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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 1
| Issue : 3 | Page : 30-33 |
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Management of dermatophytosis of nail and hair
Archana Singal, Manasa Narayan Kayarkatte
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi, India
| Date of Web Publication | 10-Oct-2017 |
Correspondence Address:
Archana Singal
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi - 110 095
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/CDR.CDR_31_17
Dermatophyte infections are common worldwide, and dermatophytes are the prevailing causes of fungal infection of the skin, hair, and nails. These infections lead to a variety of clinical manifestations; nail infection known as onychomycosis (OM) and hair infection as Tinea capitis. The diagnosis and treatment of dermatophyte infections of the Nail and hair will be reviewed here.
Keywords: Management, nondermatophytic mold, onychomycosis, tinea capitis
How to cite this article:
Singal A, Kayarkatte MN. Management of dermatophytosis of nail and hair. Clin Dermatol Rev 2017;1, Suppl S1:30-3 |
| Management of Onychomycosis | |  |
Onychomycosis (OM), a fungal infection of the nail, constitutes about 20%–40% of all onychopathies and encompasses infection of the nail unit with dermatophytes, nondermatophytic molds and Candida spp. Fingernail involvement may result in pain, discomfort, and impaired/lost tactile functions. The affection of toenails often interferes with walking, exercise, or proper shoe fit.[1] In addition, infected nail acts as a reservoir for infection, and hence, the treatment of OM is mandatory.
Diagnosis
The management of OM is double pronged and includes diagnosis and treatment. As the treatment of OM is often prolonged, it is imperative to supplement the clinical diagnosis by laboratory investigations. Various modalities available for laboratory confirmation of OM have been listed in [Table 1].
Treatment of OM can be divided into
- Topical therapy
- Systemic therapy
- Surgical modality
- Laser
- Combination of the above.
Topical therapy
In general, the treatment of OM demands systemic therapy except in some special circumstances that are as follows:
Indications of topical therapy
- Involvement limited to distal 30% of nail plate with involvement of >3 nails
- Matrix uninvolved
- Superficial white OM
- In children with thin, fast growing nails
- Where oral therapy is inappropriate
- As prophylaxis in patients at risk of recurrence.[2]
Various topical therapies have been employed but following three have US Food and Drug Administration (FDA) approval for the treatment of OM [Table 2].[3],[4],[5]
Tavaborole 5% solution[6] is a novel, boron based, topical treatment for toenail OM, approved by the US FDA in 2014. It inhibits protein synthesis and thus fungal cell growth. The drug has excellent ability to penetrate nail plate and has been found to be effective against dermatophytes, nondermatophyte molds, and yeasts including Fusarium and Malassezia species. The drug is awaiting commercial availability in India.
| Systemic Therapy | | |
Systemic therapy in the form of oral antifungal drugs has been described the most commonly used drugs have been listed in [Table 3][2],[7],[8],[9] and their common side effects have been tabulated in [Table 4].[10]
Indications
- Involvement of >30% of distal nail plate/multiple nail involvement
- Involvement of nail matrix
- Topical drug penetration is expected to be suboptimal.[2]
Nondermatophytic OM is difficult to treat and itraconazole having a broader spectrum of activity is commonly employed. The duration of therapy may be prolonged and often a combination of oral, topical, and surgical methods is required.[11]
Candidal OM responds well to systemic as well as topical treatment. Itraconazole and fluconazole are equally efficacious. Itraconazole can be used as continuous or pulse regime. Fluconazole is given as 50 mg/day or 300 mg/week to be continued for minimum 4 weeks for fingernail and 12 weeks for toenail OM also, 2–3 pulses of itraconazole have been used for the same.[11]
| Surgical Intervention | | |
Stand-alone surgical intervention has given poorer outcomes as compared to combination with medical therapy. Total surgical removal must be discouraged; the distal nail bed may shrink and become dislocated dorsally. In addition, the loss of counter pressure produced by the removal of the nail plate allows expansion of the distal soft tissue that allows the distal edge of the regrowing nail to embed itself. This can be overcome by using partial nail avulsion.[3] The presence of dermatophytoma indicates the need for a surgical intervention as the biofilm prevents the penetration of drugs.
| Laser | | |
Multiple studies have been done, employing 1064 nm neodymium: yttrium -aluminum-garnet laser system (long and short pulse types) either as a sole intervention or as a Q-switched 1064 nm/532 nm wavelengths system. Its efficacy has been found to be nonconclusive in a review of multiple studies, and its role has been justified as a supplemental modality.[12]
| Management of Tinea Capitis | | |
Tinea capitis is dermatophyte infection of the scalp hair follicles and intervening skin, mainly caused by anthropophilic and zoophilic species of the genera Trichophyton and Microsporum.
Diagnosis
Investigations that are commonly employed for tinea capitis:[13]
- Woods lamp examination: Most ectothrix infections caused by Microsporum species give a bright yellow fluorescence under Woods lamp. It is a noninvasive rapid method that can be used for screening but has a high false negative result since all fungal infections do not produce fluorescence
- 1,2-dimethoxyethane with sodium hydroxide (KOH): Ten percentages KOH is used to digest keratin following which it is examined for fungal elements under a microscope. It is a rapid method with high sensitivity
- Culture: It is a highly specific test, but has the disadvantage of longer duration of up to 6 weeks for results
- Trichoscopy: Noninvasive, rapid office-based procedure. On trichoscopy, we find broken hairs, dystrophic hairs, corkscrew hairs, comma hairs, and black dots.[14]
Although universal protocols have not been described for its treatment, systemic therapy is essential [Table 5].[15],[16],[17]
In case of kerion formation, wet compresses with removal of crusts are essential followed by antibiotics if necessary. The use of oral steroids in severe cases with widespread id reactions is also recommended under the cover of systemic antifungals. For defining mycological cure, it is recommended to examine hair root for infection at the end of the standard treatment period and then monthly until negative.[16]
Topical antifungal therapy has little place in the management of tinea capitis except as an adjunct to oral therapy. However, topical agents are used to reduce transmission of spores, and povidone–iodine, ketoconazole 2% and selenium sulfide 1% shampoos have been used. Screening family and treatment of pets with precautions for reducing transmission through fomites helps in reducing recurrences.[18]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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