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

?Psoriatic nail changes / ?Fungal

Patient persisted with amorolfine lacquer 2
months

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

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

Psoriasis

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

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