Which type of fungal infection is that ? I want know the treatment of this infection.
Thanks.
Wow
Ramveer, I'm not a medical mycologist, but that might be some sort of keratinophilic fungus like Trichophyton sp, Epidermophyton sp. Microsporum sp. or something related. Basically, they are fungi that live on skin, hair, and nails and can degrade protein called keratin, which is abundant in these structures.
There are dedicated ointments in pharmacies (the names differ from country to country) for this kind of infections, which can be bought without a prescription, but the person whom this toe belongs should definitely go to a dermatologist for a proper laboratory and symptom determination because it might not be onychomycosis after all.
hope you sort it out,
D
Ramveer:
This is a complex case based on the fact that if you do have a colonized fungal infection, it is probably secondary to other factors. Fungi are saprophytic and need a compromised host and in this case primary toenail repetitive microtrauma and onychodystrophy is underpinning the infection in my opinion.
I have questions for you:
1. Are there toes that are spared of the infection and dystrophy?
2. Is the hallux exceptionally long?
3. Note the traumatic longitudinal striae with some of these "cracks" secondarily infected as superficial white fungus.
4. There is a missing tibial border, was this taken as a specimen and if so, what was the result?
5. What is the patient's functional foot type?
6. Is the patient shod and if so is he (I think this is a he) wearing stylish, low toe boxed shoes?
7. Is the patient overly active, overweight or immunosuppressed for some reason?
Depending on your response, I will suggest multimodal treatment.
Dennis
It is mostly similar to fungal infection , should take a test for fungal infection and probably use antifungal treatment and medicine like nistatin .
@Dennis Shavelson
- This infection spared only on that toe.
- He don't know long is it. mean he is 24 year old and think its 20 year old infection
- yes white crack was there
- foot type is The Rigid Rearfoot–Flexible Fore foot Foot Type
- no specimen was taken, no testing done
- no he in not overweight. height is 5 feet 11 inch, weight is 72 Kg
I and my son.had this and we used antifungal drop and oinment . Nistatin is effectuve
It looks like onychomycosis. Only local treatment will not work. The patient should take course of Griseofulvin for 3 months or 1 month after complete clinical healing. Should be supervised by dermatologist.
We are researchers and scientists here.
Diagnosing that "it looks like fungus" or giving an anecdotal n-1 or 2 case suggesting a treatment is effective without any EBM or clinical study to back it up is merely opinion.
Suggesting an oral antifungal such as terbinafine or griseofulvin without pathlab pre-conformation is negligence as there have been fatal cases of terbinafine use that defy using it without an infection being diagnosed beyond it looks like".
An American Dermatology Association study revealed using oral antifungals without lab results is the #1 mistake of dermatologists.
As to Ramveers response to me, repetitive micro trauma, treatment of hyperhidrosis, shoe wardrobe adjustment and biomedical engineering of the lower extremities when forefoot flexibility exists + a topical antifungal or onychodystrophic (treating an unhealthy toenail) topical, laser therapy and topical antifungal are safe and applicable in the face of no KOH, PAS, DNA or dermatoscopic diagnosis of an actual fungal colonization.
Kill the fungus as the focus of treating onychodystrophy is the root of the failures in clinical care and research outcomes IMHO.
Dennis
This kind of nail dystrophy probably its not caused by fungus. Trauma, subungueal tumours, sistemic diseases, dermatologic diseases should ali be investigated. It's bether see a dermathologist!!
I wonder why this thread is not including a Podiatry consultation as another possibility to Dermatology?
R U familiar with Podiatry and "closed chain medicine" and "closed chain dermatology" as foot doctors practice?
Dear Singh, in dermatology nail description considered as a part from skin and not isolated from as a separate entity. If a provisional diagnosis is raised a Nail dystrophy is the one to be considered. Nail fold, cuticle, lanula, plate, bed and skin general examination fulfilling criteria of diagnosis in such case.
The nail shows opacification, hyperkeratosis and onycholysis at the distal edge ; because onychomycosis is responsible for only 50% of dystrophic nails , laboratory confirmation --KOH EXAMINATION AND FUNGAL CULTURE --is essential prior to treatment with antifungals ; microscopy is often negative even when there is a high clinical suspicion .So , maximize sample size and repeated collections are the best measures to avoid false negative results .Selecting an antifungal should be based primarily on the causative organism, potential adverse effects and drug interactions .Griseofulvin is no longer considered standard treatment for onychomycosis .
