ONYCHOMYCOSIS

Question 1

Acquired through direct contact of the nail with dermatophytes, yeast, or non-dermatophyte molds in the environment or through spread of fungal infection from affected skin

Answer 1

Onychomycosis

Question 2

Predisposing Factors

Answer 2

(1) Tinea pedis, psoriasis, hyperhidrosis, obesity, advancing age, contact with infected household members.
(2) Trauma, poor nail grooming, sports & fitness activities, occlusive shoes.
(3) Most often occurs in adults & the elderly; not common in younger patients.
(4) Distal subungual onychomycosis is the most common presentation
(5) Begins with white/yellow/brown discoloration of distal corner of nail that gradually spreads to the entire nail width, moving proximally.

Question 3

. Common clinical manifestations include:

Answer 3

(1) Nail discoloration, subungual hyperkeratosis, onycholysis (raised nail beds), splitting of the nail plate, and nail plate destruction
(2) Most patient concerns are based on cosmetic appearance and not functional deficit.

Question 4

Pretreatment diagnostic testing:

Answer 4

(a) Confirmation of infection is required prior to treatment due to potential for liver toxicity of treatment with oral antifungals.
(b) Potassium hydroxide (KOH) preparation (confirms presence of infection) and fungal culture (determines the type/species of the actual infecting organism).
(c) Treatment is not done on deployment due to inability to perform LFT testing.
(d) Oral antifungal therapy is considered the gold standard for onychomycosis; higher complete cure rates & shorter course of treatment compared with topical therapy.**
(e) Topical antifungal agents are poorly effective for onychomycosis because of poor penetration of the nail plate

Question 5

Differential diagnosis

Answer 5

(1) Psoriasis
(2) Eczema
(3) Onycholysis

Question 6

Labs/studies/imaging:

Answer 6

(1) KOH & fungal culture required to begin treatment

Question 7

Disposition

Answer 7

(1) Full Duty
(2) Get KOH & fungal culture
(3) If both positive, and patient desires treatment, consult to dermatology and/or podiatry.

Question 8

Complications

Answer 8

Cosmesis

transmission of fungal infection to other body sites, concurrent tinea pedis.