Toenail Fungus

WhatIs ?

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WhatCauses ?

Clinical Presentations Of

Complication Of

Treatment Options For

Prevention Of

What Is Toenail Fungus?

Toenail fungus infection is a yellowish/whitish discoloration of toe nails, a very common presentation in adults. It tends to affect multiple toenails as well as toe web spaces, associated with athlete’s feet (tinea pedis)

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Toenail fungus - Remotederm 2
Toenail Fungus
Toenail fungus - Examples - remotederm
Toenail Fungus
Toenail fungus - samples - remotederm
Toenail Fungus
What Causes Toenail Fungus?
  • Most common causative pathogens are T. rubrum, T. mentagrophytes & E. floccosum
  • Candida species are a common cause of onychomycosis in children less than 3 years of age
Clinical Presentations Of Toenail Fungus
  • Three clinical patterns based on point of fungal entry into nail unit:
    • Distal/lateral subungual, with invasion via hyponychium, the most common presentation; yellow thickened nail with subungual hyperkeratosis & eventual progression to complete nail dystrophy; usually due to T. rubrum, T. mentagraphytes or E. floccosum
    • Superficial white – direct penetration of dorsal nail plate; discrete white patches or transverse striate bands; usually due to T. mentagraphytes var interdigitale, but may also be caused by non-dermatophyte molds or candida
    • Proximal subungual – invasion through proximal nail fold, often in immunocompromised
  • Diagnosis: direct examination, culture, and histology
    • Direct examination using KOH +/- chlorazol black E stain, calcofluor fluorescent stain specific for fungal chitin, shows apple-green fluorescence
      • KOH prep: sample is placed directly on slide and 10-20% KOH is applied under coverslip; gentle heat is applied, and slide left to sit for 5-15 minutes before reading
    • Culture: for speciation, specimen is cultured at 25–30°C for 2 to 4 weeks
    • Histology – PAS or silver stain can reveal organisms
      • In onychomycosis, PAS stain of formalin fixed nail clipping has a sensitivity of 80-95% compared with 35-60% for culture alone, but cannot speciate organism
Complication Of Toenail Fungus
Treatment Options for Toenail Fungus
  • Over the counter medications
    • Topical antifungal is not as effective as oral therapy in addressing toenail fungus infection
    • Glycolic acid, lactic acid or urea reduce the amount of hyperkeratosis
  • Prescription medications
    • Topical medications
      • Efinaconazole (Jublia)
      • Ciclopirox
  • Systemic therapy
    • Terbinafine (Lamisil) once a day for 8 weeks
    • Itrconazole
Prevention Of Toenail Fungus
  • Using breathable footwear
  • Using cotton socks
  • Antifungal or absorbent powders
  • Nail clipping
  • Avoiding re-exposure by discarding old footwear

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Toenail fungus infection is a yellowish/whitish discoloration of toe nails, a very common presentation in adults. It tends to affect multiple toenails as well as toe web spaces, associated with athlete’s feet (tinea pedis)