Onychomycosis vs nail psoriasis

Onychomycosis
Presentation

  • Nails appear dystrophic with marked subungual hyperkeratosis.
  • Toe nails more commonly affected.
  • Fungal infections may be present in other areas such as axillae, groin and scalp.
  • Very dystrophic nails may cause discomfort.
  • Can affect multiple nails.

Aetiology

  • Trichophyton rubrum is the commonest causative organism. This invades the nail bed then spreads through the nail.

Diagnosis

  • Nails clippings and subungual debris sent for mycology.
  • Microscopy may reveal hyphae. If not sample can be cultured, but it may take a few weeks to obtain the results.

Treatment

  • Topical antifungal agents may help if mild disease not affecting the matrix.
  • Oral antifungals such as terbinafine usually required.
  • Prolonged course of up to six months.
  • Recurrence is common.
  • Damaged nails will need to grow out.

Nail Psoriasis
Presentation

  • Nails look dystrophic and may have surface pitting.
  • The nails have discolouration in the form of oil spots.
  • Finger nails more commonly affected by psoriasis than tinea.
  • Both toe and finger nails maybe affected.
  • Psoriasis may be present elsewhere such as skin.

Aetiology

  • Chronic condition which may be hereditary and for which at present there is no curative treatment.

Treatment

  • Topical steroids applied directly to the nail.
  • Injection of corticosteroid into the nail bed.
  • Systemic therapy with either methotrexate or systemic retinoids may be required in more troublesome cases.
  • PUVA may sometimes help.

Contributed by Dr Nigel A Stollery, a GP at Kibworth Health Centre, Leicestershire and Clinical Assistant in Dermatology at the Leicester Royal Infirmary.

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