Fungal Nail Infections

Presentation

Fungal nail infection

  • Yellowish discolouration
  • Soft subungual hyperkeratosis
  • Spread from distal edge
  • Superficial white onychomycosis

 

Management

Perform mycological examination of nail clippings INCLUDING soft subungual material to detect fungal elements.

Do not prescribe systemic antifungal drugs without laboratory confirmation of the diagnosis.

Dermatophyte nail infection

  • No treatment is an option especially in the elderly - regular podiatry if required
  • Terbinafine 250mg od for six weeks for finger and 12–16 weeks for toe nails and review progress. Caution in patients with liver and auto- immune diseases
  • Itraconazole 200mg bd for one week pulsed monthly for two courses (fingernail) or three courses (toenail)
  • Topical amorolfine lacquer for superficial white distal and lateral nail involvement only
Referral

Dermatology Referral Criteria

  • Diagnosis uncertain
  • Suspicion of subungual tumour
  • Failure of fungal nail infections to respond to treatment

Consider referral to podiatrist

  • Toe nail dystrophy secondary to trauma
  • Painful psoriatic toe nails
Patient Information
Differential Diagnosis

Subungual haematoma

  • History of trauma
  • Discolouration migrates with nail growth

Chronic paronychia

  • Rounded nail folds with loss of cuticle and ridged nail
  • Treat with clotrimazole cream four × daily
  • Protect hands with gloves for wet work

Psoriasis

Pitting and onycholysis