Polymerase chain reaction can also confirm the diagnosis but is more expensive than other tests. Biopsy and periodic acid–Schiff stain of nail clippings can help assess the degree of nail plate involvement. 16, 17įungal culture of nail clippings or subungual debris allows for species differentiation but is limited by cost and the time it takes to get results. Table 3 includes the accuracy of diagnostic testing methods. However, if KOH results are negative and there is high clinical suspicion for onychomycosis, other testing may be performed to confirm the diagnosis. 12, 15 Diagnosis by KOH preparation alone is sufficient for treatment initiation. 14Ī potassium hydroxide (KOH) preparation with direct microscopy is the preferred diagnostic method because it is highly specific, has rapid results, and is cost-effective. Laboratory confirmation of nail infection is important for accurate diagnosis. Longitudinal ridging thin, brittle nails nail pitting usually involves all 20 nails Smooth, firm, flesh-colored lumps that emerge from the nail folds Paronychia, lack of nail growth, onycholysisīrownish-yellow discoloration of the nail plate, subungual hyperkeratosis, onychorrhexis Nodules cause onycholysis or longitudinal grooves in the nail plate and splinter hemorrhages Inflammation of the nail bed associated with erythema, edema, and pain at the proximal nail folds Nail pitting, Beau lines (transverse grooves) Longitudinal grooves and fissures, progressive nail thinning, dorsal pterygium Nail pitting, onycholysis, subungual hyperkeratosis, brownish discoloration (oil stains) or salmon-colored patches Preventive measures such as avoiding walking barefoot in public places and disinfecting shoes and socks are thought to reduce the 25% relapse rate. Although photodynamic and plasma therapies are newer treatment options that have been explored for the treatment of onychomycosis, larger randomized trials are needed. Nail trimming and debridement used concurrently with pharmacologic therapy improve treatment response. Topical therapy, including ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, is less effective than oral agents but can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions. Patients taking terbinafine in combination with tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antipsychotics, beta blockers, or tamoxifen should be monitored for drug-drug interactions. Oral terbinafine is preferred over topical therapy because of better effectiveness and shorter treatment duration. Treatment decisions should be based on severity, comorbidities, and patient preference. A potassium hydroxide preparation with confirmatory fungal culture, periodic acid–Schiff stain, or polymerase chain reaction is the preferred diagnostic approach if confirmative testing is cost prohibitive or not available. Accurate diagnosis is important before initiating treatment because therapy is lengthy and can cause adverse effects. Onychomycosis should be suspected in patients with discolored nails, nail plate thickening, nail separation, and foul-smelling nails. Untreated onychomycosis can cause pain, discomfort, and physical impairment, negatively impacting quality of life. Onychomycosis is not just a cosmetic problem. Onychomycosis is a chronic fungal infection of the fingernail or toenail bed leading to brittle, discolored, and thickened nails.
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