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Onychomycosis is a fungal infection of the fingernails or toenails. The actual infection is of the bed of the nail and of the plate under the surface of the nail.


Onychomycosis is the most common of all diseases of the nails in adults. In North America, the incidence falls roughly between 2-13%. The incidence of onychomycosis is also greater in older adults, and up to 90% of the elderly may be affected. Men are more commonly infected than women.
Individuals who are especially susceptible include those with chronic diseases such as diabetes and circulatory problems and those with diseases that suppress the immune system. Other risk factors include a family history, previous trauma to the nails, warm climate, and occlusive or tight footwear.

Causes and symptoms

Onychomycosis is caused by three types of fungi, called dermatophytes, yeasts, and nondermatophyte molds. Fungi are simple parasitic plant organisms that do not need sunlight to grow. Toenails are especially susceptible because fungi prefer dark damp places. Swimming pools, locker rooms, and showers typically harbor fungi. Chronic diseases such as diabetes, problems with the circulatory system, or immune deficiency disease are risk factors. A history of athlete's foot and excess perspiration are also risk factors.
Onychomycosis can be present for years without causing pain or disturbing symptoms. Typically, the nail becomes thicker and changes to a yellowish-brown. Foul smelling debris may collect under the nail. The infection can spread to the surrounding nails and even the skin.


To make a diagnosis of onychomycosis, the clinician must collect a specimen of the nail in which infection is suspected. A clipping is taken from the nail plate, and a sample of the debris from underneath the nail bed is also taken, usually with a sharp curette. Debris from the nail surface may also be taken. These will be sent for microscopic analysis to a laboratory, as well as cultured to determine what types of fungus are growing there.


Onychomycosis is very difficult and sometimes impossible to treat, and therapy is often long-term. Therapy consists of topical treatments that are applied directly to the nails, as well as two systemic drugs, griseofulvin and ketoconazole. Topical therapy is reserved for only the mildest cases. The use of griseofulvin and ketoconazole is problematic, and there are typically high relapse rates of 50-85%. In addition, treatment must be continued for a long duration (10-18 months for toenails), with monthly laboratory monitoring for several side effects, including liver toxicity. Individuals taking these medications must also abstain from alcohol consumption.
In the past few years, newer oral antifungal agents have been developed, and include itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan). These agents, when taken orally for as little as 12 weeks, bring about better cure rates and fewer side effects than either griseofulvin or ketoconazole. The most common side effect is stomach upset. Patients taking oral antifungal therapy must have a complete blood count and liver enzyme workup every four to six weeks. Terbinafine in particular has markedly less toxicity to the liver, one of the more severe side effects of the older agents, griseofulvin and ketoconazole.
Treatment should be continued until microscopic exam or culture shows no more fungal infection. Nails may, however, continue to look damaged even after a clinical cure is achieved. Nails may take up to a full year to return to normal. If the nail growth slows or stops, additional doses of antifungal therapy should be taken.
Nail debridement is another treatment option, but it is considered by many to be primitive compared with topical or systemic treatment. Clinicians perform nail debridement in their offices. The nail is cut and then thinned using surgical tools or chemicals, and then the loose debris under the nail is removed. The procedure is painless, and often improves the appearance of the nails immediately. In addition, it helps whatever medication being used to penetrate the newly thinned nail. Patients with very thickened nails will sometimes undergo chemical removal of a nail. A combination of oral, topical, and surgical removal can increase the chances of curing the infection.

Alternative treatment

For controlling onychomycosis, as opposed to curing it, some experts advocate using Lotrimin cream, available over the counter. The cream should be thoroughly rubbed into the nail daily in order to control the infection.
In general, nutrition may also play a role in promoting good nail health and thus preventing nail disease. Adequate protein and minerals, in the form of nuts, seeds, whole grains, legumes, fresh vegetables, and fish, should be consumed. Sugars, alcohol, and caffeine should be avoided. Certain supplements may also be beneficial, including vitamin A (10,000 IU per day), zinc (15-30 mg per day), iron (ferrous glycinate 100 mg per day, vitamin B12 (1,000 mcg per day), and essential fatty acids in the form of flax, borage, or evening primrose oil (1,000-1,5000 mg twice daily).
Herbal remedies may also relieve some of the symptoms of onychomycosis. A combination of cone-flower, oregano, spilanthes, usnea, Oregon grape root, and myrrh can be used as a tincture (20 drops four times daily).
Undiluted grapefruit seed extract and tea tree oil are also said to be beneficial when applied topically to the infected nails.


Onychomycosis is typically quite difficult to cure completely. Even if a clinical cure is achieved after long therapy with either topical or oral drugs, normal regrowth takes four to six months in the fingernails, and eight to 12 months in the toenails, which grow more slowly. Relapse is common, and often, the nail or nail bed is permanently damaged. For toenails infected with onychomycosis, terbinafine seems to offer the highest cure rate (35-50%). Itraconazole cure rates typically range from 25-40%, and those with fluconazole, which was recently approved in the United States, have not been documented by long-term trials


Keeping the feet clean and dry, and washing with soap and water and drying thoroughly are important preventive steps to take to prevent onychomycosis. Other preventive measures include keeping the nails cut short and wearing shower shoes whenever walking or showering in public places. Daily changes of shoes, socks, or hosiery are also helpful. Excessively tight hose or shoes promote moisture, which in turn, provides a wonderful environment for onychomycotic infections. To prevent this, individuals should wear only socks made of synthetic fibers, which can absorb moisture more quickly than those made of cotton or wools. Manicure and pedicure tools should be disinfected after each use. Finally, nail polish should not be applied to nails that are infected, as this causes the water or moisture that collects under the surface of the nail to not evaporate and be trapped.



