Tinea unguium

Last Updated: 2020-11-19

Author(s): -

  • 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)
  • 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

 

  • Topical Therapy

·Indication

  • Distal onychomycosis
  • DSO < 50% of the nail plate affected
  • DSO ≤ 2 Nägel befallen

 

Roughen nail plate (with nail files)/milling

  • Alternatively:

  • 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

 

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 > 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. 

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