Fungal skin infections

Learning objectives

• How to identify and manage tinea ungums

Clinical features

Tinea interdigital and Trichophyton rubrum are the most common causes of trichophyton ungums. Loceryl Nail Lacquer is important to distinguish it from other forms of onychomycosis.

• Candida species can often cause paronychia
• Molds including Scopulariopsis brevicaulis, Fusarium spp., Aspergillus spp., Alternaria, Acremonium, Scytalidinium dimidiate and Scytalidinium hyaline

Tinea-ungums is becoming more prevalent with increasing age. It may affect one or several toenails, and/or fingernails. It most commonly involves the great and the little toenails. It is sometimes confused with non-infected dystrophy as a result of skin disease, such as psoriasis, lichen planus and viral warts.

It can take many forms:

• Lateral onychomycosis. An opaque white or yellow streak appears on one side.
• Subungual hyperkeratosis. Scaling happens under the nail.
• Distal onychosis. The nail ends lift up. The free edge can often fall off.
• Superficial white onychomycosis. Flaky white pits and patches appear at the top of the nails plate.
• Proximal onychomycosis. The half-moon ( , lunula), shows yellow spots.
• Total destruction of the nails

Onychomycosis

Onychomycosis could look similar to nail dystrophy that is caused by trauma. Fungal infection occurs quite often in damaged nails. Therefore, antifungal therapy doesn't always return the nail back to normal, even though culture is positive.

Nail clippings

The infected nails should be clipped from any crumbling tissue. Scrape off the nail's discolored surface. The nail can be removed from the ground by scooping up the debris.

The chance of successfully growing the fungus in culture can be reduced by previous treatment. Make sure you clip your clips before starting treatment.

• Antifungal treatment won't be effective if another reason is given for the nail condition.
• To determine the responsible organism molds or yeasts may need different treatment from dermatophytefungi.

Treatment

Mild infection less severe than 80% can be treated with topic antifungal medicines. But, for most cases, an oral antifungal medication will be required. Most fingernail infection can be treated faster than those in the toes.

Treatment is often not indicated because effective drugs are costly.

• Even though culture is positive, nail disease might not be due to fungal infection
• The infection might be asymptomatic
• It is possible that the patient does not wish to swallow or apply medication.
• Elderly people are more likely to fail than others.
• Antifungal medications can cause severe allergies, and even death.
• Drug interactions can have serious consequences

Nail plate infections can be treated with topical antifungals twice per week for 6-12 months.

• Amorolfine nail varnish
• Ciclopirox nail lacquer

Specialist approval is required for the subsidy of Azole oral Antifungals. These antifungals should not be used during pregnancy. The treatment can be completed in 6-12 weeks (fingernails), or 3-6 month (toenails).

• Terbinafine 250mg Tablets once daily
• Itraconazole 100mg Capsules, 200mg daily or 200mg bid 7 days a month

The removal of the nail is usually not necessary, but it might be considered in extreme cases. The procedure can be unpleasant and painful. Chemical evulsion is possible by using urea glue under Occlusion, and then repeating as needed. It can take several months for the nail's to regrow.

Activity

Calculate the prevalence for fungal infections of the toenails among your patients. The next 20 adults you meet should inspect their feet.