What Is The Medical Term That Denotes Fungal Skin Disease
Onychomycosis: Electric current Trends in Diagnosis and Treatment
Am Fam Physician. 2013 Dec i;88(eleven):762-770.
This version of the article contains supplmental content.
A more recent commodity on onychomycosis is available.
Patient information: Meet related handout on onychomycosis, written by the authors of this article.
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Article Sections
- Abstract
- Microbiology
- Classification
- Diagnosis
- Handling
- Treatment Failure
- References
Onychomycosis is a fungal infection of the nails that causes discoloration, thickening, and separation from the smash bed. Onychomycosis occurs in 10% of the general population, xx% of persons older than 60 years, and 50% of those older than seventy years. It is caused by a variety of organisms, only most cases are caused by dermatophytes. Accurate diagnosis involves physical and microscopic examination and culture. Histologic evaluation using periodic acid–Schiff staining increases sensitivity for detecting infection. Handling is aimed at eradication of the causative organism and return to a normal appearance of the nail. Systemic antifungals are the nigh constructive handling, with meta-analyses showing mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole. Concomitant nail debridement further increases cure rates. Topical therapy with ciclopirox is less constructive; it has a failure rate exceeding 60%. Several nonprescription treatments accept also been evaluated. Light amplification by stimulated emission of radiation and photodynamic therapies show promise based on in-vitro evaluation, but more than clinical studies are needed. Despite treatment, the recurrence rate of onychomycosis is x% to 50% as a result of reinfection or lack of mycotic cure.
Onychomycosis is a fungal infection of the fingernails or toenails that causes discoloration, thickening, and separation from the nail bed. Onychomycosis occurs in 10% of the full general population merely is more common in older adults; the prevalence is 20% in those older than 60 years and 50% in those older than 70 years.one The increased prevalence in older adults is related to peripheral vascular affliction, immunologic disorders, and diabetes mellitus. The risk of onychomycosis is 1.9 to 2.eight times college in persons with diabetes compared with the general population.2 In patients with human immunodeficiency virus infection, the prevalence ranges from 15% to twoscore%.3
Onychomycosis affects toenails more often than fingernails because of their slower growth, reduced blood supply, and frequent confinement in dark, moist environments. It may occur in patients with distorted nails, a history of nail trauma, genetic predisposition, hyperhidrosis, concurrent fungal infections, and psoriasis. It is as well more mutual in smokers and in those who utilize occlusive footwear and shared bathing facilities.ane,4
SORT: Central RECOMMENDATIONS FOR Practise
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| When preparing a smash specimen to test for onychomycosis, the nail should be cleaned with 70% isopropyl alcohol, then samples of the subungual debris and viii to x smash clippings should exist obtained. The specimen should be placed on a microscope slide with a driblet of potassium hydroxide 10% to 20% solution, then allowed to sit down for at least five minutes before viewing under a microscope. | C | 8, 11 |
| Periodic acid–Schiff staining should be ordered to confirm infection in patients with suspected onychomycosis. | C | 14 |
| Systemic antifungal agents are the virtually effective handling for onychomycosis, simply cure rates are much less than 100%. Terbinafine (Lamisil) is the nearly constructive systemic amanuensis bachelor. | C | 23 |
| When prescribing the topical agent ciclopirox, patients should be informed that it has some do good in the treatment of onychomycosis, merely besides has a high failure rate. | C | 28, 31 |
Microbiology
- Abstract
- Microbiology
- Nomenclature
- Diagnosis
- Handling
- Treatment Failure
- References
Onychomycosis is caused past various organisms, most often dermatophytes of the genus Trichophyton. Other organisms include Candida, which is more than common in fingernail infections (eFigure A) and in patients with chronic mucocutaneous candidiasis.1 Nondermatophyte molds are a less common cause in the general population. Recent studies, nonetheless, accept demonstrated that they are the predominant organisms in patients with onychomycosis and human immunodeficiency virus infection3(eTable A).
eFigure A.
Candidal subungual onychomycosis.
Photo provided by Robert T. Brodell, Md.
eTable A.
