Onychomycosis/Tinea unguium
Fungal infection of nail. Most likely due to:
Trichophyton rubrum
Trichophyton metagrophytes
Epidermophyton flocossum
Clinical features:
Distal subungual onychomycosis (Type 1):
Also called distal lateral onychomycosis
Most common type
Starts at free edge or lateral borders of nail as streaks of grey, white or yellow discolouration spreads proximally
Layers of nail plate may separate
Hyperkeratotic mass of underlying nail bed may push nail plate loose from nail bed
Superficial white onychomycosis (Type 3):
• Rare in finger nails – more common in toenails
• Starts as small white patches on surface of nail may progress to entire nail plate
• Tends not to penetrate deeply
• T. metagrophytes is most common
Proximal subungual onychomycosis (Type 2):
• Rarest type – gains entry via stratum corneum at proximal nail fold
• Appears distally as a white spot near lunula and begins to grow distally
• T. rubrum is most common
Candida subungual onychomycosis (Type 4):
• Candida albicans is opportunistic – usually infects following paronychia
• Nail appears opaque, brownish and altered in shape
Total dystrophic onychomycosis:
• Entire nail plate is affected – difficult to determine where original infection started
Treatment:
• Aggressive debridement
• often difficult with topical preparations – nail bed may be infected and the nail acts as a barrier to absorption of topical preparations
• topical application should be accompanied with regular debridement of nail
Topical agents:
Systemic agents:
Surgical:
• removal of nail plate with or without chemical cautery (phenolisation) of nail matrix – if do not destroy matrix use antifungal during regrowth
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