Onychomycosis Clinical Presentation
- Author: Antonella Tosti, MD; Chief Editor: Dirk M Elston, MD more...
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.
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.
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.
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.
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.
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. Onychomycosis due to Candida is rare.
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. Biomechanical problems with repetitive microtraumas to the nails cause onycholysis and other nail dystrophies that favor nail invasion by fungi.
Skin injury adjacent to the nail may allow organisms to colonize, thereby increasing the risk of infectious complications. Reports of complications in elderly persons and persons with diabetes include cellulitis, osteomyelitis, sepsis, and tissue necrosis.
Andre J, Achten G. Onychomycosis. Int J Dermatol. 1987 Oct. 26(8):481-90. [Medline].
Baran R, Hay RJ, Tosti A, Haneke E. A new classification of onychomycosis. Br J Dermatol. 1998 Oct. 139(4):567-71. [Medline].
Bohn M, Kraemer K. The dermatopharmacologic profile of ciclopirox 8% nail lacquer. J Am Podiatr Med Assoc. 2000 Nov-Dec. 90(10):491-4. [Medline].
Bristow IR, Spruce MC. Fungal foot infection, cellulitis and diabetes: a review. Diabet Med. 2009 May. 26(5):548-51. [Medline].
Lubeck DP. Measuring health-related quality of life in onychomycosis. J Am Acad Dermatol. 1998 May. 38(5 Pt 3):S64-8. [Medline].
Midgley G, Moore MK. Nail infections. Dermatol Clin. 1996 Jan. 14(1):41-49. [Medline].
Carney C, Tosti A, Daniel R, et al. A new classification system for grading the severity of onychomycosis: Onychomycosis Severity Index. Arch Dermatol. 2011 Nov. 147(11):1277-82. [Medline].
Cohen AD, Medvesovsky E, Shalev R, et al. An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis. J Dermatolog Treat. 2003 Dec. 14(4):237-42. [Medline].
Crawford F, Young P, Godfrey C, et al. Oral treatments for toenail onychomycosis: a systematic review. Arch Dermatol. 2002 Jun. 138(6):811-6. [Medline].
Iorizzo M, Piraccini BM, Tosti A. New fungal nail infections. Curr Opin Infect Dis. 2007 Apr. 20(2):142-5. [Medline].
Gupta AK, Scher RK, De Doncker P, Sauder DN, Shear NH. Onychomycosis. New therapies for an old disease. West J Med. 1996 Dec. 165(6):349-51. [Medline].
Jennings MB, Pollak R, Harkless LB, Kianifard F, Tavakkol A. Treatment of toenail onychomycosis with oral terbinafine plus aggressive debridement: IRON-CLAD, a large, randomized, open-label, multicenter trial. J Am Podiatr Med Assoc. 2006 Nov-Dec. 96(6):465-73. [Medline].
Katz HI, Gupta AK. Oral antifungal drug interactions. Dermatol Clin. 1997 Jul. 15(3):535-44. [Medline].
Kemna ME, Elewski BE. A U.S. epidemiologic survey of superficial fungal diseases. J Am Acad Dermatol. 1996 Oct. 35(4):539-42. [Medline].
Hull PR. Onychomycosis--treatment, relapse and re-infection. Dermatology. 1997. 194 Suppl 1:7-9. [Medline].
Cribier BJ, Paul C. Long-term efficacy of antifungals in toenail onychomycosis: a critical review. Br J Dermatol. 2001 Sep. 145(3):446-52. [Medline].
Ebihara M, Makimura K, Sato K, Abe S, Tsuboi R. Molecular detection of dermatophytes and nondermatophytes in onychomycosis by nested polymerase chain reaction based on 28S ribosomal RNA gene sequences. Br J Dermatol. 2009 Nov. 161(5):1038-44. [Medline].
Elewski B, Pollak R, Ashton S, Rich P, Schlessinger J, Tavakkol A. A randomized, placebo- and active-controlled, parallel-group, multicentre, investigator-blinded study of four treatment regimens of posaconazole in adults with toenail onychomycosis. Br J Dermatol. 2012 Feb. 166(2):389-98. [Medline].
Elewski BE. Clinical pearl: diagnosis of onychomycosis. J Am Acad Dermatol. 1995 Mar. 32(3):500-1. [Medline].
