Onychomycosis - Epidemiology, Clinical Features, and Diagnosis - UpToDate

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Onychomycosis: Epidemiology, clinical features, and

diagnosis
AUTHORS: Adam O Goldstein, MD, MPH, Neal Bhatia, MD
SECTION EDITORS: Robert P Dellavalle, MD, PhD, MSPH, Moise L Levy, MD, Ted Rosen, MD
DEPUTY EDITOR: Abena O Ofori, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2023.

This topic last updated: Jan 20, 2023.
INTRODUCTION
Onychomycosis refers to chronic fungal infection of the toenails or fingernails. Causative

fungi include dermatophytes, yeasts, and nondermatophyte molds.
Onychomycosis most often occurs in adults but also occurs in children. Common clinical
manifestations include nail discoloration, subungual hyperkeratosis, onycholysis, splitting of
the nail plate, and nail plate destruction ( picture 1A-B). Potential complications include
pain, transmission of fungal infection to other body sites, and, in immunocompromised
patients, bacterial cellulitis.
The epidemiology, clinical features, and diagnosis of onychomycosis will be reviewed here
( algorithm 1). Other causes of nail dystrophy and the management of onychomycosis are
reviewed separately. (See "Overview of nail disorders" and "Onychomycosis: Management".)
MICROBIOLOGY
Onychomycosis may result from dermatophyte, yeast, or nondermatophyte mold nail

infections. Dermatophyte infections (also known as tinea unguium) are most common and
are estimated to account for 60 to 70 percent of infections [1]. Nondermatophyte mold and
yeast infections may account for 30 to 40 percent and 10 to 20 percent of fungal nail
infections, respectively [1].
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Trichophyton rubrum is the most frequent dermatophyte found in onychomycosis. In a review

of multinational hospital-based prevalence studies, in which dermatophytes were found in 65
percent of cases of onychomycosis (including 82 percent of cases in North America), T. rubrum
infection was most common, accounting for approximately 45 percent of infections [2].
Examples of other dermatophytes implicated in onychomycosis include Trichophyton
mentagrophytes, Epidermophyton floccosum, Microsporum species, and other Trichophyton
species [1].
Candida species are the most common yeasts isolated from onychomycosis [3,4]. Examples of
nondermatophyte molds found in onychomycosis include Fusarium, Aspergillus, Acremonium,
Scytalidium, and Scopulariopsis brevicaulis [5].
The proportion of infections due to dermatophyte, yeast, and nondermatophyte molds

differs for fingernails and toenails. Toenail onychomycosis is most often caused by
dermatophytes, whereas yeast onychomycosis has been identified as the most common
cause of fingernail onychomycosis in some, but not all, studies [6-8]. Nondermatophyte mold
onychomycosis primarily affects toenails; fingernail onychomycosis secondary to
nondermatophyte molds is rare [6].
PATHOGENESIS
Onychomycosis is acquired through direct contact of the nail with dermatophytes, yeast, or
nondermatophyte molds in the environment or through spread of fungal infection from
affected skin (eg, tinea pedis). Fungal production of proteases that degrade keratin may
facilitate invasion [9]. Factors that can compromise barriers to infection, such as nail injury or
nail disease, may increase risk for fungal invasion. In addition, the status of the nail as a site
of relative immune privilege lacking effective cell-mediated immunity may contribute to
infection [10,11].
Although additional study is needed, the formation of fungal biofilms is a proposed

contributor to persistent infection [12,13]. Biofilms are multicellular communities of
organisms that adhere to tissue and may provide survival benefits to the organisms. Biofilms
may facilitate evasion from both host defenses and antimicrobial therapies.
EPIDEMIOLOGY
Onychomycosis is a common, global disorder that is estimated to account for 50 to 60

percent of abnormal nails [6]. Population-based studies have found varied estimates of
prevalence, ranging from less than 1 to 8 percent in Europe and the United States to less than
1 percent in Central Africa [2]. A systematic review of published population-based studies that

assessed the prevalence of culture-proven dermatophyte, yeast, and nondermatophyte mold

onychomycosis of the toenails found pooled prevalences of 3.22 percent (95% CI 3.07-3.38),
0.4 percent (95% CI 0.34-0.47), and 0.37 percent, (95% CI 0.32-0.43), respectively [14].
Onychomycosis is more common in adults than in children. The systematic review cited above
found pooled prevalences of pediatric dermatophyte and yeast toenail onychomycosis of 0.14
percent (95% CI 0.11-0.18) and 0.09 percent (95% CI 0.06-0.13), respectively [14]. In a separate
systematic review that included pediatric studies assessing both toenail and fingernail
onychomycosis, prevalences of onychomycosis in children ranged from 0 to 3.37 percent in
population-based studies utilizing a combination of clinical diagnosis, microscopy, and
culture for diagnosis [15]. All but one of the studies reported prevalences of less than 1
percent.
Most, but not all, studies have found a higher prevalence of onychomycosis in males than in
females [2].
RISK FACTORS
Data on risk factors for onychomycosis are limited. Proposed risk factors include [1]:
● Dermatologic diseases – Tinea pedis, psoriasis, hyperhidrosis
● Comorbidities – Diabetes, immunosuppression, venous insufficiency, malignancy,

