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8lngworm 1lnea ungulum (fungal lnfecLlon of Lhe nalls) ls somewhaL uncommon durlng chlldhood

AfLer puberLy lLs frequency lncreases wlLh age usually onychomycosls ls assoclaLed wlLh Llnea
pedls lungal culLure of Lhe nalls ls someLlmes dlfflculL buL exLremely lmporLanL ln conflrmlng Lhe
dlagnosls Cnychomycosls ls Lhe mosL dlfflculL of Lhe superflclal fungal lnfecLlons Lo LreaL because
Lhe nall plaLe ls noL peneLraLed by (mosL) Loplcally applled agenLs SysLemlc anLlfungal agenLs such as
lLraconazole and Lerblnaflne appear effecLlve ln Lhe LreaLmenL of onychomycosls 1he lllusLraLlons
show lnfecLlon wlLh dermaLophyLes noLe Lhe dlsLorLlon of nall plaLes lnfecLlon by dermaLophyLes
usually proceeds ln a dlsLalLoproxlmal dlrecLlon lnfecLlon of nalls by C alblcans ls dlfferenL ln LhaL lL
ls more acuLe (frequenLly purulenL) and Lends flrsL Lo lnvolve Lhe laLeral and proxlmal nall folds

Cnychomycosls from
1 tobtom wlLh
secondary bacLerlal lnfecLlon

CompleLe nall

nall lnfecLlon
due Lo ,ntospotom
nfs (rare)

Clinical features
Onychomycosis may aIIect one or more toenails and/or Iingernails and most oIten involves
the great toenail or the little toenail. It can present in one or several diIIerent patterns:
O ateral onychomycosis. A white or yellow opaque streak appears at one side oI the
O $ubungual hyperkeratosis. $caling occurs under the nail.
O istal onycholysis. The end oI the nail liIts up. The Iree edge oIten crumbles.
O $uperIicial white onychomycosis. Flaky white patches and pits appear on the top oI
the nail plate.
O !roximal onychomycosis. Yellow spots appear in the halI-moon (lunula).
O omplete destruction oI the nail.
Tinea unguium oIten results Irom untreated tinea pedis (Ieet) or tinea manuum (hand). It may
Iollow an injury to the nail.
andida inIection oI the nail plate generally results Irom paronychia and starts near the nail
Iold (the cuticle). The nail Iold is swollen and red, liIted oII the nail plate. White, yellow,
green or black marks appear on the nearby nail and spread. The nail may liIt oII its bed and is
tender iI you press on it.
Mould inIections are usually indistinguishable Irom tinea unguium.
Onychomycosis must be distinguished Irom other nail disorders such as:
O acterial inIection especially !seudomonas aeruginosa, which turns the nail black or
O !soriasis.
O czema or dermatitis.
O ichen planus.
O 'iral warts.
O Onycholysis
O Onychogryphosis (nail thickening and scaling under the nail), common in the elderly.
ail clippings
lippings should be taken Irom crumbling tissue at the end oI the inIected nail. The
discoloured surIace oI the nails can be scraped oII. The debris can be scooped out Irom under
the nail.
!revious treatment can reduce the chance oI growing the Iungus successIully in culture so it
is best to take the clippings beIore any treatment is commenced:
O To conIirm the diagnosis - antiIungal treatment will not be successIul iI there is
another explanation Ior the nail condition.
O To identiIy the responsible organism. Moulds and yeasts may require diIIerent
treatment Irom dermatophyte Iungi.
O Treatment may be required Ior a prolonged period and is expensive. !artially treated
inIection may be impossible to prove Ior many months as antiIungal drugs can be
detected even a year later.
Fingernail inIections are usually cured more quickly and eIIectively than toenail inIections.
Mild inIections aIIecting less than 80 oI one or two nails may respond to topical antiIungal
medications but cure usually requires an oral antiIungal medication Ior several months.
ombined topical and oral treatment is probably the most eIIective regime.
Recently, laser treatment has become available in New Zealand and elsewhere to treat
onychomycosis unsuitable Ior or resistant to antiIungal medications. There are at least three
types oI toenail laser, all emitting inIrared radiation. aser treatment is reported to saIely
eradicate nail Iungi with one to three, almost painless, sessions. However, laser treatment Ior
Iungal nail inIection is not yet FA approved and it is as yet unclear how well it works.