COMMENTARY

Onychomycosis: A proposed revision of the

clinical classification
Roderick J. Hay, DM, FRCP,a and Robert Baran, MDb,c
London, United Kingdom; and Villejuif and Cannes, France

The classification of onychomycosis, infection of the nail apparatus caused by fungi, has changed over time
with the recognition of new pathways of nail infection, new organisms, and new variations in the
appearance of diseased infected nail. Taking into account published descriptions of nail morphology in
fungal infection, the following forms of onychomycosis are recognized: distal and lateral subungual,
superficial, endonyx, proximal subungual, mixed, totally dystrophic, and secondary onychomycosis. These
can be subdivided, where appropriate, by color and pattern of nail plate change. The purpose of the
revised classification is to provide a framework to assist selection of treatment, estimate prognosis, and
evaluate new diagnostic methods. ( J Am Acad Dermatol 2011;65:1219-27.)

Key words: classification; fungus; nail disease; onychomycosis; prognosis; revised.

ince Zaias1 proposed a classification of fungal

S nail disease in 1972 there have been a number

of developments and modifications to our
understanding of the process by which fungi invade
the human nail apparatus, the range of organisms
involved, and their response to therapy. The original
classification proposed 3 distinct forms of nail plate
invasion: distal and lateral2 subungual onychomyco-
sis (DLSO), where invasion originates from the distal
and lateral undersurface of the plate; superficial
white onychomycosis, where invasion originates
from the upper surface; and proximal subungual
onychomycosis (PSO), where the attack starts from
the undersurface of the proximal nailfold. These
were reflected by the clinical appearances of the nail.
The concept of totally dystrophic onychomycosis
(TDO) was introduced later2 to explain the fact that,
in some patients, the nail plate and, often, surround-
ing periungual tissue may be involved by the infec-
tion. Subsequently there have been a number of
modifications that were introduced to explain new
findings, such as the concept of endonyx
From the Department of Dermatology, Kings College Hospital
National Health Service Trust, Denmark Hill, Londona; Nail
Disease Center, Cannesb; and Gustave Roussy Cancer Institute,
Villejuif.c
Funding sources: None.
Conflicts of interest: None declared.
Reprint requests: Roderick J. Hay, DM, FRCP, Dermatology
Department, Department of Dermatology, Kings College
Hospital National Health Service Trust, Denmark Hill, London
SE5 9RS. United Kingdom. E-mail: roderick.hay@ifd.org.
Published online April 19, 2011.
0190-9622/$36.00
2010 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2010.09.730
Abbreviations used:
CMC: chronic mucocutaneous candidosis
DLSO: distal and lateral subungual
onychomycosis
EO: endonyx onychomycosis
MPO: mixed pattern onychomycosis
PSO: proximal subungual onychomycosis
SO: superficial onychomycosis
TDO: totally dystrophic onychomycosis
onychomycosis,3 where the nail plate is attacked
from the distal end of the nail plate causing deeper
penetration of fungal hyphae and, more recently, a
revision of the concept of superficial white onycho-
mycosis and PSO,4 largely as a result of the identifi-
cation of new fungal causes, mixed patterns, and the
effect of different types of immunosuppression on
depth of penetration. The Zaias1 classification and
the subsequent additions and revisions have been
useful in promoting the development of scientific
explanations for the clinical pattern of nail disease in
relation to the principle sites of invasion.
However, changes are necessary for a number of
different reasons. We now understand that a much
wider range of organisms can attack and break down
nail keratin. Although some, such as Scopulariopsis
brevicaulis, have been known for many years as nail
pathogens that cause DLSO, there are others, such as
Fusarium species, that can produce distinct changes
ranging from paronychia to PSO through to TDO.5
Candida species, often associated with invasion of
the nail plate as opposed to the nailfold (paronychia)
on the basis of positive cultures from nail clippings,
are now recognized to be less common causes of