peripheral artery disease, obesity, inflammatory bowel disease
● Exposures – Trauma, poor nail grooming, sports and fitness activities, occupation,
smoking, occlusive shoes
● Other – Advancing age, contact with infected household members, genetic

predisposition, hallux valgus, asymmetric gait nail unit syndrome
Candida albicans onychomycosis often occurs in association with frequent exposure of the
hands to moisture, as may occur in certain occupations (eg, bartenders, housekeepers) [7].
Rarely, severe candidal onychomycosis is a manifestation of chronic mucocutaneous
candidiasis, a heterogeneous group of syndromes characterized by deficient immune
responses against C. albicans and chronic candidal infections of the skin, mucous
membranes, and nails [16]. (See "Chronic mucocutaneous candidiasis".)
CLINICAL FEATURES
Onychomycosis may present with a variety of nail abnormalities, such as discoloration,

subungual hyperkeratosis, onycholysis, splitting, and nail plate destruction.

Subtypes — The major clinical subtypes of onychomycosis are distal lateral subungual

onychomycosis, white superficial onychomycosis, and proximal subungual onychomycosis.
Additional proposed clinical subtypes are endonyx onychomycosis, total dystrophic
onychomycosis, and mixed pattern onychomycosis [5]:
● Distal lateral subungual onychomycosis – Distal lateral subungual onychomycosis is

the most common clinical subtype. Distal lateral subungual onychomycosis typically
begins with whitish, yellowish, or brownish discoloration of a distal corner of a nail. The
great toe is often the initial site of infection.
The infection gradually spreads to involve the entire width of the nail plate and extends
slowly toward the cuticle ( picture 1A-B). Subungual hyperkeratosis and onycholysis
(separation of the nail plate from the nail bed) are common. The accumulation of
keratinous debris between the nail plate and nail bed causes the nail discoloration.
The vast majority of distal lateral subungual onychomycosis is due to T. rubrum [8].
● White superficial onychomycosis – White superficial onychomycosis is characterized

by the appearance of dull, white spots on the surface of the nail plate ( picture 2). If
not treated, the involved area spreads centrifugally and may eventually involve the
entire nail plate. The white areas are soft and yield a chalky scale when scraped lightly
with a curette or surgical blade.
White superficial onychomycosis is usually caused by T. mentagrophytes, although T.

rubrum, Candida, and nondermatophyte mold infections have also been reported
[17,18].
● Proximal subungual onychomycosis – Proximal subungual onychomycosis is a

relatively uncommon subtype that affects the proximal nail in the vicinity of the cuticle
and extends distally ( picture 3A-C). This subtype usually occurs in individuals with
severely compromised immune systems and is often a marker for AIDS.
Examples of organisms that may cause proximal subungual onychomycosis include T.

rubrum, Fusarium species, C. albicans, and Aspergillus species [5].
● Endonyx onychomycosis – Endonyx onychomycosis involves only the interior of the

nail plate, sparing involvement of the nail bed [5]. Nail findings include discoloration
and splitting. Subungual hyperkeratosis is absent.
Trichophyton soudanense infection is most strongly associated with endonyx

onychomycosis; however, other organisms, such as Trichophyton violaceum, also may
cause this presentation [5].

● Total dystrophic onychomycosis – The term "total dystrophic onychomycosis" is used

to describe complete destruction of the nail plate that results in a thickened and ridged
nail bed covered with keratotic debris ( picture 4). Totally dystrophic onychomycosis is
most often a manifestation of end-stage distal lateral subungual onychomycosis or
proximal subungual onychomycosis.
● Mixed pattern onychomycosis – Mixed pattern onychomycosis is characterized by the

presence of one or more of the above subtypes. The most common mixed presentations
combine superficial white onychomycosis with either distal lateral subungual
onychomycosis or proximal subungual onychomycosis [5].
Additional findings — Dermatophytoma and fungal melanonychia are additional findings

that may occur in onychomycosis:
● Dermatophytoma – A dermatophytoma is a dense collection of dermatophyte hyphae

in the nail plate. Dermatophytomas often manifest as a linear, white, yellow, or orange
band in the nail ( picture 5). A dermatophytoma may reduce the likelihood of cure
from oral antifungal therapy [19]. (See "Onychomycosis: Management".)
● Fungal melanonychia – Fungal melanonychia describes an uncommon form of

onychomycosis caused by fungal species capable of producing melanin. Brown to black
discoloration of the nail plate is characteristic and may appear in a variety of patterns,
including diffuse, linear, and localized pigmentation ( picture 6). Nail dystrophy may
also be present.
When caused by dematiaceous fungi (pigment-producing molds), the term "ungual

phaeohyphomycosis" is also used to refer to this condition. The most common molds
isolated from affected nails are Scytalidium dimidiatum, Alternaria species, Exophiala
species, and Aspergillus species. Several nondematiaceous fungi may also cause fungal
melanonychia, including T. rubrum [20].
Associated dermatologic disorders — Dermatophyte infections of the skin (particularly

tinea pedis) and chronic paronychia may accompany onychomycosis. A prospective study of
2761 patients with toenail onychomycosis found tinea pedis in 933 patients (34 percent) [21].
The interdigital variant of tinea pedis was most common ( picture 7). (See "Dermatophyte
(tinea) infections", section on 'Tinea pedis'.)
Chronic paronychia (inflammation of the proximal or lateral nail folds) is common in patients
with Candida onychomycosis. (See "Paronychia", section on 'Chronic paronychia'.)
COMPLICATIONS

