Onychomycosis and its treatment – nail disorders creative ways to make money

Fungi (table 8.1) include dermatophytes (most frequently trichophyton rubrum), moulds (scytalidium spp., scopulariopsis spp., fusarium spp., acremonium spp., onychocola canadensis) and yeasts (candida spp.). The skin of the palms and soles is frequently involved, especially in dermatophytic infections with plantar scaling (figure 8.2). Tinea cruris is common in patients with onychomycosis due to creative ways to make money T. Rubrum and epidermophyton floccosum (see figure 8.7).

Toe nails are most frequently affected (figure 8.3). Finger nail infection is usually associated with toe nail infection, often presenting as the ‘one hand, two feet’ syndrome. Clinically the nail shows distal subungual hyperkeratosis and onycholysis; the onycholytic area appears yellow-white. Proximal spreading frequently occurs along longitudinal streaks. In some cases the nail plate is partially absent, the detached nail having been clipped by the patient (figure 8.4).

Yellow streaks along the lateral margin of the nail and/or the presence of yellow onycholytic areas in the central creative ways to make money portion of the nail (dermatophytoma) are associated with poor response to systemic antifungal medication. A poor prognosis is also reported for onychomycosis due to creative ways to make money some moulds such as scytalidium, scopulariopsis and fusarium, or for onychomycosis due to T. Rubrum var. Melanoides. The latter dermatophyte produces black pigmentation of the nail due creative ways to make money to direct production of melanin-related pigment by the fungus (figure 8.9).

By trichophyton rubrum in people infected with human immunodeficiency virus creative ways to make money (HIV). Finger nail invasion is rare. Proximal subungual onychomycosis presents as an area of leukonychia in creative ways to make money the proximal portion of the nail plate; the leukonychia is due to the presence of fungal elements creative ways to make money in the ventral portion of the proximal nail plate. The nail plate surface is normal. When PSO is caused by moulds, the periungual tissues are frequently inflamed and the condition may creative ways to make money closely resemble a bacterial infection. A purulent discharge may be present, especially in aspergillus infection. When PSO affects finger nails or the thin nails of creative ways to make money children, fungal invasion may spread to the dorsal nail layers, resulting in opacity and fragility of the superficial nail plate. This has been frequently reported under the diagnosis of ‘white superficial onychomycosis’.

Direct microscopic examination of the specimens can be performed using creative ways to make money potassium hydroxide preparations. Nail debris is placed on a glass slide and a creative ways to make money drop of a 40% KOH solution with ink (3 ml of KOH solution mixed with 1 cartridge of creative ways to make money ink) added. After applying a cover-slip, the slide is placed in a moist chamber for 2 creative ways to make money hours to permit clearing of the keratin; it is then viewed under a microscope (figures 8.26-8.28). A formulation of KOH and dimethylsulphoxide (DMSO) provides faster clearing of the specimen. Samples are cultured in sabouraud’s medium with 0.05% chloramphenicol with or without 0.4% cycloheximide, incubated at 26-28°C for 2-3 weeks. Gross colony morphology and microscopic examination of the mycelia stained creative ways to make money with lactophenol cotton blue permit the identification of the causative creative ways to make money fungus (figures 8.29-8.31).

Skin lesions is advisable since these usually give profuse dermatophyte creative ways to make money growth. Diagnosis of onychomycosis due to moulds requires a strict correlation creative ways to make money between clinical picture and mycological results. Isolation of a mould from culture is not a sufficient creative ways to make money criterion to make the diagnosis, since moulds may be contaminants or secondary colonizers of the creative ways to make money nail as well as laboratory contaminants.

Differentiating between onychomycosis and psoriasis can be difficult since subungual creative ways to make money hyperkeratosis, onycholysis, splinter haemorrhages and diffuse nail ‘crumbling’ are clinical signs of both conditions. Moreover, dermatophytes or other fungi can occasionally colonize psoriatic nails, especially when the nail plate is grossly deformed. Therefore, positive culture does not exclude the diagnosis of psoriasis. TREATMENT

Except for superficial onychomycosis, which can be treated with any topical antifungal agent after creative ways to make money scraping of the affected areas, treatment of dermatophyte onychomycosis usually requires systemic antifungal therapy. However, when only the distal nail is affected and the patient’s general condition makes systemic treatment questionable, topical therapy using the transungual drug delivery system (TUDDS) can be tried, using daily 8% ciclopirox or weekly 5% amorolfine nail lacquer. Therapy should be continued for at least 6 months in creative ways to make money finger nail onychomycosis and 12 months in toe nail infection: 8% ciclopirox once daily, 5% amorolfine nail lacquer once or twice weekly. A combination of bifonazole 1 % in a 40% urea ointment is a possible alternative.

Formerly oral treatment of onychomycosis consisted of two antifungal drugs: griseofulvin and ketoconazole, the latter being rarely used in recent years because of creative ways to make money its hepatotoxicity. Treatment of onychomycosis with griseofulvin, however, requires long-term administration of the drug (6 months for finger nails, up to 18 months for toe nails), and high drug dosages (up to 2 g per day). Toe nail infection often fails to respond and recurrence is creative ways to make money common. Three new systemic antimycotic agents have now been introduced: fluconazole, itraconazole and terbinafine. All these drugs have been shown to reach the distal creative ways to make money nail soon after therapy is started and to persist in creative ways to make money the nail plate for long periods (2-6 months) after the end of treatment. The persistence of high drug levels in the nail following creative ways to make money treatment allows for shorter treatment periods with fewer relapses and creative ways to make money side-effects. Partial nail avulsion and concomitant treatment with a topical antifungal creative ways to make money agent further reduce relapses and shorten the duration of treatment. Onychomycosis of the toe nails is more difficult to cure creative ways to make money and recurs more frequently than onychomycosis of the finger nails.

Fluconazole and itraconazole are triazole derivatives with a broad spectrum creative ways to make money of fungistatic activity. Itraconazole is effective at dosages of 200 mg per day creative ways to make money for 2-4 months. This agent has been shown to be effective even when creative ways to make money given as intermittent therapy (400 mg daily for 1 week every month for 3-6 months). Terbinafine is an allylamine derivative with primary fungicidal properties against creative ways to make money dermatophytes. This drug is probably more effective and safer than other creative ways to make money antimycotics for long-term treatment of onychomycosis due to dermatophytes. Recommended dosage is 250 mg per day for 2 months creative ways to make money (finger nails) to 4 months (toe nails). Preliminary studies show that terbinafine may also be effective at creative ways to make money the dosage of 500 mg daily for 1 week a creative ways to make money month (intermittent therapy).

Phenomenon since topical or systemic antimycotics do not cure the creative ways to make money nail abnormalities. Nail invasion by candida albicans usually indicates an underlying immunological creative ways to make money defect (figure 8.32) and is almost exclusively seen in chronic mucocutaneous candidiasis; in the latter, candida albicans invasion of the nail plate is associated with creative ways to make money an inflammatory reaction of the proximal nail fold, nail matrix, nail bed and hyponychium (figure 8.33). The affected digits have a bulbous appearence with erythema and creative ways to make money swelling of the proximal and lateral nail folds. The nail bed is hyperkeratotic and the nail plate is creative ways to make money thickened and highly dystrophic owing to diffuse ‘crumbling’. Complete destruction of the nail plate is commonly observed (figure 8.34). Oral candidiasis is present in almost all patients (figure 8.35). Diagnosis

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