Elewski BE. Diagnostic techniques for confirming onychomycosis. J Am Acad Dermatol. 1996 Sep. 35(3 Pt 2):S6-9. [Medline].
Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data. Arch Dermatol. 1998 Dec. 134(12):1551-4. [Medline].
Evans EG. Causative pathogens in onychomycosis and the possibility of treatment resistance: a review. J Am Acad Dermatol. 1998 May. 38(5 Pt 3):S32-36. [Medline].
Faergemann J, Baran R. Epidemiology, clinical presentation and diagnosis of onychomycosis. Br J Dermatol. 2003 Sep. 149 Suppl 65:1-4. [Medline].
Friedlander SF, Chan YC, Chan YH, Eichenfield LF. Onychomycosis Does Not Always Require Systemic Treatment for Cure: A Trial Using Topical Therapy. Pediatr Dermatol. 2012 Dec 28. [Medline].
Manevitch Z, Lev D, Palhan M, Lewis A, Enk CD. Direct Antifungal Effect of Femtosecond Laser on Trichophyton rubrum Onychomycosis. Photochem Photobiol. 2009 Dec 7. [Medline].
Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol. 2012 Mar. 66(3):494-502. [Medline].
Gupta AK, Palese CS, Scher RK. How to treat special populations suffering from onychomycosis. Skin and Aging. 1999. 7:54-8.
Brooks M. FDA OKs first topical triazole antifungal for onychomycosis (Jublia). Medscape Medical News. June 10, 2014. [Full Text].
Valeant Pharmaceuticals International, Inc. Valeant Pharmaceuticals announces FDA approval of Jublia for the treatment of onychomycosis [press release]. Available at http://ir.valeant.com/investor-relations/news-releases/news-release-details/2014/Valeant-Pharmaceuticals-Announces-FDA-Approval-Of-Jublia-for-the-Treatment-of-Onychomycosis/default.aspx. Accessed: June 16, 2014.
Elewski BE, Rich P, Pollak R, Pariser DM, Watanabe S, Senda H, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: Two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2013 Apr. 68(4):600-8. [Medline].
Elewski B, Zane L, Rich P, Aly R, Gonzalez Soto R, Leon N. Pivotal phase III safety and efficacy results of tavaborole (AN2690), a novel boron-based molecule for the topical treatment of toenail onychomycosis. Presented at the American Academy of Dermatology 72nd Annual Meeting. March 21-25, 2014. Denver, Colorado.
Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol. 2004 Mar. 150(3):537-44. [Medline].
Gupta AK, Scher RK. Oral antifungal agents for onychomycosis. Lancet. 1998 Feb 21. 351(9102):541-2. [Medline].
Gupta AK, Scher RK, De Doncker P. Current management of onychomycosis. An overview. Dermatol Clin. 1997 Jan. 15(1):121-35. [Medline].
Gupta AK, Zaman M, Singh J. Fast and sensitive detection of Trichophyton rubrum DNA from the nail samples of patients with onychomycosis by a double-round polymerase chain reaction-based assay. Br J Dermatol. 2007 Oct. 157(4):698-703. [Medline].
Piraccini BM, Rech G, Tosti A. Photodynamic therapy of onychomycosis caused by Trichophyton rubrum. J Am Acad Dermatol. 2008 Nov. 59(5 Suppl):S75-6. [Medline].
[Guideline] Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014 Nov. 171(5):937-58. [Medline].
[Guideline] American Academy of Dermatology. Ten Things Physicians and Patients Should Question. Choosing Wisely. Available at http://www.choosingwisely.org/societies/american-academy-of-dermatology/. October 29, 2013; Accessed: April 30, 2016.
Piraccini BM, Sisti A, Tosti A. Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. J Am Acad Dermatol. 2010 Mar. 62(3):411-4. [Medline].
Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol. 2004 Jun. 140(6):696-701. [Medline].
Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. J Am Acad Dermatol. 2000 Feb. 42(2 Pt 1):217-24. [Medline].
Tosti A, Piraccini BM, Lorenzi S, Iorizzo M. Treatment of nondermatophyte mold and Candida onychomycosis. Dermatol Clin. 2003 Jul. 21(3):491-7, vii. [Medline].
Tosti A, Piraccini BM, Stinchi C, Colombo MD. Relapses of onychomycosis after successful treatment with systemic antifungals: a three-year follow-up. Dermatology. 1998. 197(2):162-6. [Medline].