Nail disfigurement secondary to onychomycosis and associated symptoms can lead to

psychosocial distress and functional limitations, contributing a negative impact on quality of
life [22]. Especially in the presence of severe nail involvement, patients may experience
chronic pain or acute pain exacerbated by stimuli, such as nail cutting, footwear, or pressure
from bedclothes [23-25].
Onychomycosis may also serve as a reservoir for recurrence of cutaneous fungal infections
(eg, tinea pedis, tinea cruris, tinea corporis). Additionally, in patients with diabetes or other
immunocompromised states, onychomycosis may increase the risk of bacterial infections,
such as cellulitis [26,27]. (See "Dermatophyte (tinea) infections".)
DIAGNOSIS
A diagnosis of onychomycosis may be strongly suspected based upon the patient history and
physical findings. However, confirmation of the diagnosis requires the detection of fungi in a
nail specimen through microscopic examination, culture, or other laboratory testing
( algorithm 1). (See "Onychomycosis: Management", section on 'Pretreatment diagnostic
testing'.)
Overview — The diagnosis of onychomycosis begins with a focused history and physical

examination in patients who present with nail dystrophy suspicious for onychomycosis (eg,
discoloration, thickening, splitting, nail plate destruction) to establish the differential
diagnosis. If suspicion for onychomycosis remains after the history and physical examination,
various tests can be performed to confirm the diagnosis ( algorithm 1).
Tests typically used to confirm onychomycosis in the clinical setting include potassium
hydroxide (KOH) preparations, fungal cultures, histopathologic examination with a periodic
acid-Schiff (PAS) stain, and polymerase chain reaction (PCR) [28]. In addition, fungal cultures
and PCR can identify the type of fungus present, and fungal culture can confirm fungal
viability, supporting the presence of active infection.
Typically, the approach to diagnostic testing for suspected onychomycosis consists of a

relatively rapid method to detect evidence of fungal infection (KOH preparation,
histopathologic examination with a PAS stain, or PCR). Often, if identification of the causative
fungus may be helpful (eg, patient proceeding with treatment for onychomycosis), fungal
culture or PCR is also performed. Factors such as clinician skill, test availability, and cost may
influence the selection of testing.
Our approach — A KOH preparation is our preferred initial test for suspected onychomycosis
given the rapid availability of results, relatively low cost, and simplicity of the procedure
( algorithm 1). However, the sensitivity of KOH preparation is lower than histopathologic
examination with a PAS stain or PCR, and the results are dependent upon skill of the
performing clinician. If the KOH preparation is negative, we typically obtain a nail clipping for
histopathologic examination with a PAS stain. A PCR test that assesses for dermatophytes,
saprophytes, and Candida is a less widely available alternative to histopathologic
examination.
If the KOH preparation or PAS stain is positive, confirming onychomycosis, we typically obtain
a nail sample for fungal culture to identify the causative organism (dermatophyte versus
yeast versus nondermatophyte mold) if the patient plans to proceed with treatment. PCR can
also provide identification of the organism.
PCR testing is also utilized by some clinicians as the initial diagnostic test for onychomycosis,
rather than a KOH preparation. Familiarity with the limitations of the specific PCR test
selected is crucial. (See 'Polymerase chain reaction' below.)
History and physical examination — Information from the patient history and physical
examination can help to narrow the differential diagnosis. Patients should be asked about the
duration and course of nail changes, preceding nail trauma, and history of skin disorders. In
patients with nail dystrophy involving all nails, additional historical details, such as inquiries
about systemic disease or family history of nail disorders, may be helpful for identifying
patients at risk for systemic or genetic causes of onychodystrophy. (See "Overview of nail
disorders", section on 'History' and "Overview of nail disorders", section on 'Nail signs of
systemic diseases'.)
The physical examination should include examination of all nails on the hands and feet to
determine the nature and extent of involvement. Examination of the skin is also useful for
identifying risk factors for onychomycosis, such as cutaneous fungal infections or chronic
paronychia, as well as cutaneous diseases that may cause noninfectious nail dystrophy, such
as psoriasis and lichen planus. Of note, onychomycosis is common and may coexist with
other nail disorders. (See "Overview of nail disorders", section on 'Nail examination' and
"Overview of nail disorders", section on 'Skin diseases with nail involvement'.)
Examples of features consistent with, but not exclusive to, onychomycosis include:
● Acquired, slowly progressive nail dystrophy
● Dystrophy of single nail or variation in the degree or progression of involvement in