Common Pathogens in Onychomycosis
| Dermatophytes (lxxx% to ninety%) |
| Epidermophyton floccosum |
| Microsporum species |
| Trichophyton interdigitale |
| Trichophyton mentagrophytes |
| Trichophyton rubrum |
| Trichophyton tonsurans |
| Nondermatophyte molds (two% to x%)* |
| Acremonium species |
| Alternaria species |
| Aspergillus species |
| Cladosporium carrionii |
| Fusarium species |
| Geotrichum candidum |
| Lasiodiplodia theobromae |
| Onychocola species |
| Scopulariopsis species |
| Scytalidium species |
| Yeast (ii% to 11%) |
| Candida albicans |
| Candida guilliermondii |
| Candida parapsilosis |
Classification
- Abstract
- Microbiology
- Classification
- Diagnosis
- Treatment
- Treatment Failure
- References
Onychomycosis is divided into several classes based on morphologic patterns and mode of invasion of the nail (Tabular array ane).five Nomenclature provides a framework for diagnosis and expected response to handling, and tin aid predict the prognosis. The classes include distal and lateral subungual onychomycosis (Figures ane and two), proximal subungual onychomycosis (Figure 3), superficial onychomycosis (Effigy iv), and full dystrophic onychomycosis (Figure v). A fifth class, endonyx subungual onychomycosis, is rare. Some nails have features from a combination of classes.
Table ane.
Classification of Onychomycosis
| Onychomycosis class | Clinical features | Causative organism* | Mode of infection | Comments |
|---|---|---|---|---|
| Distal and lateral subungual | Begins distally at the hyponychium and spreads to the smash plate and bed; hyperkeratotic droppings accumulates and results in onycholysis; nails thicken, chip, become dystrophic, and turn yellow-white or brown-black; infection can progress proximally, causing linear channels or "spikes" that can make treatment difficult; associated with paronychia | Epidermophyton floccosum | Fungal invasion through break in the skin at the lateral or distal undersurface of the boom | Most common grade |
| Trichophyton mentagrophytes | ||||
| Trichophyton rubrum | ||||
| Fusarium species | ||||
| Scopulariopsis brevicaulis | ||||
| Scytalidium species | ||||
| Candida albicans | ||||
| Endonyx subungual | Nail develops a milky white appearance, indentations, and lamellar splitting; no hyperkeratosis or onycholysis | Trichophyton soudanense | Fungus invades the full thickness of the nail from directly nether the skin without infecting the nail bed | Rare; considered a subtype of distal and lateral subungual onychomycosis |
| Trichophyton violaceum | ||||
| Proximal subungual | Debris accumulates under the proximal portion of the nail, causing onycholysis and a white colour that spreads distally | T. rubrum | Mucus invades the proximal blast fold and cuticle; may also develop secondary to paronychia | Suggests an immunosuppressive condition (e.chiliad., human immunodeficiency virus infection) |
| Aspergillus species | ||||
| Fusarium species | ||||
| C. albicans | ||||
| Superficial | Nail appears to have pulverization-like patches of transverse striae on the surface | T. mentagrophytes | May appear on the superficial nail plate or emerge from under the nail fold; may be deep penetration of the superficial infection | Previously known as superficial white onychomycosis, but some organisms produce black droppings |
| T. rubrum | ||||
| Acremonium species | ||||
| Fusarium species | ||||
| Scytalidium species | ||||
| Total dystrophic | Complete destruction of the nail from long-standing infection; nail thickens, and nail construction is lost | — | — | Can result from any of the other classes, although it is most often from severe distal and lateral subungual onychomycosis |
Figure 1.
Distal and lateral subungual onychomycosis.
Figure 2.
Distal and lateral subungual onychomycosis with spike deformity.
Figure iii.
Proximal subungual onychomycosis.
Figure 4.
Superficial onychomycosis.
Effigy five.
Total dystrophic onychomycosis.
Diagnosis
- Abstract
- Microbiology
- Classification
- Diagnosis
- Treatment
- Treatment Failure
- References
Authentic diagnosis is crucial for successful handling and requires identification of concrete changes and positive laboratory analysis. Simply 50% of nail issues are caused by onychomycosis,6 and clinical diagnosis past physical examination alone can be inaccurate. Psoriasis, chronic nail trauma, and other causes must also be considered. The differential diagnosis of onychomycosis is presented in Table 2,seven and an algorithm outlining a suggested diagnostic arroyo is shown in Figure 6 .
Tabular array two.
