Onychomycosis Clinical Presentation

Updated: Jul 31, 2018
  • Author: Antonella Tosti, MD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

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 Examination

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 ye Distal subungual onychomycosis. Onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Distal subungual onychomycosis. Subungual hyperker Distal 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 of White 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 leukony Proximal 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 m Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.
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Complications

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.

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