Onychomycosis Classification and external resources
A toenail affected by Onychomycosis
ICD-10	B35.1
ICD-9	110.1
DiseasesDB	13125
MedlinePlus	001330
eMedicine	derm/300
MeSH	D014009

Onychomycosis means fungal infection of the nail. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings A00-A79 - Bacterial infections and other intestinal infectious diseases and STDs (A00-A09 Intestinal Infectious diseases ( The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books A fungus (ˈfʌŋgəs is a eukaryotic Organism that is a member of the kingdom Fungi (ˈfʌndʒaɪ Dermatophytosis is a group of Mycosis infections of the Skin caused by parasitic fungi ( Dermatophytes) A nail is a horn -like structure at the end of an animal's Finger or Toe. It is the most common disease of the nails and constitutes about a half of all nail abnormalities. ^[1]

This condition may affect toe- or fingernails, but toenail infections are particularly common. A nail is a horn -like structure at the end of an animal's Finger or Toe. A nail is a horn -like structure at the end of an animal's Finger or Toe. The prevalence of onychomycosis is about 6-8% in the adult population. ^[2] Onychomycosis caused by dermatophytes is also known as tinea unguium (tinea of the nails). A dermatophyte is a parasitic fungus ( Mycosis) that infects the skin Onychomycosis means fungal infection of the nail. It is the most common disease of the nails and constitutes about a half of all nail abnormalities Dermatophytosis is a group of Mycosis infections of the Skin caused by parasitic fungi ( Dermatophytes) ^[3]

Contents 1 Symptoms 2 Causes 3 Classification 4 Diagnosis 5 Treatment 5.1 Pharmacologic Rx 5.1.1 Relative effectiveness of treatments 5.2 Drug pipeline 5.2.1 Phase III 5.2.2 Phase II 5.3 Natural remedies 6 Prevention 7 See also 8 References

Symptoms

The nail plate can have a thickened, yellow, or cloudy appearance. The nails can become rough and crumbly, or can separate from the nail bed. There is usually no pain or other bodily symptoms, unless the disease is severe. ^[4]

Dermatophytids are fungus-free skin lesions that sometimes form as a result of a fungus infection in another part of the body. Dermatophytids are fungus-free disseminated skin lesions resulting from induced sensitization in patients with Ringworm infections This could take the form of a rash or itch in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction to the fungus.

Causes

The causative pathogens of onychomycosis include dermatophytes, Candida, and non-dermatophytic moulds. Candida is a Genus of Yeasts Many species of this genus are Endosymbionts WikipediaManual_of_Style#National_varieties_of_English --> Molds (or Dermatophytes are the fungi most commonly responsible for onychomycosis in the temperate western countries; meanwhile, Candida and non-dermatophytic moulds are more frequently involved in the tropics and subtropics with a hot and humid climate. A fungus (ˈfʌŋgəs is a eukaryotic Organism that is a member of the kingdom Fungi (ˈfʌndʒaɪ Candida is a Genus of Yeasts Many species of this genus are Endosymbionts WikipediaManual_of_Style#National_varieties_of_English --> Molds (or ^[5]

Trichophyton rubrum is the most common dermatophyte involved in onychomycosis. Trichophyton rubrum is a Fungus that is the most common cause of Athlete's foot, Jock itch and Ringworm. Other dermatophytes that may be involved are Trichophyton interdigitale, Epidermophyton floccosum, Trichophyton violaceum, Microsporum gypseum, Trichophyton tonsurans, Trichophyton soudanense (considered by some to be an African variant of T. rubrum rather than a full-fledged separate species) and the cattle ringworm fungus Trichophyton verrucosum. In Biology, a species is one of the basic units of Biological classification and a Taxonomic rank. Cattle, colloquially referred to as cows, are domesticated Ungulates a member of the Subfamily Bovinae of the family Ringworm (also called serpigo) is an infection of the skin characterized by a reddish to brownish raised or bumpy patch of skin that may be lighter in the center A common outdated name that may still be reported by medical laboratories is Trichophyton mentagrophytes for T. interdigitale. The name T. mentagrophytes is now restricted to the agent of favus skin infection of the mouse; though this fungus may be transmitted from mice and their danders to humans, it generally infects skin and not nails. Favus (Latin for "honeycomb" is a Disease of the Scalp, but occurring occasionally on any part of the skin and even at times on Mucous membranes Dander is material shed from the body of various animals similar to Dandruff or pet pollen

