Most patients with onychomycosis are asymptomatic and won’t notice anything physical until the cosmetic affects take place (deformities of the nail, discolouration, etc.) [6]. As the fungal infection continues, it can cause chronic pain and which can be exacerbated by nail cutting, footwear, or pressure. When the infection is not treated it can cause pain or discomfort at all times, lead to a loss of dexterity, can cause low self-esteem and a lack of social interaction due to the patient’s reduced self-consciousness caused by the cosmetic nature of the infection.

• Asymptomatic

  Symptoms and Signs of Onychomycosis Nails have asymptomatic patches of white or yellow discoloration and deformity. [msdmanuals.com]

  Most patients with onychomycosis are asymptomatic and won’t notice anything physical until the cosmetic affects take place (deformities of the nail, discolouration, etc.). [symptoma.com]

• Nail Abnormality

  It is the most common disease of the nails and constitutes about half of all nail abnormalities. The causative pathogens of onychomycosis are all in the fungus kingdom and include dermatophytes, Candida (yeasts), and nondermatophytic molds. [imedpub.com]

  What Does a Fungal Nail Infection Look Like? Onychomycosis presents as nail abnormality or a progressive degeneration of the nail tissue (dystrophy). [probitymedical.com]

  30% of all superficial infections of skin and constitutes about a half of all nail abnormalities; affecting approximately 5% of population worldwide The prevalence of onychomycosis is determined by age, social class, occupation, climate, living environment [clinicaltrials.gov]

  Onychomycosis is a fungal condition that affects nails—most commonly, the toe nails. It is very common, and it accounts for around 50% of all nail abnormalities. Nail abnormalities affect about 7% of the adult population. [healdove.com]

  Nail abnormalities are usually more marked on a corner of the nail. The nail plate may occasionally show superficial abnormalities and pitting. [tandfonline.com]

• Congestive Heart Failure

  Doctors may not recommend them for people with liver disease or congestive heart failure or those taking certain medications. Medicated nail polish. Your doctor may prescribe an antifungal nail polish called ciclopirox (Penlac). [mayoclinic.org]

  Congestive heart failure Decrease liver function Antifungal Lacquer or Nail Polish- Medications Prescribed- Ciclopirox Indication For Prescription- Mild to moderate fungal infection of the nail. [epainassist.com]

  It carries a black box warning for congestive heart failure. (Gupta,K et al, Am J Derm 2014: 15: 488) Terbinafine is the drug of choice for moderate and severe nail infections. It can be co-administered with topical agents. [mdmag.com]

  heart failure Terbinafine (Lamisil) 250 mg orally once per day for six weeks (fingernails) or 12 weeks (toenails) 66 23 76 23 Some yeasts, dermatophytes, nondermatophyte molds Gastrointestinal upset, rash, headache Antiarrhythmic agents, beta blockers [aafp.org]

• Sepsis

  Cellulitis, osteomyelitis, sepsis and necrosis in elderly patients and people with diabetes. Psychosocial problems due to embarrassment at cosmetic appearance. Pain and limitation of function, particularly in older patients. [patient.info]

  Differential Diagnosis Yellow nail syndrome Drug reaction Hypothyroidism Nail malignancy Psoriatic nail Contact dermatitis Complications Risk of infections are usually higher in diabetics and include the following: Cellulitis Sepsis Osteomyelitis Tissue [ncbi.nlm.nih.gov]

• Surgical Procedure

  Surgical procedures Nail surgery is not recommended as a routine procedure for the treatment of onychomycosis. [drfungus.org]

  In these areas of the body, the clinical benefits of this specialized surgical procedure do not exceed the potential risks. [choosingwisely.org]

• Heart Failure

  Doctors may not recommend them for people with liver disease or congestive heart failure or those taking certain medications. Medicated nail polish. Your doctor may prescribe an antifungal nail polish called ciclopirox (Penlac). [mayoclinic.org]

  Congestive heart failure Decrease liver function Antifungal Lacquer or Nail Polish- Medications Prescribed- Ciclopirox Indication For Prescription- Mild to moderate fungal infection of the nail. [epainassist.com]

  It carries a black box warning for congestive heart failure. (Gupta,K et al, Am J Derm 2014: 15: 488) Terbinafine is the drug of choice for moderate and severe nail infections. It can be co-administered with topical agents. [mdmag.com]

  failure; avoid giving to patients with ventricular dysfunction or heart failure 200mg once daily for 3 months, then 200mg twice daily for 7 days, repeated at 21 days. [pharmaceutical-journal.com]

  Topical therapy with ciclopirox is less effective; it has a failure rate exceeding 60%. Several nonprescription treatments have also been evaluated. [aafp.org]

• Hypertension

  […] disease before the initiation of treatment (P < 0.02), three or more infected nails (P < 0.0002), continuous exposure to water and detergents (P < 0.05), frequent exposure to mud and soil (P < 0.01), barefoot walking (P < 0.025), concomitant diabetes and hypertension [ncbi.nlm.nih.gov]

