days of continuous systemic antifungal therapy. Some patients will however accept and do well with pulsed systemic therapy. In moderate onychomycosis, 250mg of terbinafine daily for one week every nine weeks for three pulses is acceptable.  

Although periodic thorough debridement is unlikely to clear onychomycosis, it appears to improve the immediate patient satisfaction and aid the efficacy of medications. Concurrent treatment of the tinea pedis should be undertaken and along with the long-term daily use of an anti-fungal power to reduce reinfection and recurrence.

Enhancing Healthcare Team Outcomes

The management of onychomycosis is multidisciplinary. While the fungal infection is not life-threatening, it has enormous morbidity. The key is patient education. The public should be educated about appropriate footwear when visiting community swimming pools, saunas, and health clubs. If the patient works in a wet environment like washing dishes, then he or she should be encouraged to wear gloves. The pharmacist should inform the patient that treatment is often required for a minimum of 12 months and some patients may require prophylactic treatment to prevent recurrence. For those who want a faster option, the patient should be referred to a dermatologist or a  surgeon for complete nail removal. [14][15](Level V)

Outcomes

For patients who delay in seeking care, the nail deformity usually progresses and may lead to disfigurement and pain. Even though anti-fungal drugs are available, the treatment is often for months or years before one sees an obvious improvement. Several studies have shown that terbinafine is more effective than other antifungals. However, individuals who have yellow streaks along the lateral nail border tend to have poor responses to treatment. Overall, fungal infections of the toenails have a much poorer outcome compared to fingernail infections. Finally, despite treatment, there is a high rate of recurrence ranging from 5-50%.[16][17] (Level V)


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    Contributed by Myron Bodman, DPM
Attributed To: Contributed by Myron Bodman, DPM

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Onychomycosis - Questions

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Select the contraindication to oral treatment of onychomycosis of the toenails.



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A 55-year-old obese female presents with complaints of soreness and discoloration of multiple nails. Past medical history includes type 2 diabetes and pernicious anemia. Medications include metformin and vitamin B12. The patient has three fingernails and five toenails that are yellow, thickened and exhibit subungual onycholysis. After three months of B12 therapy, the anemia has improved but not the nails. Nail clip biopsies of several nails reveal segmented branching hyphae within the nail plate. Which of the following would be the best management of this persistent nail problem?

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A 62-year-old woman presents with severe thickening of the toenails that has failed to clear with topical ciclopirox lacquer. Medications include atorvastatin and metformin. A nail clip biopsy reports fungal elements consistent with a dermatophyte infection. Which of the following best describes the recommended duration of systemic terbinafine therapy for toenail onychomycosis?

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A 48-year-old male complains of discolored and thickened toenails that have been present for years. He wishes to try systemic antifungal therapy. Which of the following tests is the most sensitive test to confirm the clinical diagnosis of onychomycosis?



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A 65-year-old female complains of multiple thickened and discolored fingernails and toenails. Which of the following best approximates the proportion of clinically abnormal nails that are actually fungal infections?



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Onychomycosis - References

References

Karaman BFO,Açıkalın A,Ünal İ,Aksungur VL, Diagnostic values of KOH examination, histological examination, and culture for onychomycosis: a latent class analysis. International journal of dermatology. 2018 Sep 23     [PubMed]
Haghani I,Shams-Ghahfarokhi M,Dalimi Asl A,Shokohi T,Hedayati MT, Molecular identification and antifungal susceptibility of clinical fungal isolates from onychomycosis (uncommon and emerging species). Mycoses. 2018 Sep 25     [PubMed]
Becker BA,Childress MA, Common Foot Problems: Over-the-Counter Treatments and Home Care. American family physician. 2018 Sep 1     [PubMed]
Youssef AB,Kallel A,Azaiz Z,Jemel S,Bada N,Chouchen A,Belhadj-Salah N,Fakhfakh N,Belhadj S,Kallel K, Onychomycosis: Which fungal species are involved? Experience of the Laboratory of Parasitology-Mycology of the Rabta Hospital of Tunis. Journal de mycologie medicale. 2018 Aug 11     [PubMed]
Arsenijević VA,Denning DW, Estimated Burden of Serious Fungal Diseases in Serbia. Journal of fungi (Basel, Switzerland). 2018 Jun 25     [PubMed]
Lipner SR,Scher RK, Part I: Onychomycosis: Clinical Overview and Diagnosis. Journal of the American Academy of Dermatology. 2018 Jun 27     [PubMed]
Drago L,Micali G,Papini M,Piraccini BM,Veraldi S, Management of mycoses in daily practice. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia. 2017 Dec     [PubMed]
Maddy AJ,Tosti A, Hair and nail diseases in the mature patient. Clinics in dermatology. 2018 Mar - Apr     [PubMed]
Hay R, Therapy of Skin, Hair and Nail Fungal Infections. Journal of fungi (Basel, Switzerland). 2018 Aug 20     [PubMed]
Hayette MP,Seidel L,Adjetey C,Darfouf R,Wéry M,Boreux R,Sacheli R,Melin P,Arrese J, Clinical evaluation of the DermaGenius® Nail real-time PCR assay for the detection of dermatophytes and Candida albicans in nails. Medical mycology. 2018 May 11     [PubMed]
Chetana K,Menon R,David BG, Onychoscopic evaluation of onychomycosis in a tertiary care teaching hospital: a cross-sectional study from South India. International journal of dermatology. 2018 Jul     [PubMed]
Lok C, [What's new in clinical dermatology?] Annales de dermatologie et de venereologie. 2016 Dec     [PubMed]
Wollina U,Nenoff P,Haroske G,Haenssle HA, The Diagnosis and Treatment of Nail Disorders. Deutsches Arzteblatt international. 2016 Jul 25     [PubMed]
Lipner SR,Scher RK, Part II: Onychomycosis: Treatment and Prevention of Recurrence. Journal of the American Academy of Dermatology. 2018 Jun 27     [PubMed]
Hanna S,Andriessen A,Beecker J,Gilbert M,Goldstein E,Kalia S,King A,Kraft J,Lynde C,Singh D,Turchin I,Zip C, Clinical Insights About Onychomycosis and Its Treatment: A Consensus. Journal of drugs in dermatology : JDD. 2018 Mar 1     [PubMed]
Shemer A,Gupta AK,Babaev M,Barzilai A,Farhi R,Daniel Iii CR, A Retrospective Study Comparing K101 Nail Solution as a Monotherapy and in Combination with Oral Terbinafine or Itraconazole for the Treatment of Toenail Onychomycosis. Skin appendage disorders. 2018 Aug     [PubMed]
Salakshna N,Bunyaratavej S,Matthapan L,Lertrujiwanit K,Leeyaphan C, A cohort study of risk factors, clinical presentations and outcomes for dermatophyte, non-dermatophyte and mixed toenail infections. Journal of the American Academy of Dermatology. 2018 May 31     [PubMed]

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