Mutual Conditions That Can Mimic Onychomycosis
| Condition | Features |
|---|---|
| Infections | |
| Chronic paronychia | Chronic inflammation of the proximal paronychium; cross-striations of the nail; Streptococcus, Staphylococcus, or Candida found on smear and culture; common in children |
| Viral warts | Localized in smash folds and subungual tissue; longitudinal depressed grooves in the boom plate |
| Skin disorders | |
| Chronic dermatitis | Subungual dermatitis, hyperkeratosis, Swain lines, and pitting; thickened nail with corrugated surface |
| Lichen planus | Longitudinal grooves and fissures; usually affects fingernails |
| Psoriasis | Nail pitting, splinter hemorrhages, "oil staining," xanthous-gray or silverish white nails (eFigure B) |
| Twenty-nail dystrophy | Dystrophy of all 20 nails; usually resolves in babyhood; associated with the lesions of lichen planus (eFigure C) |
| Trauma | |
| Footwear | Oncholysis, ingrown toenails, subungual keratosis, blast plate discoloration and irregularities; acquired by friction against the shoe |
| Manipulation (e.g., manicures, pedicures, rubbing) | Horizontal parallel nail plate grooves, inflammation from Staphylococcus aureus or Pseudomonas infection (eFigure D) |
| Tumors | |
| Bowen disease | Squamous prison cell carcinoma; bleeding, pain, nail deformity, and nail discoloration |
| Fibroma | Oval or spherical, white or xanthous nodule; causes tunnel-like melanonychia; fibrous dermatofibroma or periungual fibroma |
| Melanoma | Dark-brown-xanthous nail with night paint extending into the periungual skin folds; poor prognosis |
eFigure B.
Nail pitting in a patient with psoriasis. The pits are enhanced by the presence of grease.
Photo provided by Robert T. Brodell, MD.
eFigure C.
Twenty-boom dystrophy (too chosen sandpaper nails) is characterized by longitudinal ridges on all 20 nails. The nails may go discolored.
Photo provided by Robert T. Brodell, Medico.
eFigure D.
Median smash dystrophy caused by repetitive trauma to the nail from habitual rubbing.
Photo provided by Robert T. Brodell, MD.
Diagnosis of Onychomycosis
Effigy half dozen.
Algorithm for the diagnosis and treatment of onychomycosis. (KOH = potassium hydroxide.)
Laboratory analysis involves evaluation of nail clippings and subungual debris from the involved portion of the nail. Samples should exist nerveless after cleansing the surface area with 70% isopropyl booze to prevent contagion. Clippings should be obtained with a sterile nail clipper or curette, and subungual debris using a No. 15 surgical blade or a two-mm curette. To better accuracy, viii to 10 nail shards should exist collected.8 Diagnostic precision is enhanced if the sample is collected with a nail drill 9 and if it is taken from a more proximal location on the nail in patients with suspected distal and lateral onychomycosis.10 In those with suspected proximal subungual onychomycosis, the upper nail plate of the proximal nail is debrided, and underlying debris is collected. In those with suspected superficial onychomycosis, the superficial aspect of the blast is scraped.
Once the specimen has been obtained, function microscopy can be performed by preparing the samples with potassium hydroxide (KOH) ten% to 20% solution. The KOH will deliquesce keratin, leaving the fungal prison cell intact. The specimen should be placed on a slide with a driblet of KOH solution, then set up aside at room temperature for 5 to 30 minutes; heating the slide or calculation a dimethyl sulfide forty% solution volition heighten keratin dissolution.11 Commercial laboratories may use KOH with calcofluor white stain, which binds to cellulose and enhances the fungal components in fluorescent microscopy.11
Identification of hyphae, pseudohyphae, or spores confirms infection but does not identify the organism. To identify the organism, culture can be performed in a laboratory.12 Samples should exist sent in a sterile container, and results are usually bachelor in four to six weeks. Histologic evaluation can also be helpful for identification of the organism, and it can provide results inside 24 hours. Periodic acrid–Schiff (PAS) staining and methenamine silver stains are used. PAS staining is less expensive,13 and in a study of 1,146 nail clippings comparing PAS histologic exam with KOH light microscopy and culture, PAS staining was the most sensitive test (82% sensitivity, compared with 53% for culture and 48% for KOH microscopy).14 Combining PAS staining with culture increased sensitivity to 96%. In a review of cases in which treatment was initiated before specimens were obtained, PAS staining had the highest sensitivity, and culture had the to the lowest degree.14
Polymerase concatenation reaction testing has been shown to exist more accurate than culture, and results can exist bachelor in three days. However, it is not yet widely bachelor.15,16
Handling
- Abstract
- Microbiology
- Classification
- Diagnosis
- Treatment
- Treatment Failure
- References
Onychomycosis is widely believed to be only a cosmetic problem, but it can be uncomfortable and can lead to cellulitis in older adults17 and foot ulcers in patients with diabetes.18 Eradication of the infection is cardinal to improving appearance and fugitive these complications, but information technology is non easily accomplished because nails are made of keratin, which is nonvascular and impermeable to many agents.19 Because of poor drug delivery to nails, results of treatment may not exist apparent for a twelvemonth.
