Onychomycosis

FOR HEALTH OFFICER STUDENTS

SOLOMON H ( MD, DVR )
 Outline

Introduction

Epidemology

Etiology

clinical classification and findings

differential diagnosis

laboratory

management
 Introduction
Onychomycosis :-

- is an Invasion of the nail plate by dermatophyte fungi, non

dermatophyte molds or yeasts.

- Ringworm of the nails

-Tinea unguium - refers strictly to dermatophyte infection of

the nail plate.
 Anatomy of the nail
1 - the nail plate- a horny “dead” product which rests on the nail
bed

* Has 3 horizontal layers - dorsal lamina

- intermediate lamina
- ventral lamina

2- four specialized epithelia:

1. Proximal nail fold- covers proximal one-quarter of the

nail plate

Cuticle - Junction of two epithelial surfaces of PNF, sealing PNF & Np

2. Nail matrix- keratinocytes differentiate, harden, die &
contribute to nail plate

Lunula- Underlies proximal fold, white in color and represents

most distal region of matrix

3- Nail bed- Contains blood vessels, lymphatics, elastic

fibers & fat cells

4 - Hyponychium- Space under free margin of the nail

plate
Nail growth-
Finger nails- 3mm/mo – may take 6months to fully grow
Toe nails - 1mm/mo - 12-18 months
Epidemiology
* Onychomycosis is the most prevalent nail disease = 50%
•

* represents up to 30% of diagnosed superficial fungal infections

î prevalence= tight shoes, increasing immunesuppression, use of

communal bath rooms
Toenail infections are several-fold more common than fingernail
infections

* Multiple nail involvement > single nail

*M>F
 Predisposing factors
-Hot & humid environment

-T. Pedis

-Occlusive foot wear

-Trauma

-Concurrent diseases like

-Diabetes
-Poor peripheral circulation

-Immunosupression
- HIV
- Drugs & transplant

-genetic
 Etiology
* Is Caused by dermatophytes, nondermatophytes & yeasts

* Dermatophytes cause the greatest majority of onychomycosis

* Trichophyton rubrum 71%,

* T.mantagrophytes var.interdigtale 20%,

* T.tonsurans & Epidermophyton flocossum are also known

*Yeast= 5% & majority are c. Albicans

•

*Non dermatophyte molds = 4%

=> most commonly occur in antecedently diseased or aged nails

 Clinical classification and findings

* Distal lateral subungual onychomycosis (DLSO)

* Proximal subungual onychomycosis (PSO)

* Superficial onychomycosis (SO)

* Endonyx onychomycosis (EO)

* Mixed pattern onychomycosis (MPO)

* Totally dystrophic onychomycosis(TDO)

* Secondary onychomycosis
 Distal lateral onychomycosis (DLSO)
*is the most common type

* Most often caused by T. rubrum

*initially invasion of the stratum corneum of the hyponychium then

distal nail bed

*Forming yellow/ white - brown opacification at the distal edge of the

nail plate,

*onycholysis, and subungual hyperkeratosis.

* Commonly start with a single nail but latter other digits involved
 Superficial onychomycosis
* white and black

* Less common

* Superficial black onycho. caused by T.rubrum & S.dimidiatum

* Superficial white onych

-T. mentagrophytes var interdigitalis
- Non- dermatophytes molds = aspergillus, Scopulariopsis
and Fusarium

*results from direct invasion of the dorsal nail plate

* powdery white to dull yellow sharply Bordered patches any-where on
the surface of the nail. (Can be scraped away)
* Toenails are usually affected,

* in AIDS patients

* it is commonly caused by T. rubrum

* both toe- and fingernails affected &

* may coexist PSO

* in SBO there will be black discoloration

 Proximal subungual onychomycosis (PSO)

*uncommon

*It is produced by T. rubrum and T. megninii,

*and may be an indication of HIV infection.

*involves the nail plate mainly from the proximal nail fold

*white to beige opacity on the proximal nail plate.

