Tinea unguium

1
Tinea unguium

• Arun Bahal

2
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

3
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

4
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

5
Nail changes

• Fungal
• Begins distal ? proximal
• Toes gt fingers
• Thickening
• Yellowing
• Onycholysis, crumbling
• Associated tinea pedis

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

6
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 gt 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

7
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 (plt0.0001)
• No differences in numbers / types of ADRs
• Demonstrated superiority of terbinafine Rx over
  3-4 months

8
Case History

• ..nail clipping mycology positive
• Nail lacquer not working (2-3 months), gt 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