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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.)
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 Hay and Baran 1221
VOLUME 65, NUMBER 6
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 7. Endonyx onychomycosis caused by Trichophyton Fig 9. Proximal subungual onychomycosis caused by
soudanense. Candida albicans causing paronychium.
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