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Onychomycosis

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Onychomycosis

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TypeFindings/ DistributionDiagnostic CluesManagement
* See Potential ARV Interactions, below, and Common Medications.
Distal subungual onychomycosis (see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)

Infection with Trichophyton rubrum in vast majority of cases

Affects great toe first; can affect all toes

Begins with discoloration of distal corner of nail, spreads across nail, then extends toward cuticle

Distal nail plate can break off, becoming heaped and irregular

Culture: most sensitive and specific

KOH preparation: clip or file nail-plate and collect scales from most proximal area

Look for hyphae and arthrospores

Low sensitivity and specificity, but up to 100% sensitive if >2 preparations examined

If negative, consider biopsy for histopathology

Indications for treatment: cellulitis, pain, patient desire for treatment

Oral therapies* (in order of decreasing efficacy), pulse dosing:

  • Terbinafine 250 mg QD for 1 week each month
  • Itraconazole 200 mg QD for 1 week each month
  • Fluconazole 150 mg once weekly
Treat 2 months (fingernails), 3-4 months (toenails)

Fluconazole 400 mg once weekly for 6 months has shown efficacy in immunocompromised patients; fluconazole has fewer drug interactions than itraconazole

Cure rates range from 76% with terbinafine to 48% with fluconazole

Topical therapies generally ineffective; ciclopirox topical nail lacquer can be used with patients who cannot safely take oral therapy; trials show 7% cure rate

Surgery: removal of nail in isolated nail infection or dermatophytoma

See Potential ARV Interactions, below, and Common Medications.

Proximal subungual onychomycosis

Trichophyton rubrum most common

Marker of HIV infection, immunocompromised state

Discoloration begins at cuticle and extends distallySame as aboveSame as above
White superficial onychomycosis

Trichophytonmentagrophytes most common

Starts as dull white spots, then spreads centrifugallyWhite areas are soft and can be scraped with a curette for culture or KOH slideSame as above
Candida onychomycosis

Candida albicans

More common in patients with HIV infection

Common cause of fingernail infection

Often in previously damaged nails

Rarely in toenails

Nail thickening and discoloration

Can lead to onycholysis

Fingernail scraping should be sent for culture of yeastOral therapies (in order of decreasing efficacy), pulse dosing:

  • Itraconazole 200 mg QD for 1 week each month
  • Terbinafine 250 mg QD for 1 week each month
Treat 2 months (fingernails), 3 months (toenails)

Mold (eg, Aspergillus, Scopulariopsis)Rare cause of toenail infectionConsider when dermatophyte infection is ruled outOral therapies (in order of decreasing efficacy), pulse dosing:

  • Itraconazole 200 mg QD for 1 week each month
  • Terbinafine 250 mg QD for 1 week each month
Treat 2 months (fingernails), 3 months (toenails)

From Dermatologic Conditions
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009