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NAIL INFECTION

ONYCHOMYCOSIS
CHRONIC NAIL INFECTION =
ONYCHOMYCOSIS

• Onychomycosis accounts for approximately 50% of reported nail disorders

• Population-based prevalence is 4.3% in Europe and North America.
Increases with aging: 20% > 60 years , 50% > 70 years (related to peripheral
vascular disease, immunologic disorders, and diabetes mellitus. [RR 1.9 to 2.8])

• More common in toenails than fingernails (because of their slower growth,
reduced blood supply, and frequent confinement in dark, moist environments).

• Primary causative organism was Trichophyton rubrum (44.9%), followed by
yeasts (21.2%) and moulds (13.3%).
Onychomycosis is classified according to the way fungi invade
the nail plate:
Distal and lateral subungual onychomycosis (DLSO),
Proximal subungual onychomycosis,
Superficial white onychomycosis,
Total dystrophic onychomycosis
SUBUNGUAL ONYCHOMYCOSIS

• Disto-lateral: most frequent, the
consequence of a plantar infection with
trichophyton rubrum (90% of cases)

• Color may vary according to the fungus

• One hand-two feet syndrome is seen in
patients who scratch their feet.
PROXIMAL SUBUNGUAL
ONYCHOMYCOSIS

• Mostly seen in females

• Index and middle finger, dominant
hand

• Manual workers, contact with
water, humidity…

• 1st is the damage of the cuticle

• Then inflammation, irritation,…are
responsible of nail dystrophy and
colonisation with candida albicans
WHAT TO DO, FACING A PATIENT WITH
ONYCHOMYCOSIS ?

• Send him to the dermatologist ?
✍ Dear colleague…
• Ask for laboratory analysis:
#
• Samples should be collected after cleansing the area with 70%
isopropyl alcohol to prevent contamination.

• Clippings should be obtained with a sterile nail clipper or curette, and
subungual debris using a No. 15 surgical blade or a 2-mm curette.

• To improve accuracy, eight to10 nail shards should be collected.
MEDICAL TREATMENT IS THE RULE AND HAS
TWO FACETS: PREVENTION IS ESSENTIAL
• Find and eliminate, or minimize, the cause

• A strict moisture/contact irritant avoidance regimen is essential

• Physical trauma to the cuticles must be avoided indefinitely

• The patient should be instructed to do the following:

• Wear light cotton gloves under heavy-duty vinyl gloves for wet work.

• Wear the cotton and vinyl gloves when peeling or squeezing citrus fruits, handling tomatoes, and peeling
tomatoes or other raw food.

• Avoid direct contact with paints, metal polish, paint thinner, turpentine, other solvents, and polish, and wear
the cotton and vinyl gloves when using them.

• Protect hands from chapping and drying in windy or cold weather by wearing unlined leather gloves.

• Use lukewarm water and very little mild soap when washing hands; be sure to rinse the soap off and dry
gently.
MEDICAL TREATMENT: USUALLY
THE ASSOCIATION OF:
• Topical treatment with lacquers (ciclospirox 8% once a day or Amorolfine once a
week)

• When used alone, ciclopirox has a mycotic cure rate of 29% to 36%, and a clinical cure
rate of 6% to 9%

• "Combining data from 2 trials of ciclopiroxolamine versus placebo found treatments failure
rates of 61% and 64% for ciclopiroxolamine. These outcomes followed long treatment times
(48 weeks) and this makes ciclopiroxolamine a poor choice for nail infections. Better results
were observed with the use of amorolfine lacquer; 6% treatment failure rates were found after
1 month of treatment but these data were collected on a very small sample of people and
these high rates of success might be unreliable. »The Cochrane Library: Topical treatments
for fungal infections of the skin and nails of the foot, 2009.

• Anti-fungal agents (association with lacquer increases their efficacy)
Terbinafine is the only anti-fungal available agent disponible in France
RESULTS FOR MEDICAL TREATMENT

• A meta-analysis of treatments for toenail onychomycosis
determined that mycotic cure rates were 76% for terbinafine,
63% for itraconazole with pulse dosing, 59% for itraconazole
with continuous dosing, and 48% for fluconazole.

• Clinical cure rates were 66% for terbinafine, 70% for
itraconazole with pulse dosing, 70% for itraconazole with
continuous dosing, and 41% for fluconazole.

Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the treatment
of onychomycosis. Br J Dermatol. 2004;150(3):537-544.
SURGICAL TREATMENT =
MARSUPIALIZATION
• First reported by Keyser and
Eaton (1976) as a crescent
excision of the proximal nail fold
from 1 mm proximal to the nail
fold at a maximal width of about
6 mm; the cuticle is preserved

Keyser11,Eaton RG. Surgical cure of chronic paronychia by eponychial marsupialization. Plast Reconstr Surg 1976;58:66-70.
• Baran suggested
complete removal of the
dorsal roof including the
eponychium (which may
produce dulling and
roughing of the nail as
well as a contracted
eponychium).

Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychias of the fingers. J Dermatol Surg Oncol
1981;7:106-7.
MARSUPIALIZATION

• Bednar reported of 28 fingers
treated with marsupialization
w/wo nail removal and had
no recurrences with nail
removal.
Results at 31 months
Bednar B, Lane LB. Eponychial marsupialization and nail removal for surgical treatment of chronic
paronychia. J Hand Surg Am. 1991 Mar;16(2):314-7.
LAST BUT NOT LEAST

• Surgical nail removal should be considered when there
is considerable deformity and thickening of the nail

• The nail matrix is scraped with a blade to remove
much of the remaining pathogenic fungi

• Especially useful for Yeasts as no medication are
available