Onychomycosis Clinical Presentation

  • Author: Antonella Tosti, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 27, 2012
 

History

Onychomycosis is usually asymptomatic; therefore, patients usually first present for cosmetic reasons without any physical complaints.

As the disease progresses, onychomycosis may interfere with standing, walking, and exercising.

Patients may report paresthesia, pain, discomfort, and loss of dexterity. They also may report loss of self-esteem and lack of social interaction.

A careful history may reveal many environmental and occupational risk factors.

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Physical

The subtypes of onychomycosis may be distinguished on the basis of their usual presenting clinical features.

In distal lateral subungual onychomycosis, the nail shows subungual hyperkeratosis and onycholysis, which is usually yellow-white in color. Yellow streaks and/or yellow onycholytic areas in the central portion of the nail plate are commonly observed. Note the images below.

Distal subungual onychomycosis. Onycholysis and yeDistal subungual onychomycosis. Onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti. Distal subungual onychomycosis. Subungual hyperkerDistal subungual onychomycosis. Subungual hyperkeratosis onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.

Endonyx onychomycosis presents as a milky white discoloration of the nail plate, but, in contrast to distal lateral subungual onychomycosis, no evidence of subungual hyperkeratosis or onycholysis is present.

White superficial onychomycosis is confined to the toenails and manifests as small, white, speckled or powdery patches on the surface of the nail plate. The nail becomes roughened and crumbles easily. Molds produce a deep variety of white superficial onychomycosis characterized by a larger and deeper nail plate invasion. Note the image below.

White superficial onychomycosis. Image courtesy ofWhite superficial onychomycosis. Image courtesy of Dr Antonella Tosti.

Proximal subungual onychomycosis presents as an area of leukonychia in the proximal nail plate that moves distally with nail growth. In proximal subungual onychomycosis caused by molds, leukonychia is typically associated with marked periungual inflammation. Note the image below.

Proximal subungual onychomycosis. Proximal leukonyProximal subungual onychomycosis. Proximal leukonychia. Image courtesy of Dr Antonella Tosti.

Total dystrophic onychomycosis presents as a thickened, opaque, and yellow-brown nail.

In Candida onychomycosis associated with chronic mucocutaneous candidiasis or immunodepression, several or all digits are affected by total onychomycosis associated with periungual inflammation. The digits often take on a bulbous or drumstick appearance. Note the image below.

Candidal onychomycosis in a patient with chronic mCandidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.
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Causes

Onychomycosis is caused by 3 main classes of fungi: dermatophytes, yeasts, and nondermatophyte molds. Dermatophytes are by far the most common cause of onychomycosis. Two major pathogens are responsible for approximately 90% of all onychomycosis cases. Trichophyton rubrum accounts for 70% and Trichophyton mentagrophytes accounts for 20% of all cases. Onychomycosis caused by nondermatophyte molds (Fusarium species, Scopulariopsis brevicaulis,Aspergillus species) is becoming more common worldwide, accounting for up to 10% of cases.[5] Onychomycosis due to Candida is rare.[6]

T rubrum is the most common pathogen in distal lateral subungual onychomycosis. Proximal subungual onychomycosis due to T rubrum infection is typical of immunosuppressed patients . Additionally, Proximal subungual onychomycosis with periungual inflammation is usually caused by molds

White superficial onychomycosis is usually caused by T mentagrophytes; nondermatophyte molds cause deep white superficial onychomycosis.

Candida albicans nail infection is observed in premature children, in immunocompromised patients, and in persons with chronic mucocutaneous candidiasis.

Risk factors for onychomycosis include family history, increasing age, poor health, prior trauma, warm climate, participation in fitness activities, immunosuppression (eg, HIV, drug induced), communal bathing, and occlusive footwear.

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Contributor Information and Disclosures
Author

Antonella Tosti, MD  Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Antonella Tosti, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, Canadian Dermatology Association, European Academy of Dermatology and Venereology, International Society of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard K Scher, MD  Adjunct Professor of Dermatology, University of North Carolina; Professor Emeritus of Dermatology, Columbia University

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Referencegratefully acknowledge the contributions of previous authors, Mark Blumberg, MD, MS, Gary R. Kantor, MD, and John Ratz, MD, MBA, to the development and writing of this article.

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Distal subungual onychomycosis. Onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Distal subungual onychomycosis. Subungual hyperkeratosis onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Proximal subungual onychomycosis. Proximal leukonychia. Image courtesy of Dr Antonella Tosti.
White superficial onychomycosis. Image courtesy of Dr Antonella Tosti.
Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.
Dermoscopy of distal subungual onychomycosis showing irregular margin of the onycholytic area with spikes projecting into the proximal nail plate, reported as the "aurora borealis" pattern. Handyscope at 20X.
 
 
 
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