Education And Debate

Fortnightly Review: Fungal nail disease: a guide to good practice (report of a Working Group of the British Society for Medical Mycology)

BMJ 1995; 311 doi: (Published 11 November 1995) Cite this as: BMJ 1995;311:1277
  1. D W Denning, senior lecturera,
  2. E G V Evans, headb,
  3. C C Kibbler, consultantc,
  4. M D Richardson, headd,
  5. M M Roberts, consultante,
  6. T R Rogers, professorf,
  7. D W Warnock, headg,
  8. R E Warren, directorh
  1. aDepartment of Infectious Diseases and Tropical Medicine (Monsall Unit), North Manchester General Hospital, Manchester M8 5RB
  2. bPHLS Mycology Reference Laboratory, Department of Microbiology, University of Leeds
  3. cDepartment of Medical Microbiology, Royal Free Hospital, London
  4. dRegional Mycology Reference Laboratory, Department of Dermatology,University of Glasgow
  5. eUniversity Department of Dermatology, Hope Hospital, Salford M6 8MD
  6. fDepartment of Infectious Diseases and Bacteriology, Royal Postgraduate Medical School,London
  7. gPHLS Mycology Reference Laboratory, Public Health Laboratory,Bristol
  8. hPublic Health Laboratory, Royal Shrewsbury Hospital
  1. Correspondence to: Dr Roberts.

    Summary points

    • Onychomycosis is usually caused by dermatophytes (85-90%),butseveral fungi that are difficult to treat affect toenails

    • Paronychia is caused by many Candida species, some resistant to azole drugs

    • Samples for mycology should be taken as proximally as possible in the nail

    • Demonstration of hyphae in a nail specimen by microscopy is sufficient to start treatment

    • Choice of treatment depends on many factors including patient's age and preference,infecting fungus, number of nails affected, degree of nail involvement,whether toenails or fingernails are infected, and other drugs being taken

    The term onychomycosis refers to fungal infection of the nails whether this is a primary event or a secondary infection of a previously diseased or traumatised nail. Infection may be due to dermatophyte (ringworm, tinea unguium), yeast, or other non-dermatophyte (mould) species, and the clinical appearance may indicate the nature of the infecting organism. In paronychia chronic infection of the nail fold is most often caused by Candida species, but bacterial infection with Gram negative species such as Pseudomonas may coexist. Acute paronychia (whitlow) due to staphylococcal infection may also occur, and the presence of these bacterial infections will influence management. Invasion of the nail plate by Candida species may occur in the presence of paronychia, immune deficiency states (including chronic mucocutaneous candidiasis), Raynaud's disease, or endocrine disorders.

    This paper reviews the clinical features of onychomycosis and the differential diagnosis of nail dystrophy, gives the reasons for appropriate mycological investigation, and discusses guidelines for appropriate treatment on the basis of laboratory findings and particular clinical situations.


    Treating onychomycoses is difficult but is important because they do not resolve spontaneously. About 30% of all superficial fungal infections affect the nail.1 2 A recent population survey of dermatophyte onychomycosis has suggested a prevalence of 2.8% for men and 2.6% for women in the United Kingdom.3 …

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