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About tinea unguium (onychomycosis)

Tinea unguium, also known as onychomycosis, is infection of the nail—usually the distal nail bed—with a dermatophytic fungus. The usual culprits are Tricophyton rubrum and Tricophyton mentagrophytes, with T. rubrum being the most common cause of distal subungual onychomycosis. The nail appears discolored with areas of yellowish-brown or white. Involvement of the nail undersurface results in debris buildup and nail separation. Infection of the top surface leads to a brittle white surface. Involvement of the proximal nail plate is a sign of HIV infection.

Tinea unguium is a common problem, with prevalence increasing with age. The toenails are affected more frequently that the fingernails. The most common complaint is regarding the thickened unsightly appearance of the nail, but the condition can also cause pain or discomfort.

With what can tinea unguium be confused?

Nail disease is difficult to diagnose by appearance alone. The nail plate appearance of tinea unguium can be confused with the changes caused by psoriasis, trauma, or aging. Psoriasis will usually have other skin findings, and trauma can usually be identified by history.

How is tinea unguium diagnosed?

A KOH preparation and fungal culture or a nail clipping confirms the diagnosis.

How is tinea unguium treated?

As is the case for tinea capitis, fungal infection of the nail often cannot be eradicated with topical therapy; oral anti-fungal agents such as terbinafine (e.g. Lamisil) or itraconazole (e.g. Sporanox) are required for weeks to months, during which time the drug accumulates in the nail. Systemic antifungal agents have side-effects and the risk-benefit must be considered. Monitoring of hepatic enzymes and hematologic parameters is recommended. Since these drugs remain in the nail for months, retreatment should not be considered for six months for fingernails and 12 months for toenails.  Recently, some have proposed laser treatment as an option. Newer topical agents Jublia and Kerydin have shown efficacy as well.

What is the prognosis for tinea unguium?

After a course of treatment, nails will still not appear completely normal. Tinea unguium is difficult to cure, and recurrence is common, especially for toenails.

More on tinea unguium (onychomycosis)

Image links

DermnetNZ: Fact sheet and photos

Other useful links

Blumberg, M and Kantor GR. Onychomycosis. e-medicine. APril 3, 2007