multiple nails
● Nail changes consistent with onychomycosis (eg, white, yellow, or brown discoloration,
subungual hyperkeratosis, onycholysis, splitting, nail destruction) (see 'Subtypes' above)
Dermoscopy of the nails may help to distinguish onychomycosis from other nail disorders. A
jagged proximal edge near areas of onycholysis, also described as an irregular macular
pattern, is a common finding that is postulated to occur in the setting of distal to proximal
invasion of dermatophytes ( picture 8) [29-31]. Other potential findings include longitudinal

striae and a "ruin-like" appearance (also referred to as a distal pulverized pattern) that occurs
in the presence of subungual hyperkeratosis ( picture 9). (See "Dermoscopy of
nonpigmented nail lesions", section on 'Onychomycosis' and "Dermoscopy of nail
pigmentations", section on 'Fungal melanonychia'.)
Diagnostic tests — The major diagnostic tests for onychomycosis include KOH preparations,
histopathologic examination of nail clippings with a PAS stain, fungal culture, and PCR.
Potassium hydroxide preparation — A potassium hydroxide (KOH) preparation provides

almost immediate results. The sensitivity of KOH preparations has been reported as 67 to 93
percent; however, the sensitivity is dependent on factors such as specimen adequacy and
clinician experience [1,32]. The specificity range is 38 to 78 percent [1,32]. Repetition of the
test may modestly increase sensitivity [33]. The sensitivity may also be enhanced through use
a stain, such as chlorazol black E [34]. (See "Office-based dermatologic diagnostic
procedures", section on 'Potassium hydroxide preparation'.)
The technique for obtaining the specimen is critical to the success of this procedure. In the
evaluation of distal lateral subungual onychomycosis, the nail should be clipped back as far
as possible and samples taken from the most proximal accessible region. Subungual debris
overlying the nail bed can be obtained with a curette. Specimens from proximal subungual
onychomycosis can be obtained by paring the overlying nail plate to allow sampling of the
ventral nail plate. In white superficial onychomycosis, the sample can be taken by scraping
the surface of involved areas with a number 15 blade.
A positive test demonstrates fungal hyphae, pseudohyphae, or yeast cells ( picture 10). The
KOH examination does not provide speciation or assess fungus viability.
Histopathology — Histopathologic examination of nail clippings with a PAS stain is easy to

perform and identifies fungal elements with high sensitivity. In locations with good access to
pathology services, results are typically available within a few days. A disadvantage of PAS
stain evaluation is the higher cost in comparison with a KOH preparation.
PAS staining of nail clippings is a sensitive test for onychomycosis [34-37]. One study included
1146 nail samples from 851 patients with clinical findings suggestive of onychomycosis [36].
Results from this study indicate that the PAS stain is a more sensitive test than culture or KOH
examination; sensitivities of PAS stain, culture, and KOH examination were 82, 53, and 48
percent, respectively.
To obtain a specimen for a PAS stain from distal lateral subungual onychomycosis, the nail
plate along with attached subungual debris is clipped just distal to its attachment to the nail
bed and placed in 10% formalin [35]. Nail clipping can also provide a sufficient specimen for
white superficial onychomycosis with distal nail involvement. Histopathologic examination of
proximal subungual onychomycosis is more challenging; a biopsy of the nail plate or partial
or full nail removal is usually necessary, making this diagnostic technique less favorable.
In a positive PAS stain, fungal elements (eg, hyphae, yeast) are typically found in the ventral
layers of the nail plate and in subungual debris ( picture 11). If white superficial
onychomycosis is sampled, fungal elements are usually found in the dorsal surface of the nail
plate [37]. As with the KOH examination, a PAS stain does not provide speciation or assess
fungus viability.
The Chicago sky blue stain, which provides a color contrast, has also been used for the
diagnosis of onychomycosis [38].
Fungal culture — A fungal culture (on Sabouraud's medium) allows for both identification
and speciation of fungal infection and is a highly specific test (83 to 100 percent specificity)
[1,32]. However, the sensitivity of culture is not high (31 to 59 percent), and results often are
not available for a few weeks [1,32,39]. If negative, repeat culture or other testing is indicated
when there is a strong clinical suspicion of onychomycosis, since almost one-third of cultures
may be falsely negative.
Cultures occasionally demonstrate nondermatophyte molds, which may represent true

nondermatophyte onychomycosis or contamination of the culture. One or more repeat
cultures demonstrating the same nondermatophyte mold are required to establish a
diagnosis of nondermatophyte mold onychomycosis [40,41]. Coinfection with dermatophytes
and nondermatophytes can occur [42].
Polymerase chain reaction — Polymerase chain reaction (PCR), a molecular technique that

allows for rapid and highly specific amplification of DNA fragments, has emerged as a
sensitive diagnostic technique for onychomycosis. An advantage of PCR is the relatively rapid
ability to both detect fungal DNA and identify the type of fungus present. Results are often
available within one to two days. Although commercial PCR tests for onychomycosis exist,
factors such as availability, cost, or insurance coverage may limit access in some settings [28].
(See "Polymerase chain reaction (PCR)".)
Familiarity with the sensitivity, specificity, and other limitations of the specific PCR test(s)
available to the clinician is essential for proper use and interpretation of results. Some tests
are only able to assess for dermatophyte infections, whereas others assess broader
categories of fungi. In addition, because PCR tests detect DNA, nonviable fungi may be
detected. Sample collection and submission should be performed according to the product
recommendations.
Other tests — Less commonly employed alternative tests include the dermatophyte test
medium (DTM) and the calcofluor white stain:

● Dermatophyte test medium – DTM culture is cheaper than culture on Sabouraud's

medium, can be performed in the clinician's office, and results are available within three
to seven days. A disadvantage is the limitation to use for the diagnosis of dermatophyte
onychomycosis.
Dermatophyte growth is indicated by a change in the color of DTM from yellow to red in
response to alkaline metabolites that result from growth of dermatophytes. It is
important to read DTM cultures in a timely fashion, since saprophytic organisms, which
might grow over several weeks, can cause the same color change. DTM cannot identify
the specific causative organism, but such identification is not necessary since all
dermatophytes are susceptible to similar therapies. In a study of 670 patients
presenting to their primary care clinician or podiatrist with clinical signs of toenail
onychomycosis, DTM cultures had good positive and negative correlation with culture
on Sabouraud's medium [43].
● Fluorescence microscopy – Calcofluor white is a florescent brightener that selectively

binds to cellulose and chitin, major components of fungal cell walls. The stain fluoresces
when exposed to ultraviolet radiation. Calcofluor white is applied to nail clippings and
can be used alone or in conjunction with preceding exposure of the clippings to KOH
[44]. A study that used the calcofluor white stain as a gold standard found the
procedure more sensitive than KOH preparation or culture (92 versus 80 and 59 percent,
respectively) [45]. The specificities were not significantly different (72, 72, and 82
percent, respectively).
Emerging diagnostic methods include an immunochromatographic strip test [46] and

reflectance confocal microscopy [47,48].
DIFFERENTIAL DIAGNOSIS
It is estimated that onychomycosis is responsible for only 50 to 60 percent of abnormal

appearing nails [6]. A wide variety of nail disorders, particularly those demonstrating
subungual hyperkeratosis, onycholysis (separation of the nail plate from the nail bed), or
onychogryphosis, may be mistaken for onychomycosis. Of note, onychomycosis may coexist
with these conditions. (See "Overview of nail disorders".)
Nail psoriasis, traumatic nail injury, and onychogryphosis are common conditions that may
resemble onychomycosis. Testing to detect fungi in the nail distinguishes onychomycosis
from these and other conditions (see 'Diagnosis' above):
● Nail psoriasis – Subungual hyperkeratosis and onycholysis are common findings of

both onychomycosis and nail psoriasis ( picture 12A-B). Additional clinical features
that suggest nail psoriasis include pitting, oil drop discoloration (irregular areas of
yellow or pink discoloration), and associated cutaneous or joint findings of psoriasis or

psoriatic arthritis. Of note, onychomycosis may coexist with nail psoriasis. (See "Nail
psoriasis".)
● Trauma – Traumatic nail injury can result in a wide variety of nail changes. A history of
trauma and exclusion of other disorders is essential for the diagnosis of trauma-induced
nail dystrophy. (See "Overview of nail disorders".)
● Onychogryphosis – Onychogryphosis describes the development of thickened,

distorted nail with increased curvature ( picture 13). The great toenail is most
frequently affected. Onychogryphosis most often occurs in older adults in association
with poor nail care or poorly fitting footwear [49].
In addition, nail changes associated with less frequent causes of nail dystrophy, such as
lichen planus ( picture 14A-B), eczema, pachyonychia congenita ( picture 15A-B), yellow
nail syndrome ( picture 16), median nail dystrophy ( picture 17), onychomatricoma
( picture 18), subungual exostosis ( picture 19), malignancy ( picture 20A-D), scabies
( picture 21) [50], and other disorders, may enter the differential diagnosis. The differential
diagnosis of nail disorders is reviewed in detail separately. (See "Overview of nail disorders".)
In patients with findings suggestive of fungal melanonychia, the possibility of other causes of
nail pigmentation, such as racial longitudinal melanonychia, exogenous pigment deposition,
and, most importantly, subungual melanoma, should be considered during patient
evaluation [20]. (See "Overview of nail disorders", section on 'Longitudinal melanonychia'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Dermatophyte
infections".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
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who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Fungal nail infections (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Epidemiology – Onychomycosis is a common nail disorder that results from infection of

the nail with dermatophytes, yeast, or nondermatophyte molds. Onychomycosis is more
common in adults than in children. (See 'Epidemiology' above.)
● Microbiology – Dermatophyte infection accounts for most cases of onychomycosis.