1219
1220 Hay and Baran J AM ACAD DERMATOL
DECEMBER 2011

primary nail dystrophy after nail plate invasion6; the change seen, we now recognize that melanonychia
clinical appearances are very similar to those seen can occur both with DLSO and superficial nail plate
with DLSO caused by other organisms including invasion.13,14 Other color changes have been re-
distal nail plate erosion and discoloration. Invasive ported such as orange discoloration caused by
Candida onychomycosis, though, can be associated Paecilomyces.15 Secondly the emergence of new
with other conditions such as chronic mucocutane- treatments that result in profound immunosuppres-
ous candidosis (CMC)6 or HIV/AIDS.7 There remains sion, and disease such as HIV/AIDS where naturally
some debate about whether acquired immunosuppres-
Candida is commoner as a sion occurs, has resulted in
true primary nail pathogen in CAPSULE SUMMARY the appearance of new forms
the tropics,8 but there is no of nail plate invasion.16,17
dThe following forms of onychomycosis
hard evidence that these Thirdly the direct spread of
are recognized under the current
cases show fungal nail plate fungi from the stratum cor-
classification: distal and lateral
invasion. Candida species neum of the surrounding skin
subungual, superficial white, endonyx,
commonly colonize the un- to the nail plate is core to the
proximal subungual, and totally
dersurface of the nail and, original classification. Yet this
dystrophic. These reflected the
therefore, to establish inva- does not explain the appear-
recognized patterns of nail invasion.
sion of the nail plate a posi- ance of PSO18 and certain
tive culture is insufficient d
Using more recent literature we have types of superficial onycho-
proof without microscopic extended this to include mixed and mycosis (SO)4,19 emerging
evidence. secondary forms of infection and refined from the proximal nailfold,
The word paronychia the definition of superficial and proximal as there is no histologic evi-
describes an inflammation subungual infection. These changes are dence that the fungi gain en-
of the nailfold that is a clini- necessary because infections are caused try via the superior aspect of
cal syndrome with multiple by a broader range of fungi than the nailfold. Although in
causes that may include in- previously reported and some may be some case these infections
fection, inflammatory skin associated with immunosuppression. may have been derived from
disease such as pemphigus,9 dThis revised classification will help a preceding, and now recov-
and adverse drug reactions clinicians to decide: (a) whether detailed ered, distal and lateral sub-
such as protease inhibitors.10 mycological investigation such as ungual nail plate extending
Candida infection can cause identification of species is necessary; and from the distal nail to the
paronychia, but, together (b) the most successful treatment proximal nailfold, nail inva-
with bacteria, yeasts can options. sion as a form of recurrence,
readily grow in a distended this can only account for
nailfold and infection may some cases that have already
therefore be a primary event or secondary to other received treatment. Alternative explanations have
conditions including irritant or allergic dermatitis.11 been proposed that include sequestration of orga-
There is often associated lateral onycholysis of the nisms in lymphatics and blood stream dissemination,
nail plate in patients with paronychia and Candida which is known to occur in certain fungal infections
species can be isolated and seen in microscopy. of the nails such as Fusarium infection in the
These lateral nail plate changes often respond to immunosuppressed.20 Bloodstream spread is also
antifungals suggesting that lateral nail dystrophy, recognized in some forms of deep dermatophyte
secondary to the presence of Candida in the nail- infection, such as maladie dermatophytique.21 In this
12
fold, is an invasive process. This can be confirmed rare deep infection there is also histologically proven
by biopsying the lateral plate to show penetration by involvement of lymph nodes. However, the method
Candida hyphae for a short distance into the under- of traffic between circulation and the nail plate is not
surface of the nail plate. known.
There are other areas where there are new Finally it is clear that in individual patients
observations including nail color, the presence of some nails show the features of more than one
immunosuppression, routes of nail plate invasion, pattern of nail infection.4 For instance where there
and mixed patterns of infection. is onychomycosis of the distal and lateral subun-
Firstly there is a wide range of color change gual type affecting a toenail, SO may develop
or dyschromia that follows nail plate invasion. on the same nail, particularly where another toe
Although in earlier reports white or yellow discol- overrides it. Fungal infection of the nail plate may
