Advertisement

Onychomycosis: Clinical Aspects

  • Aditya K. Gupta
  • Melissa A. MacLeod
  • Antonella Tosti
Chapter

Abstract

There are five types of onychomycosis based on pathogen mode of entry and clinical presentation: (1) distal and lateral subungual onychomycosis, (2) superficial onychomycosis, (3) proximal subungual onychomycosis, (4) endonyx onychomycosis, and (5) total dystrophic onychomycosis. Distal and lateral subungual onychomycosis is the most common type with infection starting in the hyponychium and distal or lateral nail bed and travelling proximally. This type has three main clinical features: subungual hyperkeratosis, onycholysis, and paronychia, albeit paronychia is uncommon. Superficial onychomycosis has two subtypes: superficial white onychomycosis and the rare superficial black onychomycosis (brown-black pigmentation known as fungal melanonychia). In both types, infection begins in the nail plate and then moves to the nail bed and hyponychium, with spots of discoloration that may gradually cover the whole nail plate. Proximal subungual onychomycosis is rare and begins in the stratum corneum, infecting the proximal nail plate and lunula. The infection moves distally and generally remains in the deeper layers of the nail. Endonyx onychomycosis also begins in the hyponychium; however, the hyponychium remains free of hyphae and the pathogen does not infect the nail bed or cause subungual hyperkeratosis or onycholysis. Instead, the pathogen infects the keratin, resulting in milky-white patches and lamellar splitting. Total dystrophic onychomycosis may be secondary or primary. Secondary total dystrophic onychomycosis is the complete progression of any of the previous types of onychomycosis. This presents with a crumbling nail plate and complete dystrophy. Primary infection occurs in immunocompromised patients and impacts all parts of the nail, often with swelling of the digits.

Keywords

Distal lateral subungual onychomycosis (DLSO) Superficial onychomycosis Proximal subungual onychomycosis (PSO) Endonyx onychomycosis Total dystrophic onychomycosis (TDO) Clinical features Dermatophytes Dermatophytoma Melanonychia 

Supplementary material

324020_4_En_9_MOESM1_ESM.pdf (35 kb)
Patient Handout (PDF 34 kb)