Trichophyton rubrum is the most common causative organism. Yeast onychomycosis is
most often due to Candida albicans infection. (See 'Microbiology' above.)
● Clinical features – Distal subungual onychomycosis is the most common clinical

subtype of onychomycosis. This variant begins with white, yellow, or brown
discoloration of the distal corner of the nail that may gradually spread to involve the
entire width of the nail ( picture 1A-B). Subungual hyperkeratosis and onycholysis are
common associated features.
Other clinical subtypes of onychomycosis include white superficial onychomycosis

( picture 2), proximal subungual onychomycosis ( picture 3A-C), endonyx
onychomycosis, total dystrophic onychomycosis ( picture 4), and mixed pattern
onychomycosis. (See 'Clinical features' above.)
● Complications – Onychomycosis may cause physical discomfort and may increase risk
for bacterial infections such as cellulitis in immunocompromised patients.
Onychomycosis can also serve as a reservoir for cutaneous fungal infections. (See
'Complications' above.)
● Diagnosis – Although a diagnosis of onychomycosis may be strongly suspected based

upon physical findings, laboratory evidence of fungal infection confirms the diagnosis.
Tests commonly utilized for diagnosis include potassium hydroxide (KOH) preparations,
fungal cultures, histopathologic examination, and polymerase chain reaction (PCR)
testing.
A KOH preparation is commonly performed as the initial test based upon rapidity, wide
availability, and low cost; however, other approaches, such as use of PCR as the initial
test, may be reasonable ( algorithm 1). (See 'Diagnosis' above.)

● Differential diagnosis – The differential diagnosis of onychomycosis includes multiple

other causes of nail dystrophy. Common disorders that may resemble onychomycosis
include nail psoriasis, traumatic nail changes, and onychogryphosis. (See 'Differential
diagnosis' above and "Overview of nail disorders".)
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of superficial fungal infections - what is used and what is needed to initiate therapy and
assess efficacy? J Eur Acad Dermatol Venereol 2019; 33:421.
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onychomycosis: a strategy to improve diagnosis efficiency. Braz J Infect Dis 2008; 12:333.
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diagnostic tests. J Am Acad Dermatol 2006; 55:620.
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comparative study and review of the literature. Arch Dermatol 2000; 136:1112.
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clipping examination in the diagnosis of onychomycosis. J Eur Acad Dermatol Venereol
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and proposal of a diagnostic algorithm. Clin Exp Dermatol 2015; 40:479.
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54:e539.
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nondermatophyte moulds in onychomycosis. Br J Dermatol 2009; 160:37.
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onychomycosis: a US nationwide prospective survey. Arch Intern Med 2002; 162:2133.
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the evaluation of onychomycosis. J Am Acad Dermatol 2003; 49:193.
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Strip. Br J Dermatol 2014; 170:328.
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toenail onychomycosis by reflectance confocal microscopy: prospective cohort study in
58 patients. J Am Acad Dermatol 2014; 71:56.
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cutaneous infections and infestations. J Eur Acad Dermatol Venereol 2016; 30:754.
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Online J 2011; 17:9.
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Lancet 2018; 391:2272.
Topic 4034 Version 34.0

GRAPHICS
Distal subungual onychomycosis
Nail discoloration and subungual hyperkeratosis are present on the

nail. The area immediately adjacent to the cuticle is not yet involved.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights

reserved.
Graphic 72013 Version 5.0

Distal subungual onychomycosis

Diagnostic assessment of suspected onychomycosis
Onychomycosis is common and may be present in conjunction with other nail

diseases. Confirmation of onychomycosis does not exclude the possibility of a
concomitant nail disorder.
KOH: potassium hydroxide; PAS: histopathologic examination of nail clipping

with periodic-acid Schiff stain; PCR: polymerase chain reaction.
* Onychomycosis may be suspected in patients with nail discoloration or nail

dystrophy in a pattern consistent with one of the clinical subtypes of
onychomycosis. Common features include yellow, white, or brown nail
discoloration; subungual hyperkeratosis; onycholysis; spitting of the nail plate;
and nail plate destruction. Refer to UpToDate topics on onychomycosis for
details on the clinical features of onychomycosis.

¶ PCR testing is utilized by some clinicians as an initial diagnostic test and is a

reasonable alternative, where available. However, not all PCR tests assess for all
fungal causes of onychomycosis, and familiarity with the coverage and other
limitations of the test selected is essential. Advantages of KOH preparation
include immediate results and low cost. Advantages of PCR include higher
sensitivity and the potential for identification of the causative fungus.
Δ Repetition of the KOH preparation is an alternative next step. A modest

increase in sensitivity may occur with repeated testing. Both PAS and PCR are
reasonable options; selection between these tests is generally based upon
availability and cost. An advantage of some PCR tests is the ability to identify the
type of fungus. Refer to the ¶ footnote definition for important PCR
considerations.
◊ Options include repetition of the test performed in the previous step or

performance of the test not previously performed (ie, PCR after PAS).
§ Refer to UpToDate topics on overview of nail disorders.

