Mycological disease of the Nail
Diagnosis
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Clinical
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Primary criteria
- white/yellow or orange/brown patches or streaks
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Secondary criteria
- Onycholysis
- Subungual hyperkeratosis/debris
- Nail-plate thickening
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Primary criteria
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Laboratory
- Positive microscopic evidence
- Positive culture of dermatophyte
- accurate diagnosis can only be made when both clinical and laboratory criteria are present
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Poor prognositc factorssher
- Area of nail involvment >50%
- Significant lateral disease
- Subungual hyperkeratosis >2 mm
- White/yelow or orange/brown streaks in nail (includes dermatophytoma)
- Total dystrophic onychomycosis (with matirx involvement)
- Nonresponsive organisms (eg, Scytalidium mold)
- Patients with immunosuppression
- Diminished peripheral circulation
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Nail changes can be nonspecific
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Onycholysis
- May result from trauma
- Psoriasis
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Subungual hyperkeratosis
- Psoriasis
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Nail-plate thickening
- trauma
- onychogryphosis
- Lichen planus
- psoriasis
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Onycholysis
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Changes likely unrelated to onychomycosis
- Longitudinal or transverse ridges
- pits
- onychoschia
- dryness
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Differential Diagnosis
- Psoriasis
- Neoplasms
- Lichen Planus
Treatment
- Topicals
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- Ciclopirox nail lacquer has only a 5.5% to 8.5% cure rate and a recurrence rate of 25% - 50% at 60 weeks
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- Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8% in the treatment of toenail onychomycosis. J Am Acad Dermatol 2000; 43(suppl)S70-80
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Oral meds
- Dose therapy
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Warshaw E, Fett D; Pulse Versus Continuous Terbinafine for Onychomycosis: A Randomized, Double-blind, controlled trial; J Am Acad Dermatol; Oct 2005, Vol 53(4); 578-584
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standard, continuous therapy shown to be superior to pulse therapy
- continuous dose group recieved 250mg daily for 3 months
- Pulse dose group recieved 500mg daily for 1 week per month for 3 months
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Cure rate of all 10 nails
- Continuous therapy group - 25%
- Pulsed therapy group - 15%
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125mg terbinafine for 6 months reported to have a 89% rate of negative mycology at 6 months
- Matsumoto T, Tanuma H, Kaneko S, Takasu H, Nishiyama S. Clinical and pharmacokinetic investigations of oral terbinafine in patients with tinea unguium. Mycoses 1995;38:135-44
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standard, continuous therapy shown to be superior to pulse therapy
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26 published clinical studies for oral treatment show only 25% - 50% complete cure rate
- Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data. Arch Dermatol 1998;134:1551-4
- FDA reports only a 14% - 38% complete cure rate for approved oral agents
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Warshaw E, Fett D; Pulse Versus Continuous Terbinafine for Onychomycosis: A Randomized, Double-blind, controlled trial; J Am Acad Dermatol; Oct 2005, Vol 53(4); 578-584
- Surgical
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Anectodal evidence suggests combination of avulsion and oral therapy (for more than 3 months), may acheive higher cure rates
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may be useful especially in nails with clinical patterns which are typically more resistant
- extensive onychauxis
- lateral pattern
- longitudinal spike
- severe onycholysis
- dermatophytoma
- McInnes BD, Dockery GL. Surgical treatment of mycotic toenails. J Am Podiatr Med Assoc 1997;87:557-64
- Gupta AK, Baran R, SummerbellR. Onychomycosis: Strategies to improve efficacy and reduce recurrence. J Eur Acad Dermatol Venereol 2002;16:579-86
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may be useful especially in nails with clinical patterns which are typically more resistant
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Anectodal evidence suggests combination of avulsion and oral therapy (for more than 3 months), may acheive higher cure rates
- Practical Considerations
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- Mycological cure signifies that the funtal infection has been successfully treated, however pt must understand at beginning of therapy that they will likely not have a 100% normal nail. Some residual changes will be present.
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- recurrence reported as high as 53%
References
- Sher RK, Tavakkol A. Onychomycosis: Diagnosis and definition of cure. J Am Acad Dermatol June 2007;56(6):939-44