Tinea unguium

Last Updated: 2020-11-19

Author(s): Anzengruber F., Navarini A.

ICD11: -

  • Meissner 1853.
  • Virchow 1854.

Onychomycosis

  • 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".

Categorisation

  • 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.

    • Mostly:
    • 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).

    • Anatomical anomalies.

    • Decreased blood circulation (artierial, venous).
    • Disorders of lymph drainage.

    • Neuropathies.

    • Diabetes mellitus.
    • Immunosuppression.
    • 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)

  1. Tinea unguium.  SpringerReference: Springer Science + Business Media.
  2. 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.
  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.
  4. 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.
  5. 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.
  6. Crawford F, Young P, Godfrey C, et al. Oral Treatments for Toenail Onychomycosis. Arch Dermatol 2002;138.
  7. Ellis DH. Diagnosis of onychomycosis made simple. Journal of the American Academy of Dermatology 1999;40:S3-S8.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Gupta AK, Ryder JE, Baran R, Summerbell RC. Non-dermatophyte onychomycosis. Dermatologic Clinics 2003;21:257-68.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. Br J Dermatol 2003;148:402-10.
  19. Scher RK, Baran R. Onychomycosis in clinical practice: factors contributing to recurrence. Br J Dermatol 2003;149:5-9.
  20. Seebacher C. Action mechanisms of modern antifungal agents and resulting problems in the management of onychomycosis. Mycoses 2003;46:506-10.
  21. Seebacher C, Brasch J, Abeck D, et al. Onychomycosis. JDDG 2007;5:61-6.
  22. Tosti A, Piraccini BM, Iorizzo M. Management of onychomycosis in children. Dermatologic Clinics 2003;21:507-9.
  23. 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.
  24. Lebwohl, Mark. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Elsevier, 2014. Print
  25. 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."