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Arisal

(1102070049)

Nahdhiah Zainuddin

(1102090114)

ADVISOR :

dr. Fitri Kadarsih Bandjar

SUPERVISOR :

dr. Widya Widita, Sp.KK, M.Kes

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Onychomychosis infection of the nail

caused by dermatophytes, yeast or

moulds.

Tinea unguium refers to infection of

the nail caused by a dermatophyte

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The incidence of onychomycosis 2-13%

in North America.

A multicenter survey in Canada showed 6.5%

Age : incidence increase with advancing

age, range 40-60 years old assosiatedwith tinea pedis & tinea manus

Sex : affects males > females

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Risk facktor :

Diabetes mellitus

Suppresed immune system

Increasing age

Trauma to the nail

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Most frequent etiologic :

Trichophyton rubrum Trichophyton mentagrophytes

var.interdigitable

Very rare etiologic : Epidermophyton floccosum

Trichophyton violaceum

Trichophyton schoenleinii

Trichophyton verrucosum (generally only at

nail finger)

Trichophyton tonsurans

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Dermatophyte infections involve three

main steps :

Adherence to keratinocytes

Penetration through and between cells

Development of a host response

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Patients usually first present for

cosmetic.

Patients may report pain, discomfort,

permanent damage to the nail.

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Dermatophyte infections occur in pattern :

Distal Lateral Subungual Onychomycosis

(DLSO)

White Superficial Onychomycosis (WSO) Proximal Subungual Onychomycosis

(PSO)

Endonyx Onychomycosis

Total Dystrophic Onychomycosis

True Candida Onychomycosis

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DLSO:

- Hyperkeratosis- Yellow-white in

color

- Usually causedby T.rubrum

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Onychomycosis of toe :

distal subungual hyperkeratosis and

onycholysis

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WSO :

White spot

The nail becomesroughened and

crumbles easily.

Most frequentlycauses by T.

mentagrophytes

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The nail plate in

WSO present

numerous white,

opaque, and friablespots

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Mainly from

the proximal

nailfoldHyperkeratosis

Proximal

onycolisisThe usual cause

is T.rubrum

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PSO : the proximal shows an area of

leukonychia. The nail surface isnormal

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milky whitediscoloration of

the nail plate

Very rare type ofonychomychosis

Caused by

T.soudanense &T.violaceum

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Milky-white discoloration of the nail platein endonyx onychomychosis in the absence

of subungual hyperkeratosis and

onycholysis

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The secondary evolution of untreated DLSO or

PSO

Presents as a thickened, opaque, and yellow-brown

nail

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Assosiated with chronic mucocutaneus candidiasis orimmunodepression

The nail is diffusely thickened and crumbled, and the

periungual tissues are inflamed with pseudoclubbing

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The clinical features of onychomycosismay mimic a large number of other nail

disorders.

Therefore, laboratory diagnosis of

onychomycosis must be confirmed

before beginning a treatment regimen.

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Potassium hydroxide (KOH) preparation

of subungual debris

The simplest and quickest method Culture of nail bed or nail plate debris

Inoculated on Mycosel and Saborauds

media

Histology of nail plate and/or nail bed

Periodic acid Schiff (PAS)

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most commonly

characterized by pits

salmonpathches,

onycholysis. Pits develop from tiny

psoriatic lesions

located in the mostproximal matrix

region.

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longitudinal ridging.pterygium formation

thick nail plate.

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Debridement

Debride dystrophic nails; patients should

debride weekly.

Topical antifungals

Amorolfine nail lacquer

Ciclopirox (Penlac) nail lacquer

Oral Therapy

Patient Educatient

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Oral Therapy

Griseofulvin is no longer consideredstandart treatment for onychomychosis

because is adverse effect

Terbinafine is an allylamine and is

prescribed of 250mg daily for 6 weeksfor fingernails and 12 weeks for toenails

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Itraconazole is fungistatic against

dermathophytes, nondermathophytes molds,

and yeast. Pulse dosing 400 mg daily for 1week per month or a continuous dose of 200

mg daily, both of which require 2 months for

fingernails and 3 months for toenails. For

children 5mg/kg/day.

Fluconazole. The usual dosage is 150-300mg once per week for 3 to 12 month, altough

450mg weekly may be used in refractory

onychomycosis.

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Combination Therapy

Combination therapies have been

shown to have a more effective

clearence rate than either oral or topical

treatment alone.

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Without effective therapy,

onychomycosis does not resolve

spontaneously; progressive involvementof multiple toenails is the rule.

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