Nail Infection, Fungal

(Onychomycosis)
Information for
In onychomycosis, a fungal nail infection, the nail typically lifts and is brittle. There may be
scaly debris below the nail.
Images of Onychomycosis (8)

Overview
Onychomycosis, commonly known as a fungal nail infection, is infection of the fingernails or
toenails by forms of fungi and yeast. Fungal nail infections account for nearly one-half of all nail
disorders. In the most common form of fungal nail infections, fungus grows under the growing
portion of the nail and spreads up the finger (proximally) along the nail bed and the grooves on
the sides of the nails. A less common type of fungal nail infection may occur in those with
HIV/AIDS.

Who's at risk?
Fungal nail infection may occur at any age but is more common in adults, particularly in older
individuals. Diabetics may be more likely than other people to develop a fungal nail infection.

Signs and Symptoms

 In general, toenails are most commonly affected with fungal nail infection. If the
fingernails are affected, the toenails are usually affected as well. Nails often become
thicker and lift from the nail bed (onycholysis) starting at the growing portion of the nail.
You might then see debris under the nails and discoloration of the affected area.

 In some forms of fungal nail infection, you might see black or white, powdery
discoloration on the surface of the nail plate.
 In some forms of fungal nail infection, you might see these abnormal changes farther up
the finger (proximally), where the nail originates.

 Fungal nail infection may occur in people with athlete's foot (tinea pedis) and/or oozing
infection (paronychia), caused by inflammation and infection with yeast and/or bacteria
in the region where the skin of the finger meets the origin of the nail.

 In fungal nail infection, one, a few, or all nails may be affected.

Self-Care Guidelines
 None necessary except good hygiene and regular washing of the hands and feet.

When to Seek Medical Care

Fungal nail infection does not always require treatment, but see your doctor for any nail disorder.
Diabetics with foot problems should be evaluated because of the possible risk for developing
foot ulcers. Your doctor may perform testing, such as scraping a nail to examine for fungi or
clipping a nail to look for bacterial or fungal growth (culture) or to obtain a special stain to look
for fungi under a microscope.

Treatments Your Physician May Prescribe

 Topical therapy with ciclopirox nail lacquer, which requires daily application for 9–12
months.

 Oral antifungal treatments offer the best chance for curing fungal nail infection. The most
commonly used agents are terbinafine, itraconazole, and fluconazole. The medications
may cause liver problems or may affect blood cell counts. Blood tests are usually
performed before starting therapy and during therapy to look for possible side effects.

 In stubborn (refractory) fungal nail infection, surgical removal of part of the nail or the
entire nail, removing the nail by applying a chemical, or thinning the nail by applying
40% urea ointment may be used, in addition topical or oral antifungal agents.

Beau's Lines
Information for
This image displays a horizontal line and groove across the nail typical of Beau's lines.
Images of Beau's Lines (5)
Overview
Beau's lines are horizontal (transverse) depressions in the nail plate that run parallel to the shape
of the white, moon-shaped portion of the nail bed (lunula) seen at the nail's origin. They result
from a sudden interruption of nail keratin synthesis and grow distally with the nail plate. As the
nail grows, the Beau's lines can disappear.

Beau's lines can be caused by trauma or local disease involving the nail fold. They can vary
based upon the width or depth of the depression, reflecting the duration or extent of the damage.
When Beau's lines are present in all nails at a similar location on the nail plate, they are likely to
have a systemic cause. They may also result from metabolic, inflammatory, or traumatic
influences.

Who's at risk?
People of all ages and ethnic backgrounds can have Beau's lines. Most commonly, they are seen
in chemotherapy patients in reaction to a drug.

Signs and Symptoms

Beau's lines occur along the fingernails and the toenails. The grooves extending across the nail
plate often span its entire breadth. The involvement of multiple nails may suggest a systemic
cause, including a side effect from medication, but the phenomenon may be limited to just the
thumb nails and big toe nails.

It is possible to measure the distance from the area where the cuticle is seen and where the nail
originates (the proximal nail fold) to the leading edge of the Beau's line to determine how much
time has elapsed since the line was formed. Because fingernails grow at a rate of approximately
0.1 mm per day, and toenails grow 0.03 mm per day, the duration of the causative insult can be
inferred from the width of the Beau's furrow itself.

