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onychomycosis, onychomycosis treatment
Onychomycosis, also known as tinea unguium, is a fungal infection of the nail2 This condition may affect toenails or fingernails, but toenail infections are particularly common

Treatment may be based on the signs3 Treatment may be with the medication terbinafine3

It occurs in about 10 percent of the adult population4 It is the most common disease of the nails and constitutes about half of all nail abnormalities5

The term is from Ancient Greek ὄνυξ ónux "nail", μύκης múkēs "fungus" and -ωσις ōsis "functional disease"


  • 1 Signs and symptoms
  • 2 Causes
    • 21 Dermatophytes
    • 22 Other
    • 23 Risk factors
  • 3 Diagnosis
    • 31 Classification
    • 32 Differential diagnosis
  • 4 Treatment
    • 41 Medications
    • 42 Other
  • 5 Prognosis
  • 6 Epidemiology
  • 7 Research
  • 8 See also
  • 9 References
  • 10 External links

Signs and symptomsedit

A case of fungal infection of the big toe

The most common symptom of a fungal nail infection is the nail becoming thickened and discoloured: white, black, yellow or green As the infection progresses the nail can become brittle, with pieces breaking off or coming away from the toe or finger completely If left untreated, the skin can become inflamed and painful underneath and around the nail There may also be white or yellow patches on the nailbed or scaly skin next to the nail,6 and a foul smell7 There is usually no pain or other bodily symptoms, unless the disease is severe8 People with onychomycosis may experience significant psychosocial problems due to the appearance of the nail, particularly when fingers – which are always visible – rather than toenails are affected9

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


The causative pathogens of onychomycosis are all in the fungus kingdom and include dermatophytes, Candida yeasts, and nondermatophytic molds10 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 climate11


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 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 genus Scytalidium name recently changed to Neoscytalidium, Scopulariopsis, and Aspergillus Candida species 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 factorsedit

Aging is the most common risk factor for onychomycosis due to diminished blood circulation, longer exposure to fungi, and nails which grow more slowly and thicken, increasing susceptibility to infection Nail fungus tends to affect men more often than women, and is associated with a family history of this infection

Other risk factors include perspiring heavily, being in a humid or moist environment, psoriasis, wearing socks and shoes that hinder ventilation and do not absorb perspiration, going barefoot in damp public places such as swimming pools, gyms and shower rooms, having athlete's foot tinea pedis, minor skin or nail injury, damaged nail, or other infection, and having diabetes, circulation problems, which may also lead to lower peripheral temperatures on hands and feet, or a weakened immune system12


To avoid misdiagnosis as nail psoriasis, lichen planus, contact dermatitis, nail bed tumors such as melanoma, trauma, or yellow nail syndrome, laboratory confirmation may be necessary10 The three main approaches are potassium hydroxide smear, culture and histology10 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,13 and nail plate biopsy using periodic acid-Schiff stain14 To reliably identify nondermatophyte molds, several samples may be necessary15


There are four classic types of onychomycosis:16

  • Distal subungual onychomycosis is the most common form of tinea unguium10 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 around 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 confirm17
  • 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 immunocompromised10
  • 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

Differential diagnosisedit

Other conditions that may appear similar to onychomycosis include: psoriasis, normal aging, yellow nail syndrome, and chronic paronychia18


A person's foot with a fungal nail infection ten weeks into a course of terbinafine oral medication Note the band of healthy pink nail growth behind the remaining infected nails

In approximately half of suspected nail fungus cases there is actually no fungal infection, but only nail deformity19 Because of this, a confirmation of fungal infection should precede treatment19 Avoiding use of oral antifungal therapy in persons without a confirmed infection is a particular concern because of the side effects of that treatment, and because persons without an infection should not have this therapy19 Screening cases diagnosed by signs and symptoms is not cost-effective and routine testing is not necessary for oral treatment with terbinafine but should be encouraged prior to topical treatment with efinaconazole20


Most treatments are topical or oral antifungal medications4

Topical agents include ciclopirox nail paint, amorolfine or efinaconazole212223 Some topical treatments need to be applied daily for prolonged periods at least 1 year22 Topical amorolfine is applied weekly24 Topical ciclopirox results in a cure in 6% to 9% of cases; amorolfine might be more effective422 Ciclopirox when used with terbinafine appears to be better than either agent alone4

Oral medications include terbinafine 76% effective, itraconazole 60% effective and fluconazole 48% effective4 They share characteristics that enhance their effectiveness: prompt penetration of the nail and nail bed,25 persistence in the nail for months after discontinuation of therapy26 Ketoconazole by mouth is not recommended due to side effects27 Oral terbinafine is better tolerated than itraconazole28 For superficial white onychomycosis, systemic rather than topical antifungal therapy is advised29


Removinghow the affected part of the nail during treatment appears to improve outcomes4

As of 2014update Evidence for laser treatment is unclear as the evidence is of low quality30 and varies by type of laser31