Treatment varies depending on the severity of nail changes, the organism involved, and concerns about agin furnishings and drug interactions. Treatments as well accept varying effectiveness, based on cure parameters that are defined differently among studies. Mycotic cure denotes that no organism is identified on microscopy and culture. Clinical cure refers to improvement in the appearance of the nail, often defined as a normal advent in 80% to 100% of the nail. It is a subjective measure that is difficult to compare across studies.20 Consummate cure indicates that mycotic and clinical cure take been achieved.
ORAL AZOLES AND ALLYLAMINES
Antifungals from the azole and allylamine classes are the most widely used oral medications for the treatment of onychomycosis. The azole course includes itraconazole (Sporanox), fluconazole (Diflucan), and ketoconazole; still, ketoconazole is rarely prescribed because of drug interactions and hepatotoxicity. The allylamine class is represented past terbinafine (Lamisil). These medications and their dosing regimens are shown in Table 3.21–27
Table three.
Ordinarily Prescribed Medications for Handling of Onychomycosis in Adults
| Medication | Dosing | Cure rates (%) | Organisms targeted | Potential agin furnishings | Potential drug interactions* | FDA pregnancy category | Estimated monthly toll† | Comments | |
|---|---|---|---|---|---|---|---|---|---|
| Clinical | Mycotic | ||||||||
| Ciclopirox 8% solution (nail lacquer) | Use once daily to affected nails and to the underside of the smash | vi to 921 | 29 to 3621 (77 when used in combination with debridement)22 | Candida species, dermatophytes | Periungual erythema, erythema of the proximal nail fold, burning sensation, smash shape changes, ingrown toenails, nail discoloration | — | B | $xi for 3.three-mL bottle | Indicated for use in immunocompetent patients with mild to moderate onychomycosis without lunular interest; patients should not bathe for eight hours subsequently applying nail lacquer; lacquer should be removed one time per week, and as much of the damaged blast every bit possible should exist removed using scissors, nail clippers, or a boom file |
| Fluconazole (Diflucan) | 100 to 300 mg orally every week for three to six months (fingernails) or six to 12 months (toenails) | 4123 | 4823 | Candida species | Nausea, vomiting, abdominal pain, diarrhea, headache, rash | Benzodiazepines, calcium channel blockers, statins | C | $13 for 30 100-mg tablets ($492 brand) | Not FDA approved for treatment of onychomycosis in children or adults; prescribing guidelines recommend periodic monitoring of liver function, renal role, and potassium levels; use with caution in breastfeeding women and in patients with hepatic or renal disease or porphyria |
| Itraconazole (Sporanox) | Pulse dosing: 200 mg orally ii times per solar day for one week per month, for two months (fingernails) or iii months (toenails) Continuous dosing: 200 mg orally once per day for six weeks (fingernails) or 12 weeks (toenails) | 7023 | 63 (pulse dosing) 69 (continu ous dosing)23 | Candida species, dermatophytes, nondermatophyte molds, Aspergillus species | Nausea, vomiting, hypokalemia, elevated transaminase and triglyceride levels, rash | Benzodiazepines, calcium channel blockers, proton pump inhibitors, statins, warfarin (Coumadin), zolpidem (Ambien) | C | $195 for 30 100-mg capsules ($523 brand) | Liver function should be monitored in patients with preexisting hepatic dysfunction, and in all patients beingness treated for longer than one month; serum drug levels should be monitored considering of erratic bioavailability with capsule formulation; renal function should be monitored; use with caution in breastfeeding women and in patients with hepatic or renal illness or porphyria; contraindicated in patients with ventricular dysfunction or congestive center failure |
| Terbinafine (Lamisil) | 250 mg orally once per day for six weeks (fingernails) or 12 weeks (toenails) | 6623 | 7623 | Some yeasts, dermatophytes, nondermatophyte molds | Gastrointestinal upset, rash, headache | Antiarrhythmic agents, beta blockers, selective serotonin reuptake inhibitors, tricyclic antidepressants, warfarin | C | $four for 30 250-mg tablets ($607 brand) | Liver transaminase levels should be checked before therapy is started; if treatment continues beyond 6 weeks, complete blood count and liver function testing should be performed; use with circumspection in breastfeeding women and in patients with hepatic or renal disease, psoriasis, or porphyria |
A meta-analysis of treatments for toenail onychomycosis determined that mycotic cure rates were 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole.23 Clinical cure rates were 66% for terbinafine, 70% for itraconazole with pulse dosing, lxx% for itraconazole with continuous dosing, and 41% for fluconazole. Common adverse effects included headache, gastrointestinal problems, and rash; these drugs too take been associated with Stevens-Johnson syndrome, prolonged QT interval, and ventricular dysfunction. The employ of these agents is discouraged in patients with liver, renal, or heart disease, and in those receiving medications with which there may exist significant drug-drug interactions.25 Liver function studies are recommended earlier start treatment and after one calendar month of therapy.24 A meta-analysis concluded that the hazard of asymptomatic elevation of transaminase levels in immunocompetent patients receiving oral antifungal agents was ii%, and that the risk of elevations requiring termination of therapy was 1%.28 Although these medications are not canonical for utilize in children, they have been used in children with positive results.29
TOPICAL AGENTS
Several topical agents are used for the treatment of onychomycosis. These agents have few contraindications and no drug-drug interactions.