Other causative pathogens include Candida and non-dermatophytic moulds, in particular members of the mould genera Scytalidium (name recently changed to Neoscytalidium), Scopulariopsis, and Aspergillus. Candida is a Genus of Yeasts Many species of this genus are Endosymbionts WikipediaManual_of_Style#National_varieties_of_English --> Molds (or Aspergillus is a Genus of around 200 Molds found throughout much of nature worldwide Candida mainly cause fingernail onychomycosis in people whose hands are often submerged in water. Candida is a Genus of Yeasts Many species of this genus are Endosymbionts Scytalidium mainly affects people in the tropics, though it persists if they later move to areas of temperate climate. The Tropics are centered on the Equator and limited in Latitude by the Tropic of Cancer in the northern hemisphere at approximately 23°26' (23

Other moulds more commonly affect people older than 60 years, and their presence in the nail reflects a slight weakening in the nail's ability to defend itself against fungal invasion.

Classification

Distal Subungual Onychomycosis

The most common form of tinea unguium usually caused by Trichophyton rubrum, which invades the nail bed and the underside of the nail plate.

White Superficial Onychomycosis

Caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. Accounts for only 10 percent of onychomycosis cases.

Proximal Subungual Onychomycosis

Fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people but found more commonly when the patient is immunocompromised.

Candidal Onychomycosis

Candida species invade fingernails usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.

Total Dystrophic Onychomycosis

Total destruction of the nail plate. It is the end result of any of the above four types.

Diagnosis

If all nails are affected then fungal infection is improbable. To avoid misdiagnosis as psoriasis, lichen planus, contact dermatitis, trauma, nail bed tumor or yellow nail syndrome, laboratory confirmation may be necessary. Psoriasis (səˈraɪəsɪs ( suh-RI-uh-sus) is a non-contagious disorder which affects the Skin and Joints It commonly causes red scaly Lichen planus is an Inflammatory Disease that affects the Skin and the Oral mucosa, and presents itself in the form of Papules Contact dermatitis is a term for a Skin reaction resulting from exposure to Allergens (allergic contact dermatitis or irritants (irritant contact dermatitis Treatment of physical trauma is described here and in First aid. See also Cancer A tumor or tumour is the name for a swelling or lesion formed by an abnormal growth of cells (termed neoplastic Yellow nail syndrome is a very rare medical Syndrome that includes Pleural effusions lymphoedema and yellow dystrophic nails The three main approaches are potassium hydroxide smear, culture and histology. This involves microscopic examination and culture of nail scrapings or clippings. Recent results indicate that the most sensitive diagnostic approaches are direct smear combined with histological examination, ^[6] and nail plate biopsy using periodic acid-Schiff stain. ^[7]

Treatment

Treatment of onychomycosis is challenging because the infection is embedded within the nail and is difficult to reach. As a result full removal of symptoms is very slow and may take a year or more.

Pharmacologic Rx

Most treatments are either systemic antifungal medications such as terbinafine and itraconazole, or topical such as nail paints containing ciclopirox or amorolfine. An antifungal drug is Medication used to treat fungal Infections such as Athlete's foot, Ringworm, Candidiasis (thrush Terbinafine hydrochloride ( Lamisil in Australia Belgium Brazil Canada France Germany Hungary Romania United Kingdom and United States also sold under the name Itraconazole (marketed as Sporanox by Janssen Pharmaceutica) invented in 1984 is a Triazole Antifungal agent that is prescribed to patients Ciclopirox olamine (also called Batrafen Loprox, Penlac and Stieprox) is a synthetic Antifungal agent for topical dermatologic Amorolfine (or amorolfin) is an allylamine Antifungal drug that inhibits D14 reductase and D7-D8 isomerase, which depletes Ergosterol There is also evidence for combining systemic and topical treatments. ^[8]

For superficial white onychomycosis systemic rather than topical antifungal therapy is advised. ^[9]

Relative effectiveness of treatments

In July 2007 a meta-study reported on clinical trials for topical treatments of fungal nail infections. In Medicine, a topical Medication is applied to body surfaces such as the Skin or Mucous membranes for example the Vagina The study included 6 randomised controlled trials dating up to March 2005. ^[10] The main findings are:

• There is some evidence that ciclopiroxolamine and butenafine are both effective but both need to be applied daily for prolonged periods (at least 1 year).
• There is evidence that topical ciclopiroxolamine has poor cure rates and that amorolfine might be substantially more effective.
• Further research into the effectiveness of antifungal agents for nail infections is required.

