Fungal Toenails Causes and Treatments

Nail Fungus Revealed

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Onychomycosis

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...

Costeffectiveness analysis

CEAs provide information about the value of the therapeutic intervention in question by accounting for the outcomes of the therapy. However, the outcome measure is not standardised and therefore cannot be used to make comparisons with other disease processes. For example, even if a reasonable outcome measure for a new therapy for seborrhoeic dermatitis may be dollars per clear scalp, this measure cannot be used when the policymaker wants to compare the CE ratio with analyses of new therapies for disparate diseases such as onychomycosis, venous ulcers or acne. Even if clear skin is used as the outcome measure, it cannot be used to make comparisons with non-dermatological problems. Another problem with CEA is that the outcomes are not weighted according to their importance. For instance, assume that new therapies for scalp psoriasis, onychomycosis and venous ulcers were cost-effective compared with their respective current therapies. Policymakers may not be able to incorporate all the...

Aims of treatment

Onychomycosis may be a cosmetic problem, especially when fingernails are infected.31 The treatment objectives are to reduce the fungal burden within the nail, ultimately curing the fungal infection, and to promote healthy regrowth of affected nails. In instances where onychomycosis is associated with a degree of morbidity, for example, pain, discomfort and soft tissue infection, timely treatment may help to eliminate symptoms and prevent complications that could be associated with more severe consequences.32

Box 331 The quality of evidence scale system employed by Cox and colleagues147

What is the role of oral antifungal therapy in the management of dermatophyte onychomycosis in adults One double-blind RCT compared griseofulvin, 500 mg day for 12 weeks, with terbinafine in the treatment of onychomycosis (Table 33.1).141 The mycological cure rate and complete cure rate were 63 and 39 , respectively.

Chapter References

DelRosso JQ Advances in the treatment of superficial fungal infections Focus on onychomycosis and dry tinea pedis. J Am Osteopath Assoc 97 339, 1997. 11. Hoffman AF, Driver VR Onychomycosis. Clin Podiatr Med Surg 13 13, 1996. 12. Midgley G, Moore MK Nail infections. Dermatol Clin 14 41, 1996. 13. Levy LA Epidemiology of onychomycosis in special risk populations. J Am Podiatr Med Assoc 87 546, 1997. 14. Gupta AK, Lynde CW, Jain HC, et al A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics A multicentre study. Br J Dermatol 136 786, 1997. 15. Gupta AK, De Doncker P, Scher RK, et al Itraconazole for the treatment of onychomycosis. Int J Dermatol 37 303, 1998. 16. Drake LA, Shear NH, Arlette JP, et al Oral terbinafine in the treatment of toenail onychomycosis North American multicenter trial. J Am Acad Dermatol 37 740, 1997. 17. Brautigam M Terbinafine versus itraconazole A controlled clinical comparison in onychomycosis of the toenails. J Am Acad Dermatol 38...

Clinical Features

The second type, which is seen in tinea manuum as well, presents as chronic, dry scales with little, if any, inflammation on the palmar or plantar surfaces. It often extends to the medial and lateral aspects of the feet but not the dorsal surface. When present on the feet in this distribution, it is often described as a moccasin distribution. Polycyclic or annular patterns may be seen. Maceration between the toes is common. Onychomycosis may be present with numerous, but usually not all, nails having onycholysis (separation of the nail from the nail bed), and thick subungual debris. Oftentimes, if one hand is involved, both feet are involved as well. It is unclear why the other hand is spared in this two foot, one hand type of fungal infection ( Fig 239-3). Furthermore, patients and physicians should be aware that these topical agents do not treat nail infections. Thus, if a patient desires treatment of onychomycosis as well, an oral agent such as itraconazole, fluconazole, or...

Medline searches

Regardless of the platform used, the key to Medline searching is to find relevant articles and to exclude irrelevant citations. Several useful techniques can greatly aid your ability to accomplish this goal. Searches are generally done on the basis of boolean combinations of search terms. For example, our search for best evidence about drug treatment of onychomycosis might read onychomycosis and (terbinafine or itraconazole or fluconazole) and not case reports .* This search would identify articles on onychomycosis using any of the listed drugs and excluding case reports.1,2 associated.2 This subheading is appended to the MeSH term, for example onychomycosis diagnosis. may be helpful. MeSH term searches can be exploded to include all terms that are logical subsets of the term entered.2 For example, exploding the MeSH term onychomycosis will retrieve all the articles that use that MeSH term, whether they have subheadings or not. Many of the programs used to search the Medline database...

Search methods

To identify studies where oral treatments -itraconazole (continuous and pulse), fluconazole, terbinafine (continuous and pulse) and griseofulvin - were used to treat adults with toenail or fingernail onychomycosis caused by dermatophytes, we searched Medline (1966-2002) for randomised controlled trials (RCTs). The reference sections of the published reports were also examined for potential studies not listed in the database. The use of nail lacquers such as ciclopirox and amorolfine to treat onychomycosis is not considered. There are many anecdotal reports of various topical agents being effective for the management of onychomycosis however, published reports of the efficacy of topical agents in onychomycosis in the indexed, peer-reviewed literature are far fewer. Other clinical trials have included tioconazole 28 solution, bifonazole with urea, fungoid tincture, miconazole, and tea tree oil. We have not considered trials where ketoconazole was used to treat onychomycosis, given the...

General comments

Several pharmacoeconomic analyses of the various oral treatments used in dermatophyte onychomycosis have been published. These studies calculate the cost-effectiveness of each therapy on the basis of the efficacy results of multiple clinical trials. The two most cost-effective regimens for the treatment of onychomycosis are continuous terbinafine and pulse itraconazole.174,195-199 Table 33.7 Treatment of dermatophyte toenail onychomycosis using fluconazole therapy therapy with either an effective topical therapy or mechanical chemical measures (for example mechanical avulsion, debridement or chemical avulsion). For example, when there is lateral onychomycosis, a dermatophytoma, severe onycholysis, a thickened nail or severe onychomycosis, it may be advantageous to consider a combination approach.42,59,68,200-202

Malassezia

Dermatophytosis has been called one of the great pretenders because there are so many potential kinds of presentation. The classic signs include alopecia and scale with central healing. One can also see just alopecia, (nasal facial) folliculitis and furunculosis, onychomycosis and granulomas. Paronychia may be the only sign in some cats. Occasionally one may see a pustular form that may appear like a bacterial pyoderma or even mimic pemphigus foliaceus or erythematosus (Plate 6.12).

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