oration was the commonest form of pigmentary also arise secondary to other conditions such as
J AM ACAD DERMATOL
VOLUME 65, NUMBER 6
psoriasis22 or keratoderma23 and in these cases it
is difficult to separate nail changes caused by
fungal invasion and those caused by the underly-
ing disease.
For all these reasons a review of the current
classification of nail disease is now required.
REVISED CLASSIFICATION
The proposed classification set out in this article
(Table I) is the result of these newer observations
and forms a revised description of the different forms
of nail disease caused by fungi (Table II). Making
such a classification is timely and relevant; as the
availability of more effective antifungal drugs and a
range of topically applied antifungal medications
may ensure that the treatment is, in part, determined
by the form of nail plate invasion.
We are proposing to modify the basic model1 and
to include subsequent changes such as the following
subtypes of fungal nail plate invasion; it is also useful
to specify whether onychomycosis is primary or
secondary to some other nail disease.
Distal and lateral subungual onychomycosis
DLSO remains the commonest form of fungal
invasion of the nail plate, where the site of invasion is
from the lateral or distal undersurface of the nail
plate (Fig 1). The main features are onycholysis with
hyperkeratosis and varying forms of dyspigmenta-
tion. Most commonly this is white or yellowish but,
on occasion, other color changes such as brown,
black, and orange discoloration have been described
as well.14,15,24,25
This pattern of nail plate invasion may be com-
plicated by other changes, as in some cases it is
associated with longitudinal streaking of the nail,
sometimes called a dermatophytoma.26,27 This may
be confined to the lateral nail border or to another
part of the nail plate. However, it is associated with
the presence of underlying spongy keratin often
infiltrated with either fungi or bacteria and treatment
failure is common unless the area is excised.
Clustering of fungal arthrospores in the nail plate
associated with cell wall thickening and the emer-
gence of spaces in the surrounding keratin is seen in
many nail plate infections28 and it is thought that
these streaks are extreme examples of the same
phenomenon. Streaking or dermatophytoma can be
seen in other patterns of onychomycosis but is
commonest with DLSO. With Scytalidium infections,
paronychia may be associated with DLSO.
Onycholysis is occasionally the only physical
abnormality associated with distal and lateral nail
plate invasion. For instance it has been described
with dermatophytosis and responds to antifungal
Hay and Baran 1221
Table I. Revised classification of onychomycosis
DLSO
Clinical features include hyperkeratosis and range of
dyschromias including melanonychia, onycholysis
(which may be sole abnormality), and longitudinal
streaking in mid or lateral nail plate regions
SO (white or black)
a) patchy or transverse
b) originating from beneath proximal nailfold
- patchy
- transverse: this pattern is commonest presenta-
tion for superficial nail plate infections originat-
ing from beneath proximal nailfold
c) with deep penetration: fungi invade from
superficial to deep aspects of nail plate
Endonyx onychomycosis (EO)
PSO
a) patchy
b) striate (transverse or longitudinal)
c) secondary to paronychia*
Mixed pattern onychomycosis (MPO): examples include
following patterns on same nail
DLSO plus SO
SO plus DLSO
SO plus PSO
DLSO plus PSO
Totally dystrophic onychomycosis (TDO)
This may occur as secondary change to advanced states
of other patterns of nail plate invasion; alternatively it
may occur as primary change where it is associated
either with disease with severe immunodeficiency, eg,
HIV/AIDS or in chronic mucocutaneous candidosis
Secondary onychomycosis
Fungal nail plate invasion may occur secondary to other
nail pathologies, eg, psoriasis; here clinical changes
are dominated by morphologic features of underlying
disease.
DLSO, Distal and lateral subungual onychomycosis; PSO, proximal
subungual onychomycosis; SO, superficial onychomycosis.
*Paronychia where fungi are present may be complicated by nail
plate invasion (PSO) or nail plate invasion, commonly DLSO, may
be followed by infection of nailfold (eg, Scytalidium infection).
treatment. It is important, though, when onycholysis
is the only sign of nail abnormality, that due care is
given to ensure that the presence of fungal invasion
of the nail plate is established, such as by micros-
copy; adherence of fungi to the undersurface of the
nail may also indicate carriage. This is common with
Candida, less so with dermatophytes, and when it
occurs with the latter may be a prelude to invasion of
the nail plate.29
DLSO is associated with a variety of different fungi
(Table II and Fig 2) and equally a wide variety of
different species are seen with the rare cases of
melanonychia (Fig 3).30
1222 Hay and Baran J AM ACAD DERMATOL
DECEMBER 2011