A 2002 study compared the efficacy and safety of terbinafine in comparison with placebo, itraconazole and griseofulvin in treating fungal infections of the nails. See also 2002 (disambiguation Year 2002 ( MMII) was a Common year starting on Tuesday of the Gregorian calendar. Terbinafine hydrochloride ( Lamisil in Australia Belgium Brazil Canada France Germany Hungary Romania United Kingdom and United States also sold under the name Itraconazole (marketed as Sporanox by Janssen Pharmaceutica) invented in 1984 is a Triazole Antifungal agent that is prescribed to patients Griseofulvin (also known as Grisovin is an Antifungal drug. It is used both in animals and in humans to treat Ringworm infections of the skin and nails ^[11] The main findings were that for reduced fungus terbinafine was found to be significantly better than itraconazole and griseofulvin, and terbinafine was better tolerated than itraconazole.

• A small study in 2004 showed that ciclopirox nail paint was more effective when combined with topical urea cream. ^[12]
• A study of 504 patients in 2007 found that aggressive debridement of the nail combined with oral terbinafine significantly reduced symptom frequency over terbinafine alone. Debridement is a medical term referring to the removal of Dead, damaged or Infected tissue to improve the healing potential of the remaining ^[13]
• A 2007 randomised clinical trial with 249 patients show that a combination of amorolfine nail lacquer and oral terbinafine enhances clinical efficacy and is more cost-effective than terbinafine alone. Amorolfine (or amorolfin) is an allylamine Antifungal drug that inhibits D14 reductase and D7-D8 isomerase, which depletes Ergosterol ^[14]

Drug pipeline

Most drug development activities are focused on

• the discovery of new antifungals
• novel delivery methods to promote access of existing antifungal drugs into the infected nail plate

Active clinical trials investigating Onychomycosis:[1]

Phase III

• A medicinal nail lacquer, NM100060 from NexMed ^[15] contains terbinafine as the active ingredient and a permeation enhancer which facilitates the delivery of the drug into the nail bed where the fungus resides. Commercial sale of the product is expected to begin no earlier than in 2008. ^[16]
• A comparison of delivery methods for Itraconzole^[17].
• Safety and tolerability of topical Terbinafine^[18].

Phase II

• A topical treatment, AN-2690, is being developed by Schering-Plough Corp. It is active against Trichophyton species. Description The Fungus genus Trichophyton is characterized by the development of both smooth-walled macro- and Microconidia. ^[19]
• Posaconazole, taken orally. Posaconazole is a Triazole antifungal drug that is used to treat invasive infections by Candida species and Aspergillus species in ^[20]

Natural remedies

As with many diseases, there are also some scientifically unverified folk or alternative medicine remedies. The term alternative medicine, as used in the modern western world encompasses any healing practice "that does not fall within the realm of conventional Medicine.

• Australian tea tree oil. Tea tree oil is an extraction from the Melaleuca tree Tea tree oil or melaleuca oil is a clear to very pale golden color Essential oil ^[21][22] There is insufficient information to make recommendations for or against the use of tea tree oil for onychomycosis. ^[23]
• Grapefruit seed extract as a natural antimicrobial is not demonstrated. Grapefruit seed extract (GSE also known as citrus seed extract, is a liquid derived from the Seeds pulp, and white membranes of Grapefruit. Its effectiveness is scientifically unverified. Multiple studies indicate that the universal antimicrobial activity is due to contamination with synthetic preservatives that were unlikely to be made from the seeds of the grapefruit. ^{[24][25][26][27][28]}
• Vicks Vaporub or other thymol- and eucalyptus-containing petroleum-based rubs

Prevention

• Avoid walking barefoot in public areas such as showers, communal changing rooms. Vicks is a line of over-the-counter Medications owned by the American company Procter & Gamble. Thymol is a Monoterpene phenol derivative of Cymene, C10H14OH Isomeric with Carvacrol, found in oil of Eucalyptus (From Greek ευκάλυπτος meaning "well covered" is a diverse Genus of Trees (and a few shrubs the members of which
• Keeping feet clean and dry.
• Avoid sharing shoes and socks

See also

• Nail disease
• List of tinea infections

References

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