Onchyomycosis

• accounts ofr around 50% nail diseae

• more common with advancing age

• mostly affects toenails (80%)

• risk factors:

  • nail trauma

  • frequent immersion in water

  • occluive footwear

  • athlete foot

  • diabetes mellitus

  • immunosuppression

  • smoking

• dermatophytes 90%

  • Trichophyton rubrum

  • Other: Candida

  • Non-dermatophyte moulds account for 2-3%

• distal and lateral subungual onychomycosis most common

• most cases characterised by:

  • thickening of nail

  • discoloration

  • oncycholysis

• Different morpholocial types

  • distal and lateral

  • superficial white:

    • Trichophyton intergiditale - 10%

  • Proximal

    • least commmon:

      • associated with immunospuression

      • PVD

  • candida

    • hands who immerse

• Lab diagnosis = recommended

  • main diff dx = psoriasis

  • Microscopy and culture of nail clippings

  • false negative may be 30-40%

Treatment

• may not be necessary for everybody - inappropriate for elderly

• Nail may not look completley normal

• oral antifungals only successful in about 70-80%

  • relapse

  • topical less effectvie

• length of treatmetns:

  • 3 months for oral

  • 2 years for topical

• potential side effects

  • increased risk:

    • diabetes,

    • PVD

    • connective tissue disorder

• Oral antifungals more effective (except for cases of superficial whilte onychomycosis)

  • 250mg terbinafine OD for 6 weeks for fingers, 12 weeks for toes

    • GI effects most common

    • rarely seriodu skin reactions: SJ syndrome…

    • Psoriasis may be aggravated

    • not recommended for people with liver disease

    • monitor 4-6/52

  • Itraconazole =treatment of choice due to candida

    • 200mg bd for 7 consectutive days/month = 2mo fingernails, 3 months

    • not used for CHF, liver diease

    • monitor LFTs

    • inhibitor of CYP3A4

      • statins, warfarin, bdz, ccb

• Topical treatment

  • amorolfine

    • twice weekly until infection resolved

    • nail needs to be filed, cleansed and degreased before application

  • ciclopirox nail lacquers

    • affected nails every 2nd day for first month

    • application dec. twice weekly for 1/12

    • then once weekly

    • removed with nail varnish once weekly and nail filed

• General treatments:

  • keep feet cool and dry

  • trim nails and file down hypertrophic nails

  • avoid high heels

  • narrow toed shoes to prevent nail trauma

  • recognise and treat athletes foot if present

  • wear foot wear in communal showers