Ciclopirox 8% solution is the only topical prescription medication available in the United States for the treatment of onychomycosis. It is a synthetic hydroxypyridine antifungal formulated every bit a nail lacquer. Adverse effects include burning, itching, and stinging at the awarding site.30 It may be used in patients who cannot take oral antifungals and in those with less than 50% of the distal nail affected and no lunular involvement.21 It has been used in children, although it is not approved for utilize in patients younger than 12 years.29 When used alone, ciclopirox has a mycotic cure charge per unit of 29% to 36%, and a clinical cure charge per unit of 6% to 9%.21 A Cochrane review noted that the treatment failure charge per unit was 61% to 64% after 48 weeks of use.31
Ciclopirox has as well been used in combination with oral agents to improve effectiveness. In one comparative study, a combination of ciclopirox and oral terbinafine had a mycotic cure charge per unit of 88% and a complete cure charge per unit of 68%, whereas terbinafine lonely had a mycotic cure rate of 65% and a complete cure rate of 50%.32
Nonprescription agents have also been used for treatment of onychomycosis (Table 4).31,33–38 These therapies have been evaluated in but a small number of studies involving few patients. Topical mentholated ointment (Vicks Vaporub) was used in a small-scale study involving 18 patients.37 After 48 weeks, 28% had mycotic and clinical cure, 56% had partial clearance, and 17% had no improvement. Tea tree oil (Melaleuca alternifolia) has been evaluated in two studies. Although i trial was favorable, combined data from both studies did not demonstrate meaning do good.29,36 Snakeroot extract (Ageratina pichinchensis) is an antifungal derived from plants of the aster family. It was studied in a randomized trial involving 96 patients who applied the extract or ciclopirox for vi months to nails with confirmed infections.33 Mycotic cure occurred in 59% of patients receiving the excerpt and in 64% of those receiving ciclopirox. Clinical cure occurred in 71% and 81% of patients, respectively. Differences betwixt the two treatments were not statistically significant. A small written report showed that a combination of cyanoacrylate, undecylenic acrid, and hydroquinone (marketed every bit Renewed Blast) demonstrated mycotic cure in 78 of 154 participants (50%).34
Table iv.
Nonprescription Treatments for Onychomycosis
| Agent | Administration | Clinical cure charge per unit (%) | Mycotic cure charge per unit (%) | Comments |
|---|---|---|---|---|
| Ageratina pichinchensis (snakeroot) extract33 | Use every tertiary solar day for the first calendar month, twice per week for the second month, then one time per week for the third month | 71 | 59 | Study of 110 patients; therapeutic effectiveness was similar to that in the control grouping, which used ciclopirox |
| Cyanoacrylate, undecylenic acrid, and hydroquinone (Renewed Blast)34 | Soak and debride afflicted nails, and then use solution every ii weeks for three to four visits; patients may also utilise at home | NA | 50 to 65 (mild to moderate cases) | Study of 154 patients with cure rates reported after iii months |
| 35 (severe cases) | ||||
| Dual-wavelength virtually-infrared laser (Noveon)35 | Treatment on days 1, 14, 42, and 120 | Mild cases: 65 (3 mm of nail clearance) 26 (four mm of nail clearance) | 30 | Toenails were evaluated on day 180 |
| Moderate to astringent cases: 63 (3 mm of boom clearance) | ||||
| Melaleuca alternifolia (tea tree) oil36 | Apply twice per twenty-four hour period | NA | NA | Cochrane review found no evidence of benefit31 |
| Mentholated ointment (Vicks Vaporub)37 | Apply small corporeality with cotton swab daily | 28 | 28 | Pilot study of 18 patients; 56% had partial clearance, and 17% had no clearance |
| Neodymium: yttrium-aluminum-garnet laser (Patholase Pinpointe)38 | One to three sessions four to six weeks apart | NA | 61 (complete cure) | Study of 37 toenails with onychomycosis |
| 19 (pregnant improvement) | ||||
| 11 (moderate improvement) |
PHYSICAL TREATMENTS
Nail trimming and debridement are often performed concomitantly with other treatments and announced to offer benefit. Study groups that received smash debridement with oral terbinafine had higher clinical cure rates than those who received oral terbinafine alone.39 When debridement was performed with concurrent assistants of ciclopirox, the mycotic cure rate was 77%, college than that for ciclopirox lonely.22 Improvement in boom appearance was reported, simply clinical cure rates were not.
