Last Updated: 2020-11-19
- Meissner 1853.
- Virchow 1854.
- Fungal infection of the nails.
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".
- Distal subungual onychomycosis (DSOM): most common form.
- Proximal subungual type (PSOM).
White, superficial onychomycosis (WOOM).
- Onychomycosis caused by moulds.
- Onychomycosis by Candida (Paronychia candidamycetica).
Total dystrophic onychomycosis.
Leukonychia trichophytica: whitish, superficial onychomycosis (usually caused by tryichophytes).
Dystrophic onychomycosis: classic form of chronic mucocutaneous candidosis.
- Onychia et Paronychia candidosa: usually caused by Candida albicans and is associated with chronic inflammation of the proximal and lateral nail wall. Discolourations and transverse grooves appear.
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.
- Incidence (Europe/USA): approx. 20%.
- Incidence (Europe/USA) > 65 years: up to 45%.
- Causative organism
Approximately 99% of all nail fungal diseases are dermatophytes.
- Trichophyton rubrum (Dermatophyte).
Trichophyton mentagrophytes (dermatophyte).
- Candida albicans.
Candida tropicalis (yeast fungus).
- Scopulariopsis brevicaulis (mould).
- Aspergillus niger (mould).
- Hendersonula toruloidea (mould).
- In most cases there is already a tinea pedis. The pathogens enter the nail bed through the hyponychium.
- Candida can cause onychomycosis more often in bakers than in the normal population. The increased moist work and the nutrient supply (glucose from dough) provide a suitable environment for yeast fungi.
The toenails are affected much more frequently than the fingernails.
- Predisposing factors:
Traumas (CAVE too tight/short shoes).
- Decreased blood circulation (artierial, venous).
Disorders of lymph drainage.
- Diabetes mellitus.
- Tinea pedum.
- After the fungi have penetrated into the nail bed via the hyponychium, subununal hyperkeratosis causes the nail plate (onycholysis semilunaris) to lift off.
- A yellow discoloration is called "dyschromasia".
A "green nail syndrome" is used for secondary infestation with Pseudomonas aeruginosa.
- Crumbnails (onychodystrophy).
- Nail material removal:
- Disinfection with 70% alcohol
- As far proximal as possible!
- Curettage technique
- Native and Culture!
- Histological examination!
With positive findings for moulds:
Repeat 3 times (only if 3 times no Dermatophytes can be detected, an onychomycosis by moulds can be assumed).
- Success rate: 50%
- Recurrence rates: 5%-20% and 40% (Grisefulvin)
- In elderly patients (and in PAD), nail growth may slow down, so that the usefulness of prolonged system therapy must be questioned.
- Improve blood circulation (nicotine abstinence)
No restrictive footwear
No airtight shoes
- Disinfection of footwear
- Avoid humidity
- Dry hands and feet thoroughly
- Frequent laundry changes
- Cook socks at 95 °C if possible
- Distal onychomycosis
- DSO < 50% of the nail plate affected
- DSO ≤ 2 Nägel befallen
Roughen nail plate (with nail files)/milling
- Removal of the diseased nail plate leads to a reduction in fungal volume and increased penetration of the active ingredient
Surgical (by podologist) or chemical (40% urea cream NRF 5.11-650)
Subsequent use of an antifungal nail polish
- Ciclopirox Nail Polish (Ciclocutan®) 2x/week for 6-12 Mon.
- Amorolfine nail polish (Loceryl®) 2x/week for 6-12 months
|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|
Topical therapies after Lebwohl
|Level of evidence|
- DSO > 50% infestation of the nail plate or nail matrix
DSO ≥ 3 nails
- Depth WOOM
- Proximal Subungual Onychomycosis (PSO)
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.
- Tinea unguium. SpringerReference: Springer Science + Business Media.
- Aman S, Haroon TS, Hussain I, Jahangir M, Bokhari MA. Distal and lateral subungual onychomycosis with primary onycholysis caused by Trichophyton violaceum. British Journal of Dermatology 2001;144:212-3.
- Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. Journal of Dermatological Treatment 2005;16:327-30.
- Baran R. Topical amorolfine for 15 months combined with 12 weeks of oral terbinafine, a cost-effective treatment for onychomycosis. Br J Dermatol 2001;145:15-9.
- Baran R, Sigurgeirsson B, Berker Dd, et al. A multicentre, randomized, controlled study of the efficacy, safety and cost-effectiveness of a combination therapy with amorolfine nail lacquer and oral terbinafine compared with oral terbinafine alone for the treatment of onychomycosis with matrix involvement. Br J Dermatol 2007;157:149-57.
- Crawford F, Young P, Godfrey C, et al. Oral Treatments for Toenail Onychomycosis. Arch Dermatol 2002;138.
- Ellis DH. Diagnosis of onychomycosis made simple. Journal of the American Academy of Dermatology 1999;40:S3-S8.
- Evans EGV, Sigurgeirsson B. Double blind, randomised study of continuous terbinafine compared with intermittent itraconazole in treatment of toenail onychomycosis. BMJ 1999;318:1031-5.
- Ghannoum MA, Hajjeh RA, Scher R, et al. A large-scale North American study of fungal isolates from nails: The frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns. Journal of the American Academy of Dermatology 2000;43:641-8.
- Gupta A, Baran R, Summerbell R. Onychomycosis: strategies to improve efficacy and reduce recurrence. Journal of the European Academy of Dermatology and Venereology 2002;16:579-86.
- Gupta AK, De Doncker P, Haneke E. Itraconazole pulse therapy for the treatment of Candida onychomycosis. Journal of the European Academy of Dermatology and Venereology 2001;15:112-5.
- Gupta AK, Gregurek-Novak T. Efficacy of Itraconazole, Terbinafine, Fluconazole, Griseofulvin and Ketoconazole in the Treatment of <i>Scopulariopsis brevicaulis</i> Causing Onychomycosis of the Toes. Dermatology 2001;202:235-8.
- Gupta AK, Ryder JE, Baran R, Summerbell RC. Non-dermatophyte onychomycosis. Dermatologic Clinics 2003;21:257-68.
- Gupta AK, Taborda P, Taborda V, et al. Epidemiology and prevalence of onychomycosis in HIV-positive individuals. International Journal of Dermatology 2000;39:746-53.
- Jennings MB, Pollak R, Harkless LB, Kianifard F, Tavakkol A. Treatment of Toenail Onychomycosis with Oral Terbinafine Plus Aggressive Debridement. Journal of the American Podiatric Medical Association 2006;96:465-73.
- Larsen GK, Haedersdal M, Svejgaard E. The Prevalence of Onychomycosis in Patients with Psoriasis and other Skin Diseases. Acta Dermato-Venereologica 2003;83:206-9.
- Lecha M. Amorolfine and itraconazole combination for severe toenail onychomycosis; results of an open randomized trial in Spain. Br J Dermatol 2001;145:21-6.
- Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. Br J Dermatol 2003;148:402-10.
- Scher RK, Baran R. Onychomycosis in clinical practice: factors contributing to recurrence. Br J Dermatol 2003;149:5-9.
- Seebacher C. Action mechanisms of modern antifungal agents and resulting problems in the management of onychomycosis. Mycoses 2003;46:506-10.
- Seebacher C, Brasch J, Abeck D, et al. Onychomycosis. JDDG 2007;5:61-6.
- Tosti A, Piraccini BM, Iorizzo M. Management of onychomycosis in children. Dermatologic Clinics 2003;21:507-9.
- Yazdanparast A, Jackson CJ, Barton RC, Evans EGV. Molecular strain typing of Trichophyton rubrum indicates multiple strain involvement in onychomycosis. Br J Dermatol 2003;148:51-4.
- Lebwohl, Mark. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Elsevier, 2014. Print
- Friou, G.J., A study of the cutaneous reactions to oidiomycin, trichophytin, and mumps skin test antigens in patients with sarcoidosis. Yale J Biol Med, 1952. 24(6): p. 533-9."