  In those that did, hypertension (36.2%), diabetes mellitus (35.5%) and concurrent hypertension and diabetes (14.5%) were the most common. [elsevier.es]

  Case 1 A female patient, 68 year old, retired, diagnosed with diabetes, dyslipidemia, and hypertension, had long periods of contact with farm animals and worked as a maid for a long time. She had mycoses in the toe and fingernails. [e-ijd.org]

  The link between psoriasis and hypertension is not currently[when?] understood. [en.wikipedia.org]

• Proximal Subungual Onychomycosis

  Proximal subungual onychomycosis and distal lateral subungual onychomycosis involving the lunula region require systemic treatment while white superficial onychomycosis and distal lateral subungual onychomycosis limited to the distal nail can usually [symptoma.com]

  PSO (proximal subungual onychomycosis): This is the least common of nail fungi and may first appear as a white or yellowish spot on the nail close to the cuticle. From there, it can progress into a plaque that collects on the underside of the nail. [healthcentral.com]

  The patient was diagnosed with proximal subungual onychomycosis due to A. flavus. Following itraconazole pulse therapy, she was cured in 6 months. [ncbi.nlm.nih.gov]

• Skin Disease

  Author information 1 Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Baode Road 1278, Shanghai, China. 2 Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine [ncbi.nlm.nih.gov]

  Diseases, Infectious Infection Mycoses Nail Diseases Skin Diseases [clinicaltrials.gov]

  It also explains how percutaneous absorption is affected by age, skin, site, race, skin disease, and damage and product form. Particular emphasis is on novel treatment approaches for major skin diseases and injuries pertaining to wounds and burns. [books.google.es]

• Sweating

  Wear sweat-absorbing socks or change your socks throughout the day. Choose shoes made of materials that breathe. Discard old shoes or treat them with disinfectants or antifungal powders. Wear footwear in pool areas and locker rooms. [mayoclinic.org]

  […] prevent infection, relapse, or reinfection of nail beds: · Washing infected hands and/or feet regularly with soapy water, then drying thoroughly · Keeping nails short, filed straight across, and without nail polish · Wearing correctly-sized shoes and sweat-absorbing [contemporaryclinic.pharmacytimes.com]

  Cut out factors which encourage fungal infection ( heat and moisture, heavy sweating, constant wear of closed-toe shoes, smoking, biting nails ). There is no down time, and it is possible to wear shoes straight away. [dr-romano-esthetique.com]

  It is also more common in people with distorted nails, nail trauma, hyperhidrosis increased sweating, multiple fungal infections particularly untreated athletes foot or Tinea Pedis, as well as psoriasis, and can even be hereditary. [nailkalm.com]

• Skin Rash

  Side effects of systemic treatment include gastrointestinal disorders, liver toxicity, skin rash and other hypersensitivities. [thpg.org]

  For example, bacterial infections (particularly Pseudomonas aeruginosa), as well as psoriasis, eczema or dermatitis, lichen planus (a skin rash triggered by the immune system), viral warts, Onycholysis (loosening of the nail from the nail bed) and Onychogryphosis [nailkalm.com]

  Oral antifungal drugs may cause side effects ranging from skin rash to liver damage. You may need occasional blood tests to check on how you're doing with these types of drugs. [mayoclinic.org]

  Side Effects Of Antifungal Medications- Skin rashes Liver damage. [epainassist.com]

  The most common side effects are headache, skin rash, and/or gastrointestinal (GI) disturbance (nausea, vomiting, diarrhea, and/or abdominal pain)4. [ncbi.nlm.nih.gov]

• Nail Deformity

  Other nail fungus (onychomycosis) symptoms and signs Broken Nails Brown Nails Crumbling Nails Curved Nails Deformed Nails Difficulty Exercising Difficulty Standing Difficulty Walking Fingernail or Toenail Pain Flaky Nails Nail Destruction Nail Odor Powdery [medicinenet.com]

  Symptoms and Signs of Onychomycosis Nails have asymptomatic patches of white or yellow discoloration and deformity. [msdmanuals.com]

  Nail Disease Centre, 42 rue des Serbes, Cannes, France. Onychomycosis is common, accounting for up to 50% of all nail disorders. Toenail onychomycosis can cause nail deformity, embarrassment, pain and walking difficulties. [raysahelian.com]

  Differential diagnosis[edit] In many cases of suspected nail fungus there is actually no fungal infection, but only nail deformity.[17][18] To avoid misdiagnosis as nail psoriasis, lichen planus, contact dermatitis, nail bed tumors such as melanoma, trauma [en.wikipedia.org]

Onychomycosis might be clinically diagnosed on a preliminary level but in order to get a confirmed diagnosis, laboratory tests are necessary. These tests can include cultures, histology, and a potassium hydroxide (KOH) examination [7] [8]. A microscopic exam will also be done alongside scrapings and clippings of the nails. There might be several samples needed in order to confirm cases when OM is caused by nondermatophytic moulds.