Although they are expensive, laser and photodynamic therapies have become popular based on the success of in-vitro studies. Several neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapies accept been approved past the U.Due south. Food and Drug Administration for treatment of onychomycosis.40 The Pinpointe Foot-laser, Cutera GenesisPlus laser, and Cooltouch Varia laser are brusk-pulse light amplification by stimulated emission of radiation systems, whereas the Light Age Q-Clear laser is a Q-switched laser. Notwithstanding, there are but limited information about the use of these therapies in patients. In one written report, Nd:YAG laser lite was used to treat 37 nails, with 1 to three treatments given four to eight weeks autonomously. At sixteen weeks, 61% were completely cured, 19% had significant comeback in the nail appearance, and 11% had moderate improvement in the boom appearance.38
Another light amplification by stimulated emission of radiation treatment, the dual-wavelength near-infrared laser (Noveon), is approved for dermatologic use, but not specifically for handling of onychomycosis.41 This treatment was used on 26 nails on days i, 14, 42, and 120. After 180 days, 91% of nails with mild infection showed clinical improvement (3 to iv mm of the nail gratuitous of clinical infection); however, only 30% had mycotic cure.42
Photodynamic therapy using photosensitizing drugs and light to destroy fungal cells has shown some success in the treatment of onychomycosis, simply further evaluation is needed.43
Treatment Failure
- Abstruse
- Microbiology
- Classification
- Diagnosis
- Treatment
- Treatment Failure
- References
Despite the number of available treatments, not all patients with onychomycosis are cured. Numerous factors have been cited to explain the lack of response to therapy, such as nonadherence to treatment, incorrect diagnosis, or advanced disease. Factors contributing to poor response or nonresponse to treatment are listed in eTable B.
eTable B.
Hazard Factors for Poor Response or Nonresponse to Handling for Onychomycosis
| Take a chance gene | Instance |
|---|---|
| Diagnostic problem | Some other cause of nail dystrophy; mixed disease (e.g., onychomycosis and psoriasis) |
| Fungal problem | Infection with drug-resistant or multiple organisms |
| Blast status that is difficult to treat | Dermatophytoma (i.east., a mass of hyphae and necrotic keratin beneath the nail plate); involvement of lateral aspect of the smash; more than l% of blast afflicted; "spikes" extending from distal to proximal boom; subungual hyperkeratosis greater than 2 mm |
| Patient characteristic or status | Older age; diabetes mellitus; immunosuppression; impaired peripheral circulation |
| Trouble with medication adherence | Early termination of therapy; incorrect dosing; missed doses |
For those who appear to be cured, recurrent infection is a take chances, with a number of factors increasing the chance of recurrence. Risk factors include concomitant disease, genetic factors, immunosuppression, wrong dosing or duration of handling, moisture, occlusive footwear, older age, poor hygiene, tinea pedis, and trauma.44 Recurrence can be caused by lack of mycotic cure or reinfection, and the reported rate of clinical recurrence of onychomycosis ranges from 10% to 53%, regardless of the treatment method used.45 Many patients tire of connected unsuccessful treatments or recurrences, and ultimately elect to undergo permanent boom removal.
Data Sources: A PubMed search was performed using the term onychomycosis combined with prevalence, classification, diagnosis, and treatment. The search included meta-analyses and systematic reviews, including those from the Cochrane database. The initial search strategy was supplemented by searches for randomized controlled trials of specific treatments identified during the review of meta-analyses and systematic reviews. Search date: March 2012.
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Figures i through five provided by Robert T. Brodell, Md.
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