Recurrent disease will produce repeated transverse grooves, separated by normal nail.

Self-Care Guidelines
None necessary.

When to Seek Medical Care

If nail changes, such as depressions in the nails, are noted, it may be helpful to seek evaluation
from a primary care provider or dermatologist.

Treatments Your Physician May Prescribe

Beau's lines are a retrospective indicator of various causes, and your physician may investigate
for possible causes.

Nail Splitting (Onychoschizia)

Information for
This image displays the plate-like splitting of the nail in onychoschizia.
Images of Onychoschizia (6)

Overview
Onychoschizia, commonly known as nail splitting but also known as onychoschisis or lamellar
dystrophy, is a condition that causes horizontal splits within the nail plate. Nail splitting is often
seen together with onychorrhexis – long-wise (longitudinal) splitting or ridging of the nail plate –
and these 2 diseases together are called "brittle nail syndrome."

 Frequent wetting and drying of the hands is the most common cause of nail splitting, so
this condition is, therefore, common among house cleaners, nurses, and hairdressers.

 Nail splitting may also be caused by nail cosmetics (hardeners, polish, polish
removers/solvents), nail procedures, and occupational exposure to various chemicals
(alkalis, acids, cement, solvents, thioglycolates, salt, sugar solutions).

 Injury (trauma) may also play a role in the development of brittle nails.

 Brittle nails may occur due to medical problems, including gland (endocrine system)
diseases, tuberculosis, Sjögren syndrome, and malnutrition.
 People with other skin diseases, such as lichen planus and psoriasis, as well as people
taking oral medications made from vitamin A, may also develop nail splitting.

Who's at risk?
 Brittle nails affect nearly 20% of the population.

 Nail splitting is seen more frequently in women and older individuals.

 People in occupations requiring frequent wetting and drying of the hands are at increased
risk for nail splitting.

Signs and Symptoms

 Nail splitting affects the fingernails and the toenails. The condition may appear as a
single horizontal split between layers of the nail plate at the growing end or as multiple
splits and loosening of the growing edge of the nail plate.

 Horizontal nail splitting may occur along with onychorrhexis, with longitudinal ridging
or splitting as well.

 Horizontal splits at the origin of the nail plate may be seen in people with psoriasis or
lichen planus or in people who use oral medications made from vitamin A.

Self-Care Guidelines
 Reduce how often you wet and dry your nails.

 Wear plastic or rubber gloves over thin cotton gloves while doing all housework,
including food preparation.

 Keep the nails trimmed short to reduce worsening of nail splitting.

 Soak the nails in water daily, 15 minutes at a time, to increase the water content
(hydration) of the nails.

 Apply moisturizers (emollients), such as petroleum jelly or Cetaphil®, to improve nail

hydration.

 Nail-hardening agents containing formaldehyde may increase nail strength, but they
should be used cautiously, as they can cause brittleness and other nail problems. Apply
these hardeners only to the free edge (growing end) of the nail.

 Acrylate-containing hardeners are also effective, but they may cause an allergic reaction
in the skin.
When to Seek Medical Care
Nail splitting is generally considered a cosmetic problem, but see your doctor if the condition
becomes bothersome.

Treatments Your Physician May Prescribe

The only oral therapy that has shown any benefit for nail splitting is biotin supplementation.

Herpetic Whitlow
Information for
The herpes simplex virus infection on the finger is known as herpetic whitlow. Grouped, fluid-
filled or pus-filled, blisters are typical and usually itch and/or are painful.
Images of Herpetic Whitlow (6)

Overview
Herpetic whitlow—also called digital herpes simplex, finger herpes, or hand herpes—is a painful
viral infection occurring on the fingers or around the fingernails. Herpetic whitlow is caused by
infection with the herpes simplex virus (HSV).

Infections with HSV are very contagious and are easily spread by direct contact with infected
skin lesions. HSV infection usually appears as small blisters or sores around the mouth, nose,
genitals, and buttocks, though infections can develop almost anywhere on the skin. Furthermore,
these tender sores may recur periodically in the same sites.