Table II. Onychomycosis: organisms most

commonly associated with different types
Organisms commonly
Type associated
DLSO
Dermatophytes (T rubrum,
T mentagrophytes,
E floccosum*)
C albicans
Fusarium species
Scytalidium species Fig 1. Distal and lateral subungual onychomycosis caused
Scopulariopsis brevicaulis by Trichophyton mentagrophytes.

SO (white or black)
Patchy T mentagrophytes, T rubrum
Transverse Fusarium, Acremonium
Scytalidium
T rubrum, Fusarium

Endonyx onychomycosis
T soudanense
T violaceum

PSO
Patchy, striate transverse, T rubrum, Fusarium
longitudinal
Mixed pattern
onychomycosis examples
include following on
same nail
DLSO plus SO T rubrum
SO plus DLSO T rubrum, Fusarium
SO plus PSO T rubrum, Fusarium
DLSO plus PSO T rubrum Fig 2. Distal and lateral subungual onychomycosis caused
Totally dystrophic by Scopulariopsis brevicaulis.
onychomycosis Dermatophytes
C albicans
Scytalidium Superficial onychomycosis
SO may present with a range of dyschromias
Paronychia depending on the organism involved; so use of the
With onychomycosis Candida species term superficial white onychomycosis is restric-
(usually DLSO or PSO) Fusarium tive. For instance, superficial black onychomycosis
Scytalidium caused by Trichophyton rubrum has been de-
Without onychomycosisy Candida species scribed31 as has Scytalidium dimidiatum.32
Fusarium As stated previously the pattern of nail plate
invasion may present with superficial patches
(patchy type) or be organized in transverse
C, Candida; DLSO, distal and lateral subungual onychomycosis;
E, Epidermophyton; PSO, proximal subungual onychomycosis;
striaeestriate leukonychia (Fig 4).4,19 Several nails
SO, superficial onychomycosis; T, Trichophyton. may be involved at the same time, with clinical
*Other dermatophytes may also cause DLSO. changes affecting similar levels. It may also appear
y
As described above infection of nailfold may be direct result of de novo on the superficial nail plate or emerge from
fungal infection but is often, particularly in established cases, under the proximal nailfold; each has different
associated with other cause of nail plate inflammation, eg, irritant
dermatitis.
therapeutic implications. In some cases there is
deep penetration of the nail plate from the superficial
aspect19,33; immunosuppression is associated in
some patients (Fig 5). These have been discussed
previously, but the main implication of the striate
J AM ACAD DERMATOL Hay and Baran 1223
VOLUME 65, NUMBER 6

Fig 3. Fungal melanonychia caused by Trichophyton

rubrum.
Fig 5. Superficial onychomycosis with deep penetration
caused by Fusarium.