Itraconazole 100 mg 2 capsules bid for 7 days with interval for 21 days to be repeated for another 7 days after LFTs evaluation is the protocol we follow in case of onychomycosis affecting finger nails only if nails of toes also affected another 7 day course after 21 days lapse added.
La photographie n'est pas en faveur d'une onychomycose, si bien qu'un prélèvement s'avère indispensable pour confirmer cette impression clinique
Dès lors, le traitement général découlera de la variété de champignon
Topical ciclopirox (8% lacquer ) is effective for tinea unguium--daily for 48 weeks--and more cost effective because of the relatively low cost .Terbinafine is FUNGICIDAL agaist dermatophytes, Aspergillus and Scopulariopsis and demonstrates variable activity agaist Candida species .A course of 250 mg daily for 6 weeks is effective for most finger nail infections while a 12-week course is required for toenail infection . I do not prescribe itraconazole and fluconazole-- for toenail infection--- because these drugs are fungistatic .
Dear Fernandes , greetings
Yes, terbinafine as fungicidal considered as one of the most effective drugs against onychomycosis in short term course for toenail infection.
Terbinafine is more effective than itraconazole in the treatment of toenail tinea infection.
(BMJ v.311 (7010); 1995 Oct 7)
(JAAD Volume 38, Issue 5, Supplement 2, Pages S57–S63)
Systemic fluconazole, itraconazole and terbinafine showed that all three drugs were effective and safe in the treatment of onychomycosis. However, fluconazole, at these doses and treatment duration, was the least effective. With regard to cost-effectiveness, side effects and the cure rates, terbinafine could be the drug of choice in the short-term treatment of toenail onychomycosis.
(Journal of Dermatological Treatment Volume 13, 2002 - Issue 1 )
L'aspect est en faveur d'une onychodystrophie plutôt que d'une infection mycosique, sauf prélèvement en faveur d'un dermatophyte ou d'une levure
I think the important caveat, at least here in the USA, is that if you are prescribing an oral antifungal, you are mandated to culture or biopsy + for fungus before commencing as there are potentially deadly liver and other side effects that contraindicate prescribing when (40-50%) are tested negative for fungus.
Bonjour docteur De Beer .
À mon avis les aspects d"une onychodystrophie ou d"une infection mycosique sont semblables ;donc , la définition uniquement clinique est presque impossible .Par ailleurs l''onychodystrophie ou une autre maladie des ongles prédisposent à l"infection fongique .
Amicalement .
..
I have taken the time to translate into English the comment of my colleague, Nurimar Fernandes and then have replied in both languages for all involved.
'À mon avis les aspects d"une onychodystrophie ou d"une infection mycosique sont semblables ;donc , la définition uniquement clinique est presque impossible .Par ailleurs l''onychodystrophie ou une autre maladie des ongles prédisposent à l"infection fongique" Amicalement .
"In my opinion the aspects of onychodystrophy or mycotic infection are similar, so the only clinical definition is almost impossible. Onychodystrophy or another nail disease predisposes to fungal infection"
My response in English and French:.
As onychomycosis represents a saprophytic, opportunistic microorganism succeeding to infect a toenail (in most cases), there are precursors (either endogenous or exogenous or both) that precede the infection disturbing the ability of that toenail to provide barrier protection for the nail unit. Diagnosing and treating these precursors, n=1, holds the key to clinical success both short and long term. I believe that I am clinically and foundationally strong and practiced at that multimodal paradigm.
“The Pathogenesis of Dystrophic Toenails - Brad Bakotic D.P.M., D.O., Dennis Shavelson, D.P.M., Podiatry Management Magazine, August 2006”
If Onychomycosis was a board game such as Monopoly, I am playing chess and most of you seem to be playing checkers. I believe that is because as a podiatrist, I am educated, researched and practiced in lower extremity biomechanics, the barrier functions of toenails, the endogenous factors of onychomycosis (diabetes, PVD, immunosuppression, toxic drug usage, etc), the microbiome of the inside of shoes and the microbiome of toenails.
Furthermore, since the research is almost totally focused on hallux toenails, short term, almost all of the substance of most of your postings, when it comes to the existing EBM, related to onychomycosis of lesser toenails and long term,are off label.