There are 2 types of HSV: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2
(HSV-2). HSV-1 infections usually occur around the mouth, lips, nose, or face, while HSV-2
infections usually involve the genitals or buttocks. However, HSV-1 can sometimes cause
infections in the genitals or buttocks, while HSV-2 can occasionally cause infections around the
mouth, lips, nose, or face.

Both types of HSV produce 2 kinds of infections: primary and recurrent. Because it is so
contagious, the herpes simplex virus causes a primary infection in most people who are exposed
to the virus. However, only about 20% of people who have a primary infection with the herpes
simplex virus actually develop visible blisters or sores. Appearing 2–20 days after a person's first
exposure to HSV, the sores of a primary infection last about 1–3 weeks. These sores heal
completely, rarely leaving a scar. Nevertheless, the virus remains in the body, hibernating in
nerve cells.

Certain triggers can cause the hibernating (latent) virus to wake up, become active, and travel
back to the skin. These recurrent herpes simplex virus infections may develop frequently (every
few weeks), or they may never develop. Recurrent infections tend to be milder than primary
infections and generally occur in the same location as the primary infection.

People develop herpetic whitlow when they come into contact with areas already infected with
HSV, either on their own bodies or on someone else's body. Usually, there is a break in the skin,
especially a torn cuticle at the base of the fingernail, which allows the virus to enter the finger
tissue and establish an infection. HSV-1 causes approximately 60% of herpetic whitlow
infections, while HSV-2 causes the remaining 40%.

Who's at risk?
Herpetic whitlow can affect people of all ages, of all races, and of both sexes. However, it is
more common in children and in dental and medical workers. Children often contract herpetic
whitlow as a result of thumb- or finger-sucking when they have a herpes infection of the lips or
mouth. Dental and medical workers may contract herpetic whitlow by touching the contagious
lesions of a patient with herpes simplex virus infection. In these groups of people—children and
health care workers—herpetic whitlow is most commonly caused by HSV-1. In everyone else,
herpetic whitlow is usually caused by infection with HSV-2.

Signs and Symptoms

The most common locations for herpetic whitlow include:

 Thumb

 Index finger

 Other fingers

Approximately 2–20 days after initial exposure to the herpes simplex virus, the infected area
develops burning, tingling, and pain. Over the next week or 2, the finger becomes red and
swollen. Small (1–3 mm) fluid-filled blisters develop, often clustered together on a bright red
base. The blisters usually rupture and scab over, leading to complete healing after an additional 2
weeks.
Other symptoms occasionally associated with the primary infection of herpetic whitlow include:

 Fever

 Red streaks radiating from the finger (lymphangitis)

 Swollen lymph nodes in the elbow or underarm area

If a person contracts herpetic whitlow from himself or herself (autoinoculation), then he or she is
likely to have a primary herpes simplex virus infection of the mouth area or of the genital area.

Repeat (recurrent) herpes simplex virus infections are often milder than the primary infection,
though they look alike. A recurrent infection typically lasts 7–10 days. Recurrent herpetic
whitlow is rare.

However, people with recurrent HSV infections may report that the skin lesions are preceded by
sensations of burning, itching, or tingling (prodrome). About 24 hours after the prodrome
symptoms begin, the actual lesions appear as one or more small blisters, which eventually open
up and become scabbed over.

Triggers of recurrent HSV infections include:

 Fever or illness

 Sun exposure

 Hormonal changes, such as those due to menstruation or pregnancy

 Stress

 Trauma

 Surgery

Self-Care Guidelines
Acetaminophen or ibuprofen may help reduce fever and pain caused by the herpes simplex virus
sores. Applying cool compresses or ice packs may also relieve some of the swelling and
discomfort.

Because herpes simplex virus infections are very contagious, it is important to take the following
steps to prevent spread (transmission) of the virus during the prodrome phase (burning, tingling,
or itching) and active phase (presence of blisters or sores) of herpetic whitlow:

 Avoid sharing towels and other personal care items

 Cover the affected finger with a bandage

 Wear gloves if you are a health care provider

 Don't pop any blisters—it may make the condition worse

Unfortunately, the virus can still be transmitted even when someone does not have active lesions.
However, this is very unusual for patients with herpetic whitlow.