References

  1. 1.
    Baran R, Hay R, Haneke E, et al. Clinical patterns correlated with main routes of entry. In: Onychomycosis: current approach to diagnosis and therapy. London: Martin Dunitz Ltd. Publishers; 1999. p. 13–9.CrossRefGoogle Scholar
  2. 2.
    Baran R, Hay RJ, Tosti A, Haneke E. A new classification of onychomycosis. Br J Dermatol. 1998;139:567–71.CrossRefPubMedGoogle Scholar
  3. 3.
    Bennett D, Rubin AI. Dermatophytoma: a clinicopathologic entity important for dermatologists and dermatopathologists to identify. Int J Dermatol. 2013;52:1285–7.  https://doi.org/10.1111/j.1365-4632.2011.05070.x.CrossRefPubMedGoogle Scholar
  4. 4.
    Burkhart CN, Burkhart CG, Gupta AK. Dermatophytoma: recalcitrance to treatment because of existence of fungal biofilm. J Am Acad Dermatol. 2002;47:629–31.CrossRefPubMedGoogle Scholar
  5. 5.
    Cantrell W, Canavan T, Elewski B. Report of a case of a dermatophytoma successfully treated with topical efinaconazole 10% solution. J Drugs Dermatol JDD. 2015;14:524–6.PubMedGoogle Scholar
  6. 6.
    Daniel CR III, Gupta AK, Daniel MP, Daniel CM. Two feet-one hand syndrome: a retrospective multicenter survey. Int J Dermatol. 1997;36:658–60.CrossRefPubMedGoogle Scholar
  7. 7.
    Elewksi BE, Charif MA, Daniel CR III. Onychomycosis. In: Scher RK, Daniel III CR, editors. Nails: therapy, diagnosis, surgery., Second. Philadelphia: W. B. Saunders Company; 1997. p. 151–62.Google Scholar
  8. 8.
    Elewski BE. Onychomycosis: pathogenesis, diagnosis, and management. Clin Microbiol Rev. 1998;11:415–29.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Ely JW, Rosenfeld S, Stone MS. Diagnosis and management of tinea infections. Am Fam Physician. 2014;90:702–10.PubMedGoogle Scholar
  10. 10.
    Faergemann J, Baran R. Epidemiology, clinical presentation and diagnosis of onychomycosis. Br J Dermatol. 2003;149(Suppl 65):1–4.CrossRefPubMedGoogle Scholar
  11. 11.
    Feldstein S, Totri C, Friedlander SF. Antifungal therapy for onychomycosis in children. Clin Dermatol. 2015;33:333–9.  https://doi.org/10.1016/j.clindermatol.2014.12.010.CrossRefPubMedGoogle Scholar
  12. 12.
    Finch J, Arenas R, Baran R. Fungal melanonychia. J Am Acad Dermatol. 2012;66:830–41.  https://doi.org/10.1016/j.jaad.2010.11.018.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Gupta AK. Types of onychomycosis. Cutis. 2001;68:4–7.PubMedGoogle Scholar
  14. 14.
    Gupta AK, Chang P, Del Rosso JQ, et al. Onychomycosis in children: prevalence and management. Pediatr Dermatol. 1998;15:464–71.CrossRefPubMedGoogle Scholar
  15. 15.
    Gupta AK, Jain HC, Lynde CW, et al. Prevalence and epidemiology of onychomycosis in patients visiting physicians’ offices: a multicenter Canadian survey of 15,000 patients. J Am Acad Dermatol. 2000;43:244–8.  https://doi.org/10.1067/mjd.2000.104794.CrossRefPubMedGoogle Scholar
  16. 16.
    Gupta AK, Pillai R. The presence of an air gap between the nail plate and nail bed in onychomycosis patients: treatment implications for topical therapy. J Drugs Dermatol JDD. 2015;14:859–63.PubMedGoogle Scholar
  17. 17.
    Gupta AK, Ryder JE, Lynch LE, Tavakkol A. The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence. J Drugs Dermatol JDD. 2005;4:302–8.PubMedGoogle Scholar
  18. 18.
    Gupta AK, Sibbald RG, Lynde CW, et al. Onychomycosis in children: prevalence and treatment strategies. J Am Acad Dermatol. 1997;36:395–402.CrossRefPubMedGoogle Scholar
  19. 19.
    Hay RJ, Baran R, Haneke E. Fungal (onychomycosis) and other infections involving the nail apparatus. In: Baran R, Dawber RPR, editors. Diseases of the nails and their management. 2nd ed. Oxford: Blackwell Scientific Publications; 1994. p. 97–122.Google Scholar
  20. 20.
    Martinez-Herrera E, Moreno-Coutiño G, Fernández-Martínez RF, et al. Dermatophytoma: description of 7 cases. J Am Acad Dermatol. 2012;66:1014–6.  https://doi.org/10.1016/j.jaad.2010.06.034.CrossRefPubMedGoogle Scholar
  21. 21.
    Norton LA. Disorders of the nails. In: Moschella SL, Hurley HJ, editors. Dermatology. 3rd ed. Philadelphia: W. B. Saunders Company; 1992. p. 1563–604.Google Scholar
  22. 22.
    Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol. 2004;140:696–701.CrossRefPubMedGoogle Scholar
  23. 23.
    Roberts DT, Evans EG. Subungual dermatophytoma complicating dermatophyte onychomycosis. Br J Dermatol. 1998;138:189–90.CrossRefPubMedGoogle Scholar
  24. 24.
    Summerbell RC. Epidemiology and ecology of onychomycosis. Dermatology. 1997;194(Suppl 1):32–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Summerbell RC. Onychomycosis: a critical study of techniques and criteria for confirming the etiologic significance of nondermatophytes. Med Mycol. 2005;43:39–59.CrossRefPubMedGoogle Scholar
  26. 26.
    Tlacuilo-Parra A, Guevara-Gutierrez E, Mayorga J, et al. Onychomycosis in systemic lupus erythematosus: a case control study. J Rheumatol. 2003;30:1491–4.PubMedGoogle Scholar
  27. 27.
    Tosti A, Baran R, Piraccini BM, Fanti PA. “Endonyx” onychomycosis: a new modality of nail invasion by dermatophytes. Acta Derm Venereol. 1999;79:52–3.CrossRefPubMedGoogle Scholar
  28. 28.
    Zaias N. Onychomycosis. Arch Dermatol. 1972;105:263–74.CrossRefPubMedGoogle Scholar
  29. 29.
    Zhan P, Ge YP, Lu XL, et al. A case-control analysis and laboratory study of the two feet-one hand syndrome in two dermatology hospitals in China. Clin Exp Dermatol. 2010;35:468–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Onychomycosis: what is it and how is it treated? https://www.youtube.com/watch?v=wvzMrhxvMXo.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Aditya K. Gupta
    • 1
    • 2
  • Melissa A. MacLeod
    • 2
  • Antonella Tosti
    • 3
  1. 1.Department of MedicineUniversity of Toronto School of MedicineTorontoCanada
  2. 2.Mediprobe Research Inc.LondonCanada
  3. 3.Department of Dermatology & Cutaneous SurgeryMiller School of Medicine, University of MiamiMiamiUSA

Personalised recommendations