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