When to Seek Medical Care

If you develop a tender, painful sore on the finger, see a physician, especially if it is not going
away or if it seems to be getting worse. You should definitely seek medical attention if you have
a finger sore as well as typical symptoms of oral or genital herpes.

Treatments Your Physician May Prescribe

Most herpes simplex virus infections are easy for physicians to diagnose. On occasion, however,
a swab from the infected skin may be sent to the laboratory for viral culture, which takes a few
days to grow. Blood tests may also be performed.

Untreated HSV infections will go away on their own, but medications can reduce the symptoms
and shorten the duration of outbreaks. There is no cure for herpes simplex virus infection.

Although herpetic whitlow symptoms will eventually go away on their own, your physician may
prescribe antiviral medications in order to help relieve symptoms and to prevent spread of the
infection to other people:

 Acyclovir pills

 Valacyclovir pills

 Famciclovir pills

 Topical acyclovir ointment

These medications are usually taken for 7–14 days.

More severe herpetic whitlow may require oral antibiotic pills if the area(s) are also infected with
bacteria.

Although it is rare, recurrent herpetic whitlow can be treated with the same oral antiviral
medications:

 Acyclovir pills
 Valacyclovir pills

 Famciclovir pills

 Topical acyclovir ointment

People who experience early signs (prodromes) before recurrent infections may benefit from
episodic treatment, by starting to take medication after the onset of tingling and burning but
before the appearance of blisters and sores.

Very rarely, individuals may have recurrent herpetic whitlow outbreaks that are frequent enough
or severe enough to justify suppressive therapy, in which medications are taken every day in
order to decrease the frequency and severity of attacks.

Nail Infection, Bacterial

(Paronychia)
Information for
This image displays cracks and swelling around the nail typical of chronic paronychia.
Images of Paronychia (6)

Overview
Paronychia, commonly known as bacterial nail infection, is inflammation of the region of the
finger or toe from which the nail plate originates, which is called the proximal nail fold (PNF).
This inflammation may occur in the short term (acute) or may be a long-term problem or one that
keeps coming back (chronic).

Acute paronychia develops along a break in the skin and is usually seen at the side of the nail.
This type of nail infection is often caused by a bacterial infection but may also be caused by
herpes, a type of viral infection.
Chronic paronychia occurs most often in people whose hands are constantly or often exposed to
moisture. This disorder often results from contact dermatitis, a type of skin inflammation caused
by exposure to chemicals that are irritating to the skin. People with chronic paronychia may have
periodic, painful flare-ups. This type of nail infection may be complicated by the addition of a
fungal infection, commonly due to a type of yeast called Candida, or bacterial infection, and this
may lead to abnormal nail growth.

Who's at risk?
Acute paronychia may occur at any age but is particularly common in children. Viral paronychia
occurs more often in adults and may be seen with genital herpes infection or in people who work
in the health care industry.

Chronic paronychia is most common in adult women and those who work in places where their
hands are kept moist, such as food handlers.

Signs and Symptoms

Bacterial nail infection most often affects the proximal nail fold of the fingers and less
commonly affects the toes.

 Acute: The proximal nail fold is red, swollen, painful, and may contain pus. Usually one
nail is affected.

 Chronic: The proximal nail fold is swollen, red, and has no cuticle (the strip of hardened
skin at the base and sides of a fingernail or toenail). One or more nails may be affected.

Self-Care Guidelines
 Try soaking the nails in warm water for acute paronychia.

 Avoid water and chemical exposure to prevent symptoms of chronic paronychia.

When to Seek Medical Care

See your doctor for an evaluation if you notice signs of bacterial nail infection.

Treatments Your Physician May Prescribe

For acute paronychia, your doctor may:

 Puncture and drain the affected area and test for bacteria or viral infection.
 Prescribe antibiotics for a bacterial infection or an antiviral medication for a herpes
infection.

For chronic paronychia, your doctor may:

 Prescribe a topical steroid.

 Prescribe a topical antifungal medication.

 Prescribe an oral antifungal medicine or antibiotics.