Multiple nails

16: Multiple nails


Many nail findings affect multiple nails. These nail findings typically reflect infectious or systemic inflammatory conditions. This chapter includes discussions of onychomycosis, nail splitting, drug eruptions, nail psoriasis, and nail lichen planus.

Key terms:


Beau’s lines

nail splitting

drug eruptions

nail psoriasis




Douglas Albreski

Clinical features

A fungal infection of the nail, referred to as “onychomycosis” or “tinea unguium,” is an infection of the nail in which the organism changes the structure and shape of the nail plate, leading to thickening, changes in appearance, and/or discoloration. Changes in appearance are dependent on the organism and site of infection.

Differential diagnosis

The differential for onychomycosis includes inflammatory nail dystrophy, bacterial nail infections, traumatic onychodystrophy, nail bed or osseous tumors, yellow nail syndrome, malignancies of the nail unit, and uncommon nail conditions like idiopathic onycholysis. Similar symptoms can sometimes also result from the use of certain drugs.


Onychomycosis requires disease confirmation by way of laboratory diagnosis because of the varying treatment options and differing lengths of therapies. Topical agents may require up to a year of therapy. Meanwhile, oral agents tend to be safe but can have various medical contraindications and potential drug interactions.

Initial steps in management

Treatment options vary; the two most common methods involve topical agents and oral antifungal medications. A decision on treatment course is determined by the patient’s medical history, drug interactions, and patient compliance with the recommended course of treatment. Topical treatments are lengthy and less successful; oral medications have shorter therapeutic courses and higher success rates but carry a higher risk for an adverse medical outcome.

Oral antifungal agents

The most common oral antifungal agents are terbinafine and itraconazole.

Topical antifungal agents

Topical antifungal agents are commonly used when there is minimal disease, only a few nails are involved, and/or underlying medical concerns contraindicate the use of oral agents. Unlike oral antifungal agents, topicals have poorer penetration, resulting in lower effectiveness. Topical agents also have a higher incidence of contact dermatitis and skin irritation. On the other hand, topical agents can be used and are highly successful in the treatment of white superficial onychomycosis because of the excellent drug-to-fungal exposure. Nevertheless, many insurances will not cover the cost of these preparations and the patient will have to pay out of pocket. The most efficacious, and common, topical antifungal nail solutions available are efinaconazole, tavaborole, and ciclopirox.

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Jul 22, 2021 | Posted by in Dermatology | Comments Off on Multiple nails

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