Onychomycosis
White superficial onychomycosis caused by Trichophyton

mentagrophytes.
Courtesy of John T Crissey, MD.

Proximal subungual onychomycosis
Whitish discoloration originating under the surface of the proximal nail

plate is present.

reserved.

Whitish discoloration originating under the surface of the proximal nail

plate is present.

reserved.

Proximal, white discoloration of the nail plate is noted. The nail fold
is uninvolved.

reserved.

Totally dystrophic onychomycosis
Total destruction of the nail with a ridged, hyperkeratotic nail bed is

present in this patient with totally dystrophic onychomycosis.

reserved.

Onychomycosis
Distal, lateral, subungual onychomycosis with associated toenail discoloration, subungual debris, and
dermatophytoma. Dermatophytomas appear as opaque, white or yellow, linear bands in the nail.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

Clinical and dermoscopic image of fungal melanonychia
(A) Fungal melanonychia presenting as a diffuse, dark brown nail pigmentation.
(B) Dermoscopy shows multicolored pigmentation with yellow strikes.
Courtesy of Antonella Tosti, MD.

Tinea pedis with interdigital maceration
Erythema and white, macerated skin between the toes in a patient with
tinea pedis.

Dermoscopic image of toenail onychomycosis
Onychomycosis: The proximal margin of the onycholytic area shows yellow-white

spikes projecting into the proximal nail plate.

Dermoscopic image of toenail onychomycosis
Onychomycosis: Free edge dermoscopy showing "ruined" appearance of the

subungual hyperkeratosis.

Potassium hydroxide (KOH) preparation from dermatophyte infection
Multiple septate hyphae on a background of squamous cells in a KOH preparation taken from the site of a
dermatophyte infection.
Courtesy of Beth G Goldstein, MD.

Onychomycosis
Nail clippings stained with a periodic acid-Schiff (PAS) stain showing septal hyphal elements culture prove
Trichophyton species within the nail plate keratin.
Reproduced with permission from: Rubin AI, Griffin TD. Inflammatory diseases of the nail. In: Lever's Histopathology of the Skin, 1
Elder DE, Elenitsas R, Rosenbach M, et al (Eds), Wolters Kluwer, Philadelphia 2015. Copyright © 2015 Wolters Kluwer. www.lww.com

Nail psoriasis with subungual hyperkeratosis
Marked subungual hyperkeratosis is present on several nails of this

patient with psoriasis.

reserved.

Nail psoriasis
Crumbling of the nail plate resulting in loss of part of the dystrophic nail in a patient with nail psoriasis.

Onychogryphosis
Onychogryphosis, also called "ram's horn nail," usually affects the great toenail
of older adult and neglected individuals. The nail appears thickened, yellow-brown in
color, increased in length, and distorted.
Image created by Ken Gross, MD. Reproduced with permission from: www.visualdx.com. Copyright VisualDx.
All rights reserved.

Longitudinal nail fissuring caused by lichen planus

Trachyonychia induced by lichen planus
Roughness, longitudinal ridging, and pitting of the nail plates on the fingers.

Pachyonychia congenita
Thickened, discolored nails are present in this patient with

pachyonychia congenita.

reserved.

Pachyonychia congenita
Hypertrophic nail dystrophy in a patient with pachyonychia congenita type PC-K6a.
Image used with permission of Pachyonychia Congenita Project. Copyright © 2018.

Yellow nail syndrome

Median nail dystrophy, also called median canaliform

dystrophy of Heller

Onychomatricoma

Subungual exostosis

Invasive squamous cell carcinoma of the nail

Periungual Bowen disease (squamous cell carcinoma

in situ)
Reproduced with permission from: The Dermatology Online Atlas, www.dermis.net.

Copyright © 2012. All rights reserved.

Amelanotic subungual melanoma

Nail melanoma in situ

Crusted scabies
Crusted scabies displaying subungual, scaly concretions under the toenails.

Contributor Disclosures
Adam O Goldstein, MD, MPH No relevant financial relationship(s) with ineligible companies to
disclose. Neal Bhatia, MD Grant/Research/Clinical Trial Support: Valeant Pharmaceuticals
[Onychomycosis, tinea pedis]. Consultant/Advisory Boards: Valeant Pharmaceuticals [Onychomycosis,
tinea pedis]. Speaker's Bureau: Valeant Pharmaceuticals [Onychomycosis, tinea pedis]. All of the
relevant financial relationships listed have been mitigated. Robert P Dellavalle, MD, PhD, MSPH Equity
Ownership/Stock Options: Altus Labs [Itch, eczema]. Grant/Research/Clinical Trial Support: Pfizer
[Patient decision aids, inflammatory and immune-mediated skin disease]. Other Financial Interest:
Cochrane Council meetings [Expense reimbursement]. All of the relevant financial relationships listed
have been mitigated. Moise L Levy, MD Grant/Research/Clinical Trial Support: Castle Creek Biosciences
[Epidermolysis bullosa]; Janssen Pharmaceuticals [Psoriasis]; Krystal Biotech [Epidermolysis bullosa];
Regeneron Pharmaceuticals [Atopic dermatitis]. Consultant/Advisory Boards: Abeona Therapeutics
[Epidermolysis bullosa]; Castle Creek Biosciences [Epidermolysis bullosa]; Novan [Molluscum
contagiosum treatment]; Regeneron Pharmaceuticals [Atopic dermatitis]. Other Financial Interest:
Mayne Pharma [Data and safety monitoring board for ichthyosis trial]. All of the relevant financial
relationships listed have been mitigated. Ted Rosen, MD Consultant/Advisory Boards: Almirall [Actinic
keratosis]; Beiersdorf [Dry skin]; DermTech [Melanoma]. All of the relevant financial relationships listed
have been mitigated. Abena O Ofori, MD No relevant financial relationship(s) with ineligible companies
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.
Conflict of interest policy

