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Fungal nail infection (onychomycosis) - Management
When should I suspect fungal nail infection?

  • Suspect fungal infection whenever the nail looks abnormal — the colour is the most important clue to diagnosis.
  • A variety of typical presentations have been described (and recognizing them can help guide treatment):
    • White or yellow opaque streaks appear along one side of the nail (lateral onychomycosis).
    • Scaling occurs under the distal nail; the nail is discoloured, opaque, and thickened (subungual hyperkeratosis).
    • The end of the nail lifts up, and the free edge erodes (distal onycholysis).
    • Small flaky white patches and pits appear on the top of the nail plate; the nail becomes roughened and crumbles easily (superficial white onychomycosis).
    • White or yellow spots appear in the half-moon (lunula), the proximal growing end of the nail (proximal onychomycosis). This should not be confused with the common white spots caused by injury.
    • The nail is completely destroyed (total dystrophic onychomycosis).
    • Images of these presentations of fungal nail infection are available at www.dermnetnz.org/fungal/onychomycosis.html.
  • Suspect Candida nail infection when an abnormal nail is associated with paronychia. There is redness and swelling next to the nail, and there may be a collection of pus.
  • Remember that fungal nail infection commonly coexists with other nail disorders such as psoriasis, lichen planus, and eczema.

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