* Can affect both toe and finger nails

*This opacity gradually enlarges to affect the entire nail,

*subungual hyperkeratosis, leukonychia, proximal onycholysis

* Proximal nail plate invasion may occur sec. to paronychia by candida
species

=> narrow area of onycholysis

at the lateral border

*Others - s. dimidiatum , S.hyalinum, cause nail fold infection with

aspergiles,Fusarium /with out NP invasion

 Mixed pattern
onychomycosis (MPO)
* common but less common
than DLSO,

*In the same individual or in

the same nail

*Different patterns have been

described with various
combinations,

*the commonest of which are

PSO with SO or DLSO with SO.
 Totally dystrophic
onychomycosis (TDO)

1. primary TDO

*may occur as primary

change where it is associated
either with severe immuno
deficiency, e.g. HIV/AIDS

*or in chronic
mucocutaneous candidosis

*In patients with CMC the whole nail unit is thickened as a result of
extensive hyperkeratosis then becomes totally dystrophic
2. Secondary TDO

* occur as secondary change to advanced states of other patterns of nail

plate invasion

* the end stage of a variety of different modes of nail plate invasion

caused by different organisms.

*It most commonly follows DLSO but PSO also results it

*the nail plate crumbles away and the nail bed is thickened , ridged and
usually covered with debris.

*Very extensive end stage nail infection may be secondary to

dermatophytes such as T rubrum and molds
 Endonyx onychomycosis
*Seen with dermato. causing endothrix scalp infection

*Mostly caused by T. soudanense But also T. violaceum

* fungal hyphae penetrating the distal nail plate directly

* absence of nail bed invasion but internal nail plate invasion

*Nail plate invasion distinguished by

-lamellar splitting of the nail, scarred with pits,

-discoloration of the nail plate (milky patches)

 Secondary onychomycosis
*Fungal penetratation nail secondary to other non fungal pathologies.

*e.g. are psoriasis and traumatic nail dystrophy.

*In many such cases the appearances of the nail are usually more typical
of the underlying condition,

*such as hyperkeratosis resulting in thickening the nail plate in

psoriasis.

*diagnosis based on clinical suspicion is particularly difficult and

laboratory investigations are necessary to confirm the presence of fungi.
 Diagnosis

Diagnosis is made with clinical and laboratory investigations

1- Direct microscopic with KOH preparation

80%- 85%
2- culture- alone 30-70% sensitive

3- histopathology- 85% sensitive

• Fig 1. candidal spores and pseudo hyphae
fig 2. septated hyphae dermatophytes
 Management

reasons for treating OM

1. results in cosmetic and functional disability.

2. lack of spontaneous remission

3. To decrease transmission

4. In patients with DM or peripheral vascular disease it will be cost

effective to treat the initial disease than the latter complications like
cellulites and osteomylitis
 Treatment options

*Treatment of onychomycosis depends both on the severity of nail

involvement and on the causative fungus

*in cases where matrix is involved= systemic or combination Rx

* With out matrix involvement= topical alone

1.Topical therapy

2.Systemic Rx = alone or in combination

3. Surgical intervention
 Topical therapeutic agents

* the first choice in SO& early DLSO

1. Ciclopirox - is 8 % lacquer

*It is effective against Candida sp. and some molds.

• is applied daily for 48 weeks.

2. Amorolfine

•is another agent specifically prepared for use as a nail lacquer.

*It is the first member of a new class of anti fungal drugs, the
morpholine derivatives.
 2. Systemic therapy
*Oral antifungals should be used for

*refractory,

*severe,

*non dermatophytic Onychomycosis

 Terbinafine
 Itraconazole
 Fluconazole
 Grisofulvin
* For Final refractory cases

- surgical avulsion

- chemical removal ofthe nail with 40% urea compound

- in combination with topical or oral antifungals is effective

as it decreases fungal load & increases drug penetration
Complications

* cellulitis,

*osteomyelitis,

*sepsis

*tissue necrosis
Prevention
* avoiding use of communal bathing & communal nail instruments

* Avoiding occlusive shoes

* Minimizing wet work and using absorbant powders for foot

* Frequent nail triming

* Treating T. Pedis & T.mannum promptely

* Avoiding trauma
Thank You!