As of 2013 tea tree oil has failed to demonstrate benefit in the treatment of onychomycosis10 A 2012 review by the National Institutes of Health found some small and tentative studies on its use32


Following effective treatment recurrence is common 10-50%4 Nail fungus can be painful and cause permanent damage to nails It may lead to other serious infections if the immune system is suppressed due to medication, diabetes or other conditions The risk is most serious for people with diabetes and with immune systems weakened by leukemia or AIDS, or medication after organ transplant Diabetics have vascular and nerve impairment, and are at risk of cellulitis, a potentially serious bacterial infection; any relatively minor injury to feet, including a nail fungal infection, can lead to more serious complications33 Osteomyelitis infection of the bone is another, rare, possible complication6


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%3435 Prevalence was observed to increase with age In Canada, the prevalence was estimated to be 648%36 Onychomycosis affects approximately one-third of diabetics37 and is 56% more frequent in people suffering from psoriasis38


Research suggests that fungi are sensitive to heat, typically 40–60 °C 104–140 °F The basis of laser treatment is to try and heat the nail bed to these temperatures in order to disrupt fungal growth39 There is ongoing research as of 2013 which looks promising4 There is also development into the use of photodynamic therapy which uses laser or LED light to activate photosensitisers that eradicate fungi40

See alsoedit

  • Athlete's foot


  1. ^ a b Rapini, Ronald P; Bolognia, Jean L; Jorizzo, Joseph L 2007 Dermatology: 2-Volume Set St Louis: Mosby p 1135 ISBN 1-4160-2999-0 
  2. ^ "onychomycosis" at Dorland's Medical Dictionary
  3. ^ a b Mikailov, A; Cohen, J; Joyce, C; Mostaghimi, A March 2016 "Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis" JAMA dermatology 152 3: 276–81 PMID 26716567 doi:101001/jamadermatol20154190 
  4. ^ a b c d e f g h Westerberg DP, Voyack MJ Dec 1, 2013 "Onychomycosis: current trends in diagnosis and treatment" American family physician 88 11: 762–70 PMID 24364524 
  5. ^ Szepietowski JC, Salomon J 2007 "Do fungi play a role in psoriatic nails" Mycoses 50 6: 437–42 PMID 17944702 doi:101111/j1439-0507200701405x 
  6. ^ a b NHS Choices: Symptoms of fungal nail infection
  7. ^ Mayo clinic: Nail fungus
  8. ^ Onychomycosis at eMedicine
  9. ^ Szepietowski JC, Reich A September 2008 "Stigmatisation in onychomycosis patients: a population-based study" Mycoses 52 4: 343–9 PMID 18793262 doi:101111/j1439-0507200801618x 
  10. ^ a b c d e f Westerberg DP, Voyack MJ December 2013 "Onychomycosis: Current Trends in Diagnosis and Management" Am Fam Physician Review 88 11: 762–70 PMID 24364524 
  11. ^ Chi CC, Wang SH, Chou MC 2005 "The causative pathogens of onychomycosis in southern Taiwan" Mycoses 48 6: 413–20 PMID 16262878 doi:101111/j1439-0507200501152x 
  12. ^ Mayo Clinic – Nail fungus – risk factors
  13. ^ Karimzadegan-Nia M, Mir-Amin-Mohammadi A, Bouzari N, Firooz A 2007 "Comparison of direct smear, culture and histology for the diagnosis of onychomycosis" Australas J Dermatol 48 1: 18–21 PMID 17222296 doi:101111/j1440-0960200700320x 
  14. ^ Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L 2003 "Comparison of diagnostic methods in the evaluation of onychomycosis" J Am Acad Dermatol 49 2: 193–7 PMID 12894064 doi:101067/S0190-96220301480-4 
  15. ^ Shemer A, Davidovici B, Grunwald MH, Trau H, Amichai B 2009 "New criteria for the laboratory diagnosis of nondermatophyte moulds in onychomycosis" The British journal of dermatology 160 1: 37–9 PMID 18764841 doi:101111/j1365-2133200808805x 
  16. ^ James, William D; Berger, Timothy G 2006 Andrews' Diseases of the Skin: clinical Dermatology Saunders Elsevier ISBN 0-7216-2921-0 
  17. ^ "AAPA" Cmecornercom Retrieved 2010-08-05 
  18. ^ Hall, Brian 2012 Sauer's Manual of Skin Diseases 10 ed Lippincott Williams & Wilkins p Chapter 33 ISBN 9781451148688 