Comme l'onychomycose représente un microorganisme opportuniste saprophyte réussissant à infecter une ongle d'orteil (dans la plupart des cas), il doit y avoir un précurseur (endogène ou exogène ou les deux) qui précède l'infection perturbant la capacité de cet ongle pour fournir une protection barrière pour l'ongle unité. Le diagnostic et le traitement de ces précurseurs sont la clé du succès clinique à court et à long terme et je crois que je suis cliniquement et fondamentalement fort et pratiqué à ce paradigme multimodal.
"La pathogénie des ongles dystrophiques des orteils - Brad Bakotic D.P.M., D.O., Dennis Shavelson, D.P.M., Podiatry Management Magazine, Août 2006"
Si l'onychomycose était un jeu de société comme Monopoly, je joue aux échecs et la plupart d'entre vous semblent jouer aux dames. Je crois que c'est parce qu'en tant que podiatre, je suis instruit, recherché et pratiqué dans la biomécanique des membres inférieurs, les fonctions barrières des ongles des orteils, les facteurs endogènes de l'onychomycose (diabète, PVD, immunosuppression, toxicomanie, etc.), le microbiome de la À l'intérieur des chaussures et le microbiome des ongles des pieds.
De plus, puisque la recherche est presque entièrement axée sur les ongles d'orteil, à court terme, presque tout le contenu de la plupart de vos messages, quand il s'agit de l'EBM existant, sont hors étiquette
Dr Shavelson , greetings .
As a dermatologist in a tertiary hospital I am aware of the following data : higher rates of onychomycosis are associated with male gender , age, smoking and peripheral arterial disease ; the dermatophytosis commonly begins as tinea pedis before extending to nail bed where eradication is more difficult ; this site then serves as a reservoir for recurrent distal infections , particularly in the setting of a hot and humid environment created by occlusion or tropical climates ; the importance of systemic diseases evaluation to identify trigger factors ; and at last but not at least the relevant contribution of the podiatrist in the diabetic foot care, for instance .
A year has past without any new EBM, without an answer as to what to do for the ugly toenail that cultures negative.
The Dermatology community seems to be sitting on its hands on this one.
The Podiatry community is at least looking for a consensus that will lead to white papers and research that is viable and applicable to this subject.
My input at this point:
1. Onychodystrophy, whether it exists with or without primary or secondary fungal infection and colonization is a multimodal, n=1 problem that requires a multimodal, n=1 set of diagnoses and treatments
2. Onychodystrophy requires a multimodal maintenance program that focuses on keeping toenails healthy and capable of resisting a pathological fungal relationship (fosters a symbiotic one)
3. Research will never be viable and applicable at a high level peer reviewed standard when testing one means of care only. There are bullets of underpinning pathology that exist n=1 that cannot be researched n=1000.
4. These bullets include:
- hyperhidrosis
- shoe related issues
- underpinning biomechanical pathology
- Endogenous factors affecting toenail health
- Exogenous factors affecting toenail health
- Primary or secondary saprophytic/bacterial/??? invasion and infection
5. Accepting as accurate research for onychomycosis 3-6 mm's on toenail clearing of a hallux toenail along with negative culture as a "cure" for this complex civilized disease that affects millions upon millions is the underpinning of your folly IMHO.
Do I have consensus on all or part of this comment from which we can proceed together?
Micological Direct Examination is the best way to confirm a fungal infection by dermatophytes (see article attached we puplished). This case may be a dermatophyte infection or not. Also, the infection can be superposed to a already distrophic nail. There may be mixt infection to. Lots of diseases can cause dystrophic nails.
I read your article and found that it and your posting seem to defend my position (biased though it may be).
"This case my be a dermatophyte infection" or "it may be superimposed to an already dystrophic nail"
It may be a dermatopthye or some other organism (s).
It may test negative or test false negative or false positive.
As a clinician, I ask you in light of the question and your response:
How do you suggest treating this patient short term?
This is definitely a dystrophic hallux toenail with repetitive microtrauma as the root cause.
Fungus, if present is secondary.
I am predicting that there are "normal looking" toenails on other digits in this patient (most likely 3-4). If primary fungus, 6 or more toenails would be infected.
Rule Here: Don't follow the fungus red herring.
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