Tinea unguium

Arun Bahal

Case History

27 yr old male, keen sportsman Hx of psoriasis Topical treatment with calcipotriol 1 year Hx of bilateral hallux nail changes

Thickening, discoloration, crumbling

No joint pain or symptoms Had tried topical anti-fungal (amorolfine lacquer)

For 6 weeks, no improvement

Case History

On examination

Both big toe nails & 2nd toe nail right foot affected Varying degrees of nail thickening, yellowing, onycholysis & crumbling No pitting Joints ok

?Psoriatic nail changes / ?Fungal Patient persisted with amorolfine lacquer 2 months

No change

Nail clipping mycology positive

Tinea Unguium

Onychomycosis T.rubrum / T.mentagrophytes Prevalence increases with age Not common in children Can follow tinea pedis Athletes, DM, steroids Cosmetic reasons for treatment Clippings for mycology (gold std)

From crumbly nail tissue 1. If diagnosis uncertain 2. If considering systemic Rx False negatives up to 30%

Nail changes

Fungal
Begins distal proximal Toes > fingers Thickening Yellowing Onycholysis, crumbling Associated tinea pedis

Psoriasis
Nail bed in up to 50% Fingers > Toes Pitting Oily brown-yellow patch Onycholysis Associated arhropathy

Tinea Unguium

Management (hygiene, avoid towel sharing)

1 or 2 nails lacquer / paint Amorolfine lacquer 2x/week after filing, for 9-12 months Remove diseased nail 2 weeks after urea paste If unsuccessful or > 2 nails Confirm with nail clipping mycology & counsel patient Terbinafine (250mg od 6 12 weeks or longer) 134 Pulsed itraconazole (200mg bd 1 week every month for 3 months) 84 Beware hepatotoxicity (LFTs), heart failure with itraconazole

LION Study

Evans EGV, Sigurgeirsson B. Study of continuous terbinafine compared with intermittent itraconazole in treatment of toe nail onychomycosis. The LION study group. BMJ (1999), 381, 1031-5

(Griseofulvin no longer 1st line narrower spectrum, longer Rx) Oral terbinafine vs pulsed itraconazole for tinea unguium Double-blind, randomised, multicentre (35), 6 countries 496 pts clinical & mycological diagnosis, 87 drop-outs Mycological cure rates at 72 weeks

75-80% Terbinafine groups vs 38-49% Itraconazole groups (p<0.0001) No differences in numbers / types of ADRs

Demonstrated superiority of terbinafine Rx over 3-4 months

Case History

..nail clipping mycology positive Nail lacquer not working (2-3 months), > 2 nails Counselled re: terbinafine

systemic side effects, compliance, possibility of recurrence

Patient commenced oral terbinafine 2 months ago Subjectively some improvement! ..can wear sandals on holiday in future