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Onychomycosis or Tinea Unguntum indicates fungal infection of the nail. It occurs in 10 percent of general population. Its prevalence may be more in hot and humid climates. It constitutes half of all nail abnormalities. It is rare in children and most common in the elderly. Males are more affected compared to the females. Onychomycosis is more common in immune compromised persons, persons taking immune-suppressant drugs following organ transplantation and in persons suffering from diabetes mellitus, malignant disease & Peripherial vascular disease. It is the most common disorder of the nail. Early diagnosis of the condition is the key of treatment -success. However in many cases re-occurrence is noticed. In spite of prolonged treatment, sometimes complete cure may not be obtained.
SYMPTOMS & SIGNS
Onychomycosis causes discoloration, thickening, disfiguration and separation from nail bed. Affected finger nail or toe nail loses its normal brightness. It may become brittle. Color may become off white, greenish, brownish or black. There may be crust formation below the nail bed. Foul smell may come from the nail. There is usually no pain unless disease becomes severe. At one stage discomfort of the nail may give some amount of pain sensation. Patient becomes mentally nervous or psychologically upset and there is loss of working capability of the person concerned. Initially onychomycosis was considered as a cosmetic problem, but now a day much importance is given on its treatment. This fungal disorder may cause employment – related problems.
Most common dermatophytes (fungi) involved in onychomycosis are Trychophyton rubrum and Trychophyton mentagophytes. Candida and other non-dermatophytic molds of the tropics may be the other pathogen to produce such condition of the finger nail and toe nail.
Paronychea, Psoriasis, contact dermatitis, chronic dermatitis, Lichen planus, Bowen disease, 20 nail dystrophy, Tumors of the nail (Fibroma, Mellanoma) are some similar condition which may look like fungal infection of the nail.
Diagnosis may be confirmed by demonstrating fungus under microscope from the affected nail. For this purpose affected nail should be cleaned of dust, debris & bacteria by using alcohol swab, then a small piece may be cut to look under the microscope. There are many other methods for confirmation of diagnosis. Viz. Biopsy, Histology, Culture, acid Schiff stain etc.
SUBTYPES OF ONYCHOMYCOSIS
Distal subungual onychomycosis (DSO) is the commonest type where Trychophyton rubrum invades nail bed.
White superficial onychomycosis (WSO) account for 10 percent of onychomycosis cases. In this condition there is invasion of superficial layers of nail plate.
Proximal subungual onychomysosis (PSO) is noticed in immune-compromised patients.
Endonyx onychomycosis (EO)
Candidal onychomycosis – generally precipated by infection or trauma. Person handling water frequently for longer duration are more prone to it.
ORAL / SYSTEMIC – Antifungal drug Griseofulvin was invented in 1939. It is a useful and effective drug, but may have the following side effects viz. reduce effectiveness of oral contraceptives, lack of concentration, confusion, headache, urticaria, diarrhea, insomnia, oral thrush etc.
Amongest a long list of antifungal drugs the following have become more popular viz. Amphotericin B, Fluconazole, Ketoconazole, Miconazole, Itraconazole, Nystatin. These drugs may have many side effects and drug interactions. Hence these drugs are not to be used in patients suffering from Cardiac and Hepatic disorders.
TOPICAL – Nystatin, Tolnaftate, Terbinafine, Ketoconazloe, Miconazole, Econazole, Ciclopirox, Sertaconazole, Tavaborate, Efinaconazole, Cotrimazole,Undercylenic acid, Salycylic acid with sodium disulphate, Butenafine,Naftifine etc.
SURGICAL – Part of damaged nail may be cut by a surgeon or a dermatologist.
LASER – Now a day by laser therapy attempt is made to destroy the nail fungus.
Generally in the treatment of tinea unguentum better result is obtained by applying a combination of oral, topical and surgical management. Nail comprises of hard keratin material and it is of low vascularity & impermeable to the fluids. Hence treatment of onychomycosis may require several months time and in spite of that sometimes it becomes difficult to get a cent percent cure.
Urea cream may be used of softening the nail.
Hydrogen peroxide and alcohol may be used to clean the nail from dirt and bacteria.
~Dr Bhupen Saikia,
Doha, Qatar; 21 January 2017
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