  19. ^ a b c American Academy of Dermatology February 2013, "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Dermatology, retrieved 5 December 2013  Which cites:Roberts DT, Taylor WD, Boyle J 2003 "Guidelines for treatment of onychomycosis" PDF The British journal of dermatology 148 3: 402–410 PMID 12653730 doi:101046/j1365-2133200305242x 
  20. ^ Mikailov A, Cohen J, Joyce C, Mostaghimi A 2015 "Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis" JAMA Dermatology: 1–6 PMID 26716567 doi:101001/jamadermatol20154190 
  21. ^ Rodgers P, Bassler M 2001 "Treating onychomycosis" Am Fam Physician 63 4: 663–72, 677–8 PMID 11237081 
  22. ^ a b c Crawford F, Hollis S 2007 Crawford, Fay, ed "Topical treatments for fungal infections of the skin and nails of the foot" Cochrane Database Syst Rev 3: CD001434 PMID 17636672 doi:101002/14651858CD001434pub2 
  23. ^ Gupta AK, Paquet M 2014 "Efinaconazole 10% nail solution: a new topical treatment with broad antifungal activity for onychomycosis monotherapy" Journal of cutaneous medicine and surgery 18 3: 151–5 PMID 24800702 
  24. ^ Loceryl 5% amorolfine package labelling
  25. ^ Elewski, BE July 1998 "Onychomycosis: pathogenesis, diagnosis, and management" Clinical Microbiology Reviews 11 3: 415–29 PMC 88888  PMID 9665975 
  26. ^ Elewski, BE; Hay, RJ August 1996 "Update on the management of onychomycosis: highlights of the Third Annual International Summit on Cutaneous Antifungal Therapy" Clinical Infectious Diseases 23 2: 305–13 PMID 8842269 doi:101093/clinids/232305 
  27. ^ "Nizoral ketoconazole Oral Tablets: Drug Safety Communication - Prescribing for Unapproved Uses including Skin and Nail Infections Continues; Linked to Patient Death" FDA 19 May 2016 Retrieved 20 May 2016 
  28. ^ Haugh M, Helou S, Boissel JP, Cribier BJ 2002 "Terbinafine in fungal infections of the nails: a meta-analysis of randomized clinical trials" Br J Dermatol 147 1: 118–21 PMID 12100193 doi:101046/j1365-2133200204825x 
  29. ^ Baran R, Faergemann J, Hay RJ 2007 "Superficial white onychomycosis—a syndrome with different fungal causes and paths of infection" J Am Acad Dermatol 57 5: 879–82 PMID 17610995 doi:101016/jjaad200705026 
  30. ^ Bristow, IR 2014 "The effectiveness of lasers in the treatment of onychomycosis: a systematic review" Journal of foot and ankle research 7: 34 PMC 4124774  PMID 25104974 doi:101186/1757-1146-7-34 
  31. ^ "Laser Therapy for Onychomycosis: Fact or Fiction" Journal of Fungi 1: 44–54 2015 doi:103390/jof1010044 
  32. ^ "Tea tree oil" National Center for Complementary and Integrative Health NCCIH Retrieved 11 March 2016 
  33. ^ Mayo clinic – Nail fungus: complications
  34. ^ Burzykowski T, Molenberghs G, Abeck D, Haneke E, Hay R, Katsambas A, Roseeuw D, van de Kerkhof P, van Aelst R, Marynissen G 2003 "High prevalence of foot diseases in Europe: Results of the Achilles Project" Mycoses 46 11–12: 496–505 PMID 14641624 doi:101046/j0933-7407200300933x 
  35. ^ Verma S, Heffernan MP 2008 Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra In K Wolff et al, eds, Fitzpatrick's Dermatology in General Medicine, 7th ed, vol 2, pp 1807–1821 New York: McGraw Hill
  36. ^ Vender RB, Lynde CW, Poulin Y 2006 "Prevalence and epidemiology of onychomycosis" Journal of cutaneous medicine and surgery 10 Suppl 2: S28–S33 PMID 17204229 doi:102310/7750200600056 
  37. ^ Gupta AK, Konnikov N, MacDonald P, Rich P, Rodger NW, Edmonds MW, McManus R, Summerbell RC 1998 "Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: A multicentre survey" The British journal of dermatology 139 4: 665–671 PMID 9892911 doi:101046/j1365-2133199802464x 
  38. ^ Gupta AK, Lynde CW, Jain HC, Sibbald RG, Elewski BE, Daniel CR, Watteel GN, Summerbell RC 1997 "A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: A multicentre study" The British journal of dermatology 136 5: 786–789 PMID 9205520 doi:101046/j1365-213319976771624x 
  39. ^ "Device-based Therapies for Onychomycosis Treatment" Retrieved 23 December 2012 
  40. ^ Piraccini, BM; Alessandrini A 2015 "Onychomycosis: A Review" J Fungi 1: 30–43 doi:103390/jof1010030 CS1 maint: Uses authors parameter link

External linksedit

  • ICD-10: B351
  • ICD-9-CM: 1101
  • MeSH: D014009
  • DiseasesDB: 13125
External resources
  • MedlinePlus: 001330
  • eMedicine: derm/300
  • Patient UK: Onychomycosis

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