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7/7/23, 21:20 Onychomycosis: Epidemiology, clinical features, and diagnosis - UpToDate

Official reprint from UpToDate®

Onychomycosis: Epidemiology, clinical features, and

Literature review current through: Jun 2023.

Onychomycosis refers to chronic fungal infection of the toenails or fingernails. Causative

Onychomycosis may result from dermatophyte, yeast, or nondermatophyte mold nail

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 1/49

Trichophyton rubrum is the most frequent dermatophyte found in onychomycosis. In a review

The proportion of infections due to dermatophyte, yeast, and nondermatophyte molds

Although additional study is needed, the formation of fungal biofilms is a proposed

Onychomycosis is a common, global disorder that is estimated to account for 50 to 60

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 2/49

assessed the prevalence of culture-proven dermatophyte, yeast, and nondermatophyte mold

● Dermatologic diseases – Tinea pedis, psoriasis, hyperhidrosis

● Comorbidities – Diabetes, immunosuppression, venous insufficiency, malignancy,

● Other – Advancing age, contact with infected household members, genetic

Onychomycosis may present with a variety of nail abnormalities, such as discoloration,

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 3/49

Subtypes — The major clinical subtypes of onychomycosis are distal lateral subungual

● Distal lateral subungual onychomycosis – Distal lateral subungual onychomycosis is

● White superficial onychomycosis – White superficial onychomycosis is characterized

White superficial onychomycosis is usually caused by T. mentagrophytes, although T.

● Proximal subungual onychomycosis – Proximal subungual onychomycosis is a

Examples of organisms that may cause proximal subungual onychomycosis include T.

● Endonyx onychomycosis – Endonyx onychomycosis involves only the interior of the

Trichophyton soudanense infection is most strongly associated with endonyx

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 4/49

● Total dystrophic onychomycosis – The term "total dystrophic onychomycosis" is used

● Mixed pattern onychomycosis – Mixed pattern onychomycosis is characterized by the

Additional findings — Dermatophytoma and fungal melanonychia are additional findings

● Dermatophytoma – A dermatophytoma is a dense collection of dermatophyte hyphae

● Fungal melanonychia – Fungal melanonychia describes an uncommon form of

When caused by dematiaceous fungi (pigment-producing molds), the term "ungual

Associated dermatologic disorders — Dermatophyte infections of the skin (particularly

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 5/49

Nail disfigurement secondary to onychomycosis and associated symptoms can lead to

Overview — The diagnosis of onychomycosis begins with a focused history and physical

Typically, the approach to diagnostic testing for suspected onychomycosis consists of a

● Acquired, slowly progressive nail dystrophy

● Dystrophy of single nail or variation in the degree or progression of involvement in

invasion of dermatophytes ( picture 8) [29-31]. Other potential findings include longitudinal

Potassium hydroxide preparation — A potassium hydroxide (KOH) preparation provides

Histopathology — Histopathologic examination of nail clippings with a PAS stain is easy to

Cultures occasionally demonstrate nondermatophyte molds, which may represent true

Polymerase chain reaction — Polymerase chain reaction (PCR), a molecular technique that

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=4030… 9/49

● Dermatophyte test medium – DTM culture is cheaper than culture on Sabouraud's

● Fluorescence microscopy – Calcofluor white is a florescent brightener that selectively

Emerging diagnostic methods include an immunochromatographic strip test [46] and

It is estimated that onychomycosis is responsible for only 50 to 60 percent of abnormal

● Nail psoriasis – Subungual hyperkeratosis and onycholysis are common findings of

yellow or pink discoloration), and associated cutaneous or joint findings of psoriasis or

● Onychogryphosis – Onychogryphosis describes the development of thickened,

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Epidemiology – Onychomycosis is a common nail disorder that results from infection of

● Microbiology – Dermatophyte infection accounts for most cases of onychomycosis.

● Clinical features – Distal subungual onychomycosis is the most common clinical

Other clinical subtypes of onychomycosis include white superficial onychomycosis

● Diagnosis – Although a diagnosis of onychomycosis may be strongly suspected based

https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis/print?search=tiña de la cabeza&topicRef=403… 12/49

● Differential diagnosis – The differential diagnosis of onychomycosis includes multiple