Sections

Onychomycosis

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.

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 yellow streak. Image courtesy of Dr Antonella Tosti.

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

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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 Dr Antonella Tosti.

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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 leukonychia. Image courtesy of Dr Antonella Tosti.

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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 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.

Differential Diagnoses

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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. [QxMD MEDLINE Link].
Cuchí-Burgos E, Rubio-Casino R, Ballestero-Téllez M, Pariente-Jiménez F, Pérez-Jové J, Blanco-Suárez A. Commercial real time PCR implementation for rapid diagnosis of onychomycosis: A new workflow in a clinical laboratory. Enferm Infecc Microbiol Clin. 2020 Jul 15. [QxMD MEDLINE Link].
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Piraccini BM, Iorizzo M, Lencastre A, Nenoff P, Rigopoulos D. Ciclopirox Hydroxypropyl Chitosan (HPCH) Nail Lacquer: A Review of Its Use in Onychomycosis. Dermatol Ther (Heidelb). 2020 Oct. 10 (5):917-929. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
Gupta AK, Hall S, Zane LT, Lipner SR, Rich P. Evaluation of the efficacy and safety of tavaborole topical solution, 5%, in the treatment of onychomycosis of the toenail in adults: a pooled analysis of an 8-week, post-study follow-up from two randomized phase 3 studies. J Dermatolog Treat. 2017 May 30. 1-5. [QxMD MEDLINE Link].
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.
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Gupta AK, Scher RK. Oral antifungal agents for onychomycosis. Lancet. 1998 Feb 21. 351(9102):541-2. [QxMD MEDLINE Link].
Gupta AK, Scher RK, De Doncker P. Current management of onychomycosis. An overview. Dermatol Clin. 1997 Jan. 15(1):121-35. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol. 2004 Jun. 140(6):696-701. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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Media Gallery

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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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, International Society of Dermatology, European Academy of Dermatology and Venereology, Women's Dermatologic Society, Canadian Dermatology Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PharmaDerm<br/>Received income in an amount equal to or greater than $250 from: Valeant; Pharmaderm.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, The Society of Federal Health Professionals (AMSUS), International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully 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.

Onychomycosis Clinical Presentation

History

Physical Examination

Complications

References

Tables

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