Tinea unguium

Last Updated: 2023-07-07

Author(s): Anzengruber F., Navarini A.

ICD11: 1F28.1

  • Lichen ruber planus
  • Plaque-type psoriasis
  • Acrodermatitis chronica atrophicans
  • Atopic eczema
  • Paronychia (acute, chronic, superficial and deep)
  • Candida paronychia
  • Allergic contact dermatitis
  • Cumulative-toxic hand eczema
  • Malignant melanoma (pigm./amelanot.)
  • Pityriasis rubra pilaris Devergie
  • Pseudomonas infections

  • Meissner, 1853
  • Virchow, 1854

Onychomycosis, nail mycosis, nail fungus.

  • Fungal infection of the nails
  • If the nail is infected with dermatophytes alone, it is called "tinea unguium". If yeasts or moulds infect the nail (or in the case of a mixed infection), it is an "onychomycosis"

Division

  • Distal subungual onychomycosis (DSOM): most common type.
  • Proximal subungual type (PSOM).
  • White superficial onychomycosis (WOOM).
  • Onychomycosis due to moulds.
  • Onychomycosis due to Candida (Paronychia candidamycetica).
  • Total dystrophic onychomycosis.
  • Leukonychia trichophytica: whitish, superficial onychomycosis (usually caused by tryichophytes).
  • Dystrophic onychomycosis: classic form seen in chronic mucocutaneous candidiasis.
  • Onychia et Paronychia candidosa: usually caused by Candida albicans and is associated with chronic inflammation of the proximal and lateral nail wall. Discolouration and transverse grooves are seen

"Immune phenomena in dermatophytoses

  • When the human organism is attacked by dermatophytes, antibodies are formed in the skin. This can be detected by means of intradermal testing.
  • A type I or type IV reaction may occur after injection of (trichophytin)

  • Incidence (Europe/USA): approx. 20%
  • Incidence (Europe/USA) > 65 y.: up to 45%

  • Exciter
    • Approximately 99% of all fungal nail infections are dermatophytes
    • Mostly:
      • Trichophyton rubrum (dermatophyte)
      • Trichophyton mentagrophytes (dermatophyte)
      • Candida albicans (yeast)
      • Candida tropicalis (yeast)
      • Scopulariopsis brevicaulis (mould)
      • Aspergillus niger (mould)
      • Hendersonula toruloidea (mould)
  • In most cases, tinea pedis already exists. The pathogens enter the nail bed via the hyponychium
  • In bakers, onychomycosis due to Candida may occur more frequently than in the normal population. The increased moisture work and nutrient supply provide a suitable environment for yeast fungi
  • The toenails are affected significantly more often than the fingernails
  • Predisposing factors
    • Trauma (CAVE too tight/short shoes)
    • Anatomical anomalies
    • ↓ Blood circulation (articular, venous)
    • Disorders of lymphatic drainage
    • Neuropathies
    • Diabetes mellitus
    • Immune suppression
    • Tinea pedum

  • After the fungi have invaded the nail bed via the hyponychium, the subungunal hyperkeratosis causes the nail plate to detach (onycholysis semilunaris)
  • A yellow discolouration is called "dyschromasia"
  • The term "green nail syndrome" is used for secondary infestation with Pseudomonas aeruginosa
  • ↑ subungual keratosis à crumb nails (onychodystrophy)

  • Nail material removal:
  • Disinfection with 70% alcohol
  • As proximal as possible!
  • Curettage technique
  • Native and culture!
  • Histological examination!

In case of pos. findings for moulds:

  • Repeat 3 times (only if no dermatophytes can be detected 3 times is onychomycosis due to moulds to be assumed)

  • Success rate: 50%
  • Recurrence rates: 5%-20% or 40% (grisefulvin)

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