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.

• 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]

  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]

  There are times when it becomes difficult to tell onychomycosis apart from other conditions that cause nail abnormalities such as psoriasis and trauma. [probitymedical.com]

  […] caused by dermatophytes, yeast and non-dermatophyte molds that lead to distortion, discoloration, thickening and detachment from the nail bed Onychomycosis accounts for up to 30% of all superficial infections of skin and constitutes about a half of all nail [clinicaltrials.gov]

• Chronic Watery Diarrhea

  Abstract We present a case of a 73-year-old woman who presented with chronic watery diarrhea, weight loss, and frequent sinus and nail fungal infections. [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]

  Onychomycosis is suspected by appearance in patients who also have tinea pedis; predictive clinical features include involvement of the 3rd or 5th toenail, involvement of the 1st and 5th toenails on the same foot, and unilateral nail deformity. [merckmanuals.com]

  For those who want a faster option, the patient should be referred to a dermatologist or a surgeon for complete nail removal. [14] [15] (Level V) Outcomes For patients who delay in seeking care, the nail deformity usually progresses and may lead to disfigurement [ncbi.nlm.nih.gov]

  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]

• Pachyonychia

  There was no family history of psoriasis, Darier's disease, pachyonychia congenita, or lichen planus. The infant was born to parents with no known risk factors for human immunodeficiency virus infection, thus testing of the infant was not addressed. [jamanetwork.com]

  Pachyonychia congenita. Nail lesions in a 7-year-old boy. All nails show mild thickening with distal onycholysis and subungual hyperkeratosis. Published online: 10 January 2014 Figure 8. [tandfonline.com]

  Pachyonychia congenita – Marked subungual hyperkeratosis with accumulation of hard keratinous material resulting in uplifting of the nail plate. [visualdx.com]

  The differential diagnosis includes inflammatory disorders such as psoriasis and lichen planus; genetic disorders such as pachyonychia congenita; as well as nail unit neoplasms, repeated trauma, drugs, bacterial infections, and systemic diseases. [dermatologyadvisor.com]

  Differential diagnosis include idiopathic onycholysis, bacterial infections, traumatic onychodystrophies, lichen planus, psoriasis, contact dermatitis, pachyonychia congenita and nail bed tumors. [scielo.br]

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.

• Alanine Aminotransferase Increased

  aminotransferase increased 9 (8.9) 0 (0.0) Aspartate aminotransferase increased 8 (7.9) 0 (0.0) Blood creatinine increased 1 (1.0) 0 (0.0) γ‐Glutamyltransferase increased 16 (15.8) 1 (1.9) Hemoglobin decreased 1 (1.0) 0 (0.0) Red blood cell count decreased [ncbi.nlm.nih.gov]

• Aspartate Aminotransferase Increased

  aminotransferase increased 8 (7.9) 0 (0.0) Blood creatinine increased 1 (1.0) 0 (0.0) γ‐Glutamyltransferase increased 16 (15.8) 1 (1.9) Hemoglobin decreased 1 (1.0) 0 (0.0) Red blood cell count decreased 1 (1.0) 0 (0.0) White blood cell count decreased [ncbi.nlm.nih.gov]

• Creatinine Increased

  increased 1 (1.0) 0 (0.0) γ‐Glutamyltransferase increased 16 (15.8) 1 (1.9) Hemoglobin decreased 1 (1.0) 0 (0.0) Red blood cell count decreased 1 (1.0) 0 (0.0) White blood cell count decreased 1 (1.0) 0 (0.0) White blood cell count increased 1 (1.0) [ncbi.nlm.nih.gov]

• Hemoglobin Decreased

  decreased 1 (1.0) 0 (0.0) Red blood cell count decreased 1 (1.0) 0 (0.0) White blood cell count decreased 1 (1.0) 0 (0.0) White blood cell count increased 1 (1.0) 0 (0.0) Blood alkaline phosphatase increased 2 (2.0) 1 (1.9) Discussion Itraconazole and [ncbi.nlm.nih.gov]

• Liver Function Tests Abnormal

  The incidence of increased γ‐GT was higher than those of other liver function test abnormalities. [ncbi.nlm.nih.gov]

• Aspergillus Clavatus

  We present a case of onychomycosis due to Aspergillus clavatus for the first time worldwide. The patient was an immunocompetent 32-year-old woman who identified with Psoriasis of the nail. [ncbi.nlm.nih.gov]

  Mehraban Falahati, Aynaz Ghojoghi, Mahdi Abastabar, Zeinab Ghasemi, Shirin Farahyar, Maryam Roudbary, Mohammad Taghi Hedayati, Mojtaba Taghizadeh Armaki and Akbar Hoseinnejad, The First Case of Total Dystrophic Onychomycosis Caused by Aspergillus clavatus [doi.org]

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.