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Dermatophyte fungi are the most frequent cause of nail plate invasion, with T. rubrum being the most common organism. Other organisms that can lead to nail infection include Scopulariopsis brevicaulis, Scytalidium species, Aspergillus species, Acremonium species, and Candida. The elderly, patients with psoriasis, diabetics, and immunocompromised individuals are more prone to developing onychomycosis.1112,!3 and14 Nail infections usually spread from surrounding infected skin. The infection can be either under or within the nail plate. If allowed to progress, these infections lead to severe disturbances in nail growth. The affected toenails appear opaque, discolored, and, at times, hyperkeratotic. Treatment of this disease process is complicated by the fact that topical antifungals are poorly absorbed through the nail. Newer oral antifungals (itraconazole, terbinafine, and fluconazole) have become the preferred first-line agents used in the treatment of onychomycosis. Continuous (daily for 12 weeks) and pulse (daily therapy for 1 week a month for 3 to 4 months) therapies have been studied. Pulse therapy appears to be as effective and have fewer side effects than continuous therapy. Oral terbinafine appears to be the most cost-effective of these agents. 11151 1,18 and 19

Surgical or chemical debridement of the nail matrix may play a role as adjunctive therapy to the preceding oral antifungals. Patients should be referred to a podiatrist or other appropriate practitioner for continued care because these lesions often require prolonged care. Even with optimal treatment there is a very high recurrence rate. Autoavulsion and traumatic avulsion of involved toenails is common. «1 19

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