Differentail diagnosis of onychomycosis may be misdiagnosed as nail psoriasis, lichen planus, contact dermatitis, yellow nail syndrome, iron deficiency, chronic paronychia or simple trauma.

The type of treatment necessary is dependent on the type of onychomycosis, severity of the condition, and how many nails are affected by the infection [9]. Proximal subungual onychomycosis and distal lateral subungual onychomycosis involving the lunula region require systemic treatment while white superficial onychomycosis and distal lateral subungual onychomycosis limited to the distal nail can usually be successfully treated topically. Some cases may need a combination of topical and systemic treatments. 

Oral medications include terbinafine, itraconazole, griseofulvin and fluconazole. Topical agents available for the treatment of onychomycosis include ciclopirox nail paint, amorolfine, tavaborole or efinaconazole. Depending on the type of onychomycosis and severity of the condition, other medications and treatment options such as laser or light therapy and surgery may be beneficial.

Since onychomycosis is a fungal infection, recurrence can occur even after successful treatment and recovery. This has been seen in 10 to 50 percent of reported cases [5]. The infection can cause pain and discomfort in patients and can also leave the nail permanently damaged or disfigured. Associated infections can occur due to OM if the patient is immunocompromised from a preexisting condition like diabetes. Diabetic patients, people suffering from leukemia, and patients who have undergone an organ transplant are thought to be high risk for this infection.

There are various pathogens that are associated with the onset of OM. Dermatophytes, yeasts, or nondermatophyte molds are associated with OM [2]. The dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes account for the majority of cases.

Certain pathogens seem to be more prevalent in different regions. For example, dermatophytes seem to be more responsible for OM in western countries that have temperate conditions and candida and nondermatophytic moulds are more associated with OM in patients that live in the subtropics or tropics where the climate is humid and warm.

Internationally, onychomycosis affects around three to eight percent of people in developed countries including Spain, Finland, and the United Kingdom. In North America, OM affects between two and 13 percent of the population [3].

This fungal infection is responsible for around 50 percent of all reported nail disorders and it is considered to be the most common nail disease in the adult population. 

As previously stated, different pathogens can lead to the development of onychomycosis depending on the region. The subtype of the fungal infection can also change the pathophysiology of it.

Distal lateral subungual onychomycosis is considered to be the most common form of OM and is usually distinguishable by the inflammation associated with it. DLSO spreads from the plantar skin to the nail bed through the hyponychium [4]. In endonyx onychomycosis, a form of distal lateral subungual onychomycosis, the pathogen infects the nail through the skin surrounding the nail before directly entering the nail plate.

White superficial onychomycosis is less common and the nail plate is the primary site of invasion. In the case of proximal subungual onychomycosis an invasion of pathogens via the proximal nail fold through the cuticle area.

Finally, the most severe cases of OM, total dystrophic OM, involves the entire nail unit including the plate, the bed, and the matrix.

Preventing onychomycosis has to do with hygiene and general upkeep for the finger and toenails. The following steps may be advised [10]:

• Avoid walking barefoot
• Avoid wearing old shoes that offer little protection
• Avoid unsanitary nail salons that can lead to fungal infections
• Avoid using artificial nails and glues
• Keep nails short and dry
• Use antifungal agents 
• Wash and dry hands and feet properly
• Wash hands after coming into contact with infected nails to avoid spreading
• Wear absorbent socks to keep feet dry
• Wear rubber gloves when exposed to excessive water (washing dishes, for example)
• Wear shoes that can vent air and reduce humidity

Onychomycosis, abbreviated OM, is a fungal infection that affects the fingernails and toenails [1]. It is divided into five subtypes including candidal onychomycosis, distal lateral subungual onychomycosis (DLSO), endonyx onychomycosis (EO), proximal subungual onychomycosis (PSO), and white superficial onychomycosis (WSO). There is a chance that more than one subtype of OM can be present at one given time. The more advanced form of general OM which encompasses all of the subtypes is known as total dystrophic onychomycosis. The fungal infection involves the all parts of the nail structure including the nail plate, the nail bed, and the nail matrix.

This condition is not fatal at all but it can be painful and lead to permanent disfigurement. It is also a cosmetic concern to people. The pain and possible disfigurement can lead to physical and occupational limitations and psychosocial and emotional issues due to the cosmetic aspect of the disorder. These emotional problems can have an overall impact on a person’s quality of life.

Onychomycosis (OM), is a fungal infection that attacks the finger and toenails. It is quite common especially in humid climates. The infection is characterized by a white or yellow discoloration that appears under the nail. As the infection progresses and grows, the spot gets bigger and becomes more noticeable. The nail will become unhealthy and begin to crumble around the edges at this point. In most cases, only one nail is affected but it is possible for the infection to spread if left untreated.

OM is usually considered to be a mild infection and it is easily treated with either topical or systemic medications or it can remedy itself. It can cause pain and discomfort but it it’s mild it might not affect the person physically at all. There are more severe cases that can cause a good amount of physical pain and lead to permanent deformities and a loss of dexterity.