Tinea unguium
Last Updated: 2020-11-19
ICD11: -
Last Updated: 2020-11-19
Author(s): Anzengruber F., Navarini A.
ICD11: -
Onychomycosis
If the nail is only infested with dermatophytes, one speaks of a "tinea unguium". If yeast or mould infest the nail (or also in the case of a mixed infection), it is an "onychomycosis".
Categorisation
White, superficial onychomycosis (WOOM).
Total dystrophic onychomycosis.
Leukonychia trichophytica: whitish, superficial onychomycosis (usually caused by tryichophytes).
Dystrophic onychomycosis: classic form of chronic mucocutaneous candidosis.
Immunophenomena in dermatophytosis
If the human organism is infected by dermatophytes, antibodies are formed in the skin. Evidence can be obtained by means of intradermal testing.
After injection of (trichophytin) a type I or type IV reaction may occur.
Approximately 99% of all nail fungal diseases are dermatophytes.
Trichophyton mentagrophytes (dermatophyte).
Candida tropicalis (yeast fungus).
The toenails are affected much more frequently than the fingernails.
Traumas (CAVE too tight/short shoes).
Anatomical anomalies.
Disorders of lymph drainage.
Neuropathies.
A "green nail syndrome" is used for secondary infestation with Pseudomonas aeruginosa.
With positive findings for moulds:
Repeat 3 times (only if 3 times no Dermatophytes can be detected, an onychomycosis by moulds can be assumed).
No restrictive footwear
No airtight shoes
Topical Therapy
·Indication
Roughen nail plate (with nail files)/milling
Alternatively:
Surgical (by podologist) or chemical (40% urea cream NRF 5.11-650)
Subsequent use of an antifungal nail polish
System therapy
1st choice Therapy by Lebwohl | No information regarding the evidence level |
Terbinafin p.o. 250 mg 1x per day | 6 weeks for fungal infestation of fingernails |
12 weeks for fungal infestation of toenails | |
Therapy 2nd choice after Lebwoh | |
Itraconazole p.o. 200 mg 1x per day or 2x per day for 1 week, then therapy break for 3 weeks |
2 cycles in case of fungal attack of the fingernails 3 cycles for fungal infestation of toenails |
Fluconazole p.o. 300-450 mg 1x weekly |
6 months for fungal infestation of fingernails 12 months for fungal infestation of toenails |
Posaconazol p.o. 300 mg 2x daily (1st day), 1x daily (from 2nd day) | Duration depends on severity and clinical response |
Therapy 3rd choice after Lebwohl |
|
Terbinafin p.o (see above) & Amorolfine Nail Polish | 6 weeks for fingernails, 12 weeks for toenails |
Terbinafin p.o. (see above) & nail milling | 6 weeks for fingernails, 12 weeks for toenails |
Photodynamic Therapy | |
Topical therapies after Lebwohl |
Level of evidence |
Amorolfine | A |
Ciclopirox | A |
Terbinafin | B |
Indication:
DSO ≥ 3 nails
Terbinafin (Lamisil® tablet) p.o. 250 mg 1x per day for months or 250 mg 1x per day for 1 week, then 250 mg 1x weekly (Tietz scheme). Always use until healed. Indication: T. rubrum, T. interdigital, T. mentagrophytes, S. brevicaulis.
Itraconazole (e.g. Sporanox®) 400 mg p.o. once a week, followed by a therapy break of 3 weeks. Repeat cycle 2x (3 cycles in total) or 400 mg once a day for 1 week, then once a week (Tietz scheme). Always use until healed. Indication: T. rubrum, C. albicans, S. brevicaulis.
Fluconazole (e.g. Diflucan®) p.o. 150 mg 1x weekly or 150 mg 1x per day for 7 days, then 1x weekly (Tietz scheme). Always use until healed. Indication: T. rubrum, C. albicans, M. canis.
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