RISK FACTORS: Dermatophytes - Warmth, moisture, hyperhidrosis, Tight fitting shoes, rubber shoes, Peripheral vascular disease, Depressed cell-mediated immunity,Indirect contamination
. Candidal - Direct contamination - ano-vulvar
RISK FACTORS
. Dermatophytes
. Warmth, moisture, hyperhidrosis
. Tight fitting shoes, rubber shoes
. Peripheral vascular disease
. Depressed cell-mediated immunity
. Indirect contamination
. Candidal
. Direct contamination - ano-vulvar, perirectal pruritus
. Chemical or mechanical damage to cuticle
. Maceration or occlusion
. Contact with substances containing sugar
. Hyperhidrosis
. Chilblain
. Cold hands (Raynaud phenomenon)
. Psoriatic onycholysis
. Diabetes mellitus
. Hyperparathyroidism
. Addison disease
. Malnutrition
. Malabsorption
. Dyscrasias
. Malignancies
. Postoperative conditions
. Altered immune function
. Molds
. Soil contamination
. Peripheral vascular disease
. Overlapping toes
. Onychogryphosis (deforming overgrowth of nails resulting in hooked or curved state)
GENERAL MEASURES
• Avoid factors that promote fungal growth (heat, moisture)
• Treat underlying disease risk factors
• Treat other fungal infections
• Treat secondary infections
SURGICAL MEASURES
. Nail removal to remove infected keratin
. Mechanical: soften with occlusive dressing with 40% urea gel, detach from nailbed with tweezers or file
with abrasive paper/grinding stone
. Chemical: protect peripheral tissue with adhesive strips, apply ointment of 30% salicylic acid, 40% urea or 50% potassium iodide under occlusive dressing
. Surgical avulsion: for involvement of a few nails
ACTIVITY Restrictions based on promoting factors, underlying disease or secondary infection
DRUG(S) OF CHOICE
. Dermatophytes - local: Less effective than systemic, apply under occlusive dressing, may mix with keratinolytic chemicals
. Imidazoles: Clotrimazole (Lotrimin, Mycelex), miconazole (Monistat), butoconazole, tioconazole, econazole (Spectazole), ketoconazole (Nizoral), sulconazole (Exelderm), oxiconazole (Oxistat), terbinafine (Lamisil)
. Unsaturated fatty acid derivatives: Propionic acid, undecylenic acid; haloprogin (Halotex); tolnaftate (Tinactin)
. Ciclopirox (Penlac) 8% topical lacquer for patients without lunula involvement
. Amorolfine (Loceryl) 5% lacquer
. Dermatophytes - systemic:
. Fluconazole (Difl ucan) 300 mg po weekly for 6 months (pulse therapy), overall better tolerated than
ketoconazole; expensive; reserve for extreme cases (disseminated disease, immunocompromised)
. Itraconazole (Sporanox): 200 mg po bid for a week per month for 2 months for fingernails and 3-4 months for toenails (pulse therapy)
. Terbinafine (Lamisil) 250 mg po qd for 3 months
. Candida:
. Imidazole derivative
. If bacterial infection present, use antibacterial plus anti-Candidal, e.g., nystatin (Mycostatin), topical
amphotericin B (Fungizone), itraconazole (Sporanox) 200 mg po qd for 3 months, or fl uconazole 300 mg po
weekly for 6 months (pulse therapy)
. Mold:
. 1% iodinated alcohol, benzoic acid, (Whitfields ointment), silver nitrate, glutaraldehyde, imidazole
derivatives, itraconazole
ALTERNATIVE DRUGS
• Dermatophytes - local: ciclopirox (Loprox, Penlac), naftifine (Naftin), cationic surfactants, e.g., benzalkonium
chloride (Cetylcide), cetrimide, cetylpyridinium chloride (Ony-Clear, Fungoid)], halogenated / chlorinated / iodinated derivatives [chloramine, tincture of iodine], dyes [malachite green, crystal violet], mercury derivatives
[thimerosal], phenols, glutaraldehyde
• Dermatophytes - systemic: griseofulvin (Fulvicin, Gris-PEG, Grisactin) ultramicrosize, usual adult dose 250-500 mg bid with meals for 6-12 month
PATIENT MONITORING
• Topical agents: slow response expected; visits q 6-12 weeks
• Griseofulvin: CBC and liver function tests initially, then q 3 months
• Ketoconazole: liver function tests q 3 weeks for the first 3 months, then monthly
• Itraconazole and fluconazole - liver function tests at start and at 4 weeks
• Terbinafine - liver function and hematologic tests at start and at 4 weeks
• Treatment duration (months): fi ngernails 6-9, toenails 9-12, great toenail 12-24
PREVENTION/AVOIDANCE
• Keep affected area clean and dry
• Avoid rubber or other occlusive footwear
• Avoid tight or ill-fi tting footwear
• Wear absorbent cotton socks - avoid wool or synthetic fibers
• Change clothing and towels frequently and launder in hot water
POSSIBLE COMPLICATIONS
• Secondary infections with progression to cellulitis/osteomyelitis
EXPECTED COURSE/PROGNOSIS
• Relapse common; prognosis especially poor if one hand, 2 feet or multiple nails involved
• 20-40% of nails fail to respond
• 40-70% of patients show long term relapse