Mom brings her 5 year old in with this.

ONYCHOMYCOSIS

Onychomycosis is infection of the nail by a fungus and is the most common nail disease.

• Some studies show a prevalence in the adult population of 5%.
• Onychomycosis is many times more common of the toenails than fingernails.
• When an older patient presents with several deformed or misshapen toenails, it may be impossible to distinguish by examination alone onychomycosis from old age.
  
• One study of patients over 60 found that 66% of patients had dystrophic nails suggestive of onychomycosis but culture showed that only 40% actually were infected.
• Either KOH, culture or PAS staining of the nail plate may be necessary to diagnosis onychomycosis.

Treatment

Oral terbinafine for 6 weeks (fingernails) or 12 weeks (toenails) is the most effective. Topical antifungals have a low cure rate but may be tried for minimal disease.

The risk of liver damage is extremely low. Clinically apparent liver injury from terbinafine treatment occurs in 1 per 50,000 to 120,000 cases. Asymptomatic elevations in liver enzymes occur in < 1% of patients.

If cure is obtained, measures to prevent reinfection should be taken. See here.

Additional Pictures

Distal subungual onychomycosis (DSO) is the most common pattern of fungal infection of the nail.

Here, the clinician is using a currette to obtain subungual debris for culture.

Superficial white onychomycosis is a pattern of infection on the surface of the nail. The clinical appearance is that of a powdery, rough nail surface.

In endonyx onychomycosis, there is only color change of the nail plate (usually milky white) without onycholysis nor buildup of subungual debris.

The pattern of some nails dystrophic and other nails normal is a helpful clue to fungal infection.

Old age nails. NOT onychomycosis.

RegionalDerm

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