Onychomycosis is seen frequently in individuals of all ages, and its prevalence increases with age. Patients can present with different variants of onychomycosis. The most frequent type is the distal and lateral subungual onychomycosis. Other variants include white superficial onychomycosis and proximal subungual onychomycosis. Trichophyton rubrum is the most frequent cause of all except white superficial onychomycosis, which is caused most often by Trichophyton mentagrophytes. Superficial white onychomycosis manifests with a fine, white, crumbling surface to the nail. When it is curetted off, the white areas of fungal involvement are found to affect only the outermost portion of the nail plate. The material is a combination of fungal elements and nail keratin. Therapy includes curetting the white involved portion of the nail and applying a topical antifungal agent for at least 1 month.
Distal and lateral subungual onychomycosis manifests with thickened, yellow, dystrophic appearing nails with subungual debris. There are varying amounts of onycholysis (nail plate lifting off the nail bed). One nail may be solitarily involved but it is more common for several nails to be involved and for the surrounding skin to be involved with tinea manuum or tinea unguium. Fungal nail infections are much more frequently seen on the toenails than on the fingernails. The nails can become painful, especially with ambulation. Occasionally, the entire nail is shed as a result of significant onycholysis, and the nail that regrows will again be involved with onychomycosis. The thick and dystrophic nails may become a passage for bacterial invasion of the body. This is especially true in patients with diabetes. Bacteria can gain entrance into the skin and soft tissue via the abnormal barrier between nail and nail fold, and this can lead to paronychia, felon, and the most serious complication, cellulitis. Distal and lateral subungual onychomycosis almost always needs to be treated with an oral antifungal medication for any chance of a cure. Topical agents may be helpful in limited nail disease, but their use is typically limited to an adjunctive role. Oral azole antifungals, griseofulvin, and terbinafine have all been used, with similar results.
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