Diagnosis: Onychomycosis (proximal subungual type)
Case submitted by Alaa Saad to the dermRounds community.
Clinical photograph(s) submitted for peer review and discussion.
Submitted by Alaa Saad. Originally posted September 29, 2010.
See case discussion.
• Psoriatic nail disease • Lichen planus (nail) • Nail trauma/dystrophy • Yellow nail syndrome • Melanonychia • Squamous cell carcinoma of nail unit
• Confirm diagnosis before treating — nail clipping for PAS stain is most sensitive; KOH and culture also used • Distal/lateral subungual onychomycosis (DLSO) is the most common pattern — caused by T. rubrum • White superficial onychomycosis: T. mentagrophytes — white, crumbly nail surface • Proximal subungual onychomycosis: uncommon — consider HIV testing • Oral terbinafine has highest cure rates (~70-80%) — liver function monitoring recommended • Topical efinaconazole 10% and tavaborole 5% for mild disease without matrix involvement • Dermatophytoma (thick keratotic mass within nail plate) is resistant to medical therapy — may need avulsion
Tags: onychomycosis, proximal, subungual, type, alaa saad