Fig 4. Superficial onychomycosis caused by Trichophyton

mentagrophytes.

form is that where the infection emerges from under

the proximal nailfold it is impracticable to use topical
therapy as it is seldom effective; there is also an
increased risk that there is co-incident infection of
the undersurface of the nail plate, in this case PSO
(Fig 6). In these patients oral therapy is likely to be
more effective. In the classic forms that present with
patchy infiltration of the upper aspect of the nail
plate topical therapy can be used as initial treatment.
However, as yet there are no large clinical therapeu-
tic studies to support this advice.
Endonyx onychomycosis (EO)
The nail plate invasion is distinguished by the
combination of lamellar splitting of the nail, discol-
oration of the nail plate (eg, milky patches), and
absence of nail bed invasion but internal nail plate
invasion. The route of infection is thought to follow
fungal hyphae penetrating the distal nail plate,
directly. It is distinguished pathologically by absence
Fig 6. Striate superficial onychomycosis originating as
proximal subungual onychomycosis caused by Fusarium.
of inflammation and fungi in the nail bed or of
subungual hyperatosis but many fungal hyphae in
the interior of the nail plate.
It was originally described as an infection with
T soudanense (Fig 7), which most commonly causes
hair shaft invasion and tinea capitis.3,34 However,
cases caused by other organisms, such as T viola-
ceum, have been seen. It is not clear if this is only
seen with organisms that have the capacity to invade
hair as well or why T soudanense in particular seems
to be mainly associated with the infection.
1224 Hay and Baran
Fig 7. Endonyx onychomycosis caused by Trichophyton
soudanense.
Fig 8. Proximal white subungual onychomycosis caused
by Trichophyton rubrum.
Proximal subungual onychomycosis
PSO has also been reassessed as the changes are,
again, organized in diffuse patches or transverse
striate patterns.1,4,18 Classically the infection is seen
originating from under proximal nail and nailfold
(Fig 8). But those forms presenting with transverse
bands (striate pattern) are often associated with a
concurrent SO (see above). The infection slowly
extends distally. There are other varieties such as one
where there is formation of a longitudinal band
extending from the proximal nailfold to the distal nail
J AM ACAD DERMATOL
DECEMBER 2011
Fig 9. Proximal subungual onychomycosis caused by
Candida albicans causing paronychium.
plate or a form that spreads rapidly at the same level
associated with immunosuppression particularly
HIV/AIDS.16 PSO is also seen with a range of orga-
nisms including dermatophytes, usually T rubrum,
and Fusarium, C albicans,35 and Aspergillus36 spe-
cies. It is a form of infection that is difficult to treat
and always requires oral therapy, although relapse is
common. Combined approaches using both oral and
topical treatment with or without surgery may be
needed.
Proximal nail plate invasion also occurs second-
ary to paronychia (Fig 9). The commonest fungi
associated with this pattern are Candida species37
and there is usually a narrow area of lateral onychol-
ysis with varying hyperkeratosis extending from the
nailfold to the distal nail margin. It also occurs with
Fusarium and other mold infections.5 These are
discussed in more detail below.
Paronychia and nail plate invasion caused by
fungi (onychomycosis) secondary to paronychia
merit further consideration (Table I). As stated pre-
viously inflammation of the nailfold, paronychia, is a
clinical syndrome of which fungal infection is but
one cause.29,37 In setting this out it must be recog-
nized that where fungi such as Candida are associ-
ated with paronychia it is not always clear whether
the organisms are, at the time of presentation,
causing or contributing to nailfold dystrophy.
Although this may seem a subtle distinction, other
factors contribute to the pathogenesis of paronychia
such as immediate contact dermatitis to food38 and
secondary bacterial infection. In immunosuppressed
J AM ACAD DERMATOL
VOLUME 65, NUMBER 6
Fig 10. Distal and lateral subungual onychomycosis
showing secondary nailfold swelling in infection caused
by Scytalidium dimidiatum.
Fig 11. Digital cellulitis and mixed pattern onychomycosis
caused by Acremonium in neutropenic patient.
patients, including those with CMC, Candida infec-
tion of the nailfold is often significant. Removing
both bacteria and fungi with topical or systemic
antimicrobials remains a goal of treatment even
though treatment with anti-inflammatory agents,
including oral, intralesional, or topical corticoste-
roids or tacrolimus,39 is often highly effective.