Harrell T. K., et al. "Onychomycosis: Improved Cure Rates withItraconazole and Terbinafine." Journal of the American Board of Family Practitioners July-August 2001: 268-73.
Scher Robert K. "Novel Treatment Strategies for Superficial Mycoses." Journal of the American Academy of Dermatology 1999.


American Academy of Dermatology. 930 N. Meacham Road, PO Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. http://www.aad.org.



Key terms

Curette — Spoon-shaped instrument for removing debris, growths, or infected nail matter.
Dermatophytes, yeasts, and nondermatophyte molds — Three types of fungi responsible for fungal infections of the nails.


fungal disease of the nails; the nails become opaque, white, thickened, and friable.


Very common fungus infections of the nails, causing thickening, roughness, and splitting, often caused by Trichophyton rubrum or T. mentagrophytes, Candida, and occasionally molds.
Synonym(s): ringworm of nails
[onycho- + G. mykēs, fungus, + -ōsis, condition]


/on·y·cho·my·co·sis/ (-mi-ko´sis) tinea unguium.


A fungal infection of the fingernails or toenails that results in thickening, roughness, and splitting of the nails.


Etymology: Gk, onyx + mykes, fungus, osis, condition
any fungal infection of the nails.
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Any infection of the nail caused by fungi, including nondermatophytes and yeast.

Onychomycosis, major types
• Candidal onychomycosis;
• Distal subungual onychomycosis;
• Proximal subungual onychomycosis;
• White superficial onychomycosis.


Dermatophytic onychomycosis, fungal nail infection, mycotic toenail, ringworm of nail, tinea unguium Dermatology A fungal infection of nails, which makes them white, opaque, thicker, brittle High risk groups Older ♀–linked to estrogen deficiency which ↑ risk of infection, DM, small vessel vasculitis, artificial nails–acrylic or 'wraps'–the nail surface is usually abraded with an emery board, which itself may be a vector for fungi that really really like the moist, warm environment of the nails


Very common fungal infections of the nails, causing thickening, roughness, and splitting, often caused by Trichophyton rubrum or T. mentagrophytes, Candida in the immunodeficient, and various molds in old people.
[onycho- + G. mykēs, fungus, + -ōsis, condition]
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(on?i-ko-mi-ko'sis) [ onycho- + mycosis]
A fungal infection of the nails usually caused by Trichophyton and Tinea species and occasionally by Candida or other fungi. The hallmarks of the disease are thickening, scaling, and discoloration of the nailbed.

Patient Care

Foot and nail care include keeping the feet and toes clean and dry, wearing fresh socks, changing shoes daily, and applying topical creams to the foot if the skin has cracked from athlete's foot. Paring away excessive nail growth (“debridement') reduces the thickness and length of affected nails and may enhance the effectiveness of medications. Some patients may have debridement performed professionally by a podiatrist.

Topical medications or oral (systemic) medications improve the appearance of fungal nail changes, but both are expensive and efficacy is only moderate. Oral antifungal drugs also carry the risk of liver damage and should be avoided by those with underlying liver compromise. Relapse rates after treatment are high.

Synonym: tinea unguium See: illustrationillustration


Fungus infection of the nails, usually by Candida or epidermophyton species.


fungal infection of the nail unit, due to Trichophyton rubrum or T. mentagrophytes infection; characterized by nail plate thickening and dystrophy, white/yellow/brown discoloration, chalkiness, friability and splitting, and a musty smell; treated by topical antifungal lacquers for 6 months or more, and/or systemic drugs such as terbinafine 250mg daily for 12-16 weeks (Table 1 and see Table 2)
Table 1: Clinical presentations of onychomycosis
DLSODistal and lateral subungual onychomycosis: commonest presentation of onychomycosis; hyponychium is infected by the fungus leading to hyperkeratosis of the distal nail bed; spreads proximally to cause hyperkeratosis of the proximal nail bed and onycholysis
SWOSuperficial white onychomycosis: less common than DLSO; caused by infection with Trichophyton mentagrophytes ; affecting the dorsal nail plate; may respond to topical treatments
PSOProximal subungual onychomycosis: involvement of the proximal nail bed, spreading distally; due to infection with Candida sp. , T. rubrum and Scropulariopsis brevicaulis
TDOTotal dystrophic onychomycosis: the end result of untreated DLSO, SWO or PSO
COCandidal onychomycosis: nail involvement due to local spread from a chronic paronychia (typical of patients whose hands are habitually wet), distal nail plate infection (rare - mainly affecting patients with Raynaud's), chronic mucocutaneous candidiasis (due to an inborn defect of cell-mediated immunity) or due to opportunist yeast infection of psoriatic nails
EOEndonyx onychomycosis: a rare form of onychomycosis caused by infection with T. soudanense
Table 2: Characteristics of fungal infections in the foot
Interdigital skin infection (intertrigo)Macerated tissue and webspace fissures Or dry, flaking tissue and webspace fissures ± pruritus
Moccasin skin infectionDry, flaking skin affecting most of plantar surface, border skin and extending on to the dorsum from the interdigital spaces, ± pruritus
Hyperkeratotic skin infectionIncreased formation of plantar keratin, with fissuring (especially around heels)
Vesicular skin infectionIntensely itchy, vesicular eruptions along plantar web line and medial longitudinal arch
Superficial nail infectionFormation of white, powdery patches or plaques on dorsal surface of one or many nails (also known as white superficial onychomycosis)
Tobacco nailFormation of white/yellow/brown streak extending from distal to proximal area of intermediate nail plate, with local plate dystrophy
Total onychomycosisContamination of the entire nail plate by fungal infection, leading to plate hypertrophy, dystrophy, discoloration and onycholysis


fungal disease of the nails or claws; the nails (claws) become misshapen, discolored, thickened and friable.
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