Likewise treating lateral nail plate dystrophy, a lateral
dystrophy spreading from the proximal nailfold, ie,
PSO, secondary to a paronychium with antifungals
can result in resolution of the nail abnormality.
It is also now known that other fungi can cause
nailfold infection with or without nail plate invasion.
The two best known examples are Scytalidium
dimidiatum (Fig 10) and Scytalidium hyalinum40
and Fusarium species.41 Recognizing these types is
important not only because there are implications for
treatment but also in the case of Fusarium infections
inflammation of the nailfold or paronychia extend-
ing proximally along the digit to produce a localized
form of cellulitis (Fig 11) may herald the develop-
ment of bloodstream spread of this infection in the
neutropenic patient.20 In both the examples cited
above (Scytalidium and Fusarium) involvement of
the nailfold is secondary to one of the patterns of
onychomycosis described in this article.
Hay and Baran 1225
Fig 12. Mixed pattern onychomycosis; in this case infec-
tion caused by Trichophyton rubrum causing distal and
lateral subungual onychomycosis and superficial
onychomycosis.
Fig 13. Totally dystrophic onychomycosis caused by
Trichophyton rubrum.
Mixed pattern onychomycosis (MPO)
As stated previously, different patterns of nail
plate infection are often seen both in the same
individual but also in the same nail. Although it is
less common than DLSO, a mixed form of onycho-
mycosis is proposed (Fig 12). Different patterns have
been described but include various combinations,
the commonest of which are PSO and SO or DLSO
and SO.19,42 These almost always require oral
therapy.
Totally dystrophic onychomycosis
This concept has not changed since it was orig-
inally proposed.2 TDO represents the end stage of a
variety of different modes of nail plate invasion
caused by different organisms.2,16 It most commonly
follows DLSO but other forms, particularly PSO, can
result in this end stage. Here the nail plate crumbles
away and the nail bed is thickened and ridged and
usually covered with debris. Very extensive end-
stage nail infection may be secondary to dermato-
phytes such as T rubrum (Fig 13) and mold fungi
whose initial path of invasion is described in the
preceding sections. In patients with CMC the whole
nail unit is thickened as a result of extensive hyper-
keratosis (Fig 14). This pattern of nail change reflects
the rapidity of nail plate invasion, and in nail disease
1226 Hay and Baran
Fig 14. Totally dystrophic onychomycosis caused by
Candida albicans in patient with chronic mucocutaneous
candidosis.
secondary to immunosuppression. Hyperkeratotic
TDO can be caused by dermatophytes in patients
with CMC and Candida.
Secondary onychomycosis
Fungi can also penetrate the nail plate and
surrounding tissues secondary to other nonfungal
pathologies. The best recognized of these are psori-
asis and traumatic nail dystrophy. In many such cases
the appearances of the nail are usually more typical
of the underlying condition, such as hyperkeratosis
resulting in thickening the nail plate in psoriasis. In
these secondary forms of fungal nail dystrophy
diagnosis based on clinical suspicion is particularly
difficult and laboratory investigations are necessary
to confirm the presence of fungi.
Summary
Classification is sometimes seen as an abstraction
that complicates clinical diagnosis and management.
In the case of nail disease it may appear hard to
justify. However, the clinical appearances of the
different forms of onychomycosis may provide in-
formation that will guide management. For instance,
the division of PSO into different varieties should
alert the clinician to those forms that are more likely
to be seen in patients with immune defects, those
that are recalcitrant to treatment, and those that are
most often seen with nondermatophyte mold fungi
such as Fusarium species. Likewise the presence of
transverse and striate nail plate infection in SO or of
longitudinal streaks in distal and lateral onychomy-
cosis should alert dermatologists to infections that
are more difficult to treat; in the case of these
superficial infections oral rather than topical therapy
is more likely to be successful. Attempts to build
these changes into treatment guidelines have gained
a measure of approval43,44 and will allow the
J AM ACAD DERMATOL
DECEMBER 2011
development of clinical trials to test the validity of
warning signs of difficult-to-treat infections. It may
also help to clarify the role of fungi in nail change as
advances in molecular diagnostics provide new
methods such as detection of the expression of
protein indicators of nail invasion.45
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