Baran and Dawber’s
`Diseases of the Nails
`and their Management
`
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`

`
`Baran and Dawber's
`Diseases of the Nails
`and their Management
`
`EDITED BY
`
`R. Baran
`
`MD
`Le Grand Palais, Nail Disease Centre, Cannes, France
`
`R.P.R. Dawber
`
`MA, MB, ChB, FRCP
`Consultant Dermatologist and Clinical Senior Lecturer,
`Department of Dermatology, The Churchill Hospital, Oxford, UK
`
`D.A.R. de Berker
`
`MB, BS, MRCP
`Consultant Dermatologist and Honorary Senior Lecturer,
`Department of Dermatology, Bristol Royal Infirmary, Bristol, UK
`
`E. Haneke
`
`Prof Dr Med
`Klinikk Bunas, Sandvika, Oslo, Norway
`
`A. Tosti
`
`MD
`Professor of Dermatology, fstituto di Clinica Dermatologica,
`dell' Universita di Bologna, Bologna, Italy
`
`T H I R D EDITION
`
`b
`
`Blackwell
`Science
`
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`

`
`Q 1984,1994,2001 by
`Blackwell Science Ltd
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`Osney Mead, Oxford OX2 OEL
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`The rights of the Authors to be identified
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`
`First published 1984
`Second edition 1994
`Reprinted 1995,1997
`Third edition 2001
`
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`A catalogue record for this title
`is available from the British Library
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`
`Library of Congress
`Cataloging-in-publication Data
`Baran and Dawber’s diseases of the nails and their management/
`edited by R. Baran . . . [etal.].-3rded.
`p. ; cm.
`Includes bibliographical references and index.
`ISBN 0-632-05358-5
`1. Nails (Anatomy)-Diseases.
`2. Nail manifestations of general diseases.
`I. Title: Diseases of the nails and their management.
`11. Baran, R. (Robert)
`111. Dawber, R. P. R. (Rodney P. R.)
`IV. Diseases of the nails and their management.
`[DNLM: 1. Nail Diseases.
`2. Nails-abnormalities. W R 475 82251 20011
`RLl65 .D572001
`6 16.S47Ac2 1
`
`00-058490
`
`For further information on
`Blackwell Science, visit our website:
`www. blackwell-science.com
`
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`

`
`Contents
`
`Contributors, vi
`
`Preface to the Third Edition, vii
`
`Preface to the First Edition, viii
`
`1 Science of the nail apparatus, 1
`R.P.R. Dawbcr, D.A.R. de Berker & R. Baran
`
`2 Physical signs, 48
`R. Baran, R.P.R. Dawbcr & B. Richert
`
`3 The nail in childhood and old age, 104
`R. Baran, R.P.R. Dawber & D.A.R. de Berker
`
`4 Fungal (onychomycosis) and other infections involving the nail apparatus, 129
`R.J. Hay, R. Baran & E. Haneke
`
`5 The nail in dermatological diseases, 172
`D.A.R. dc Berker, R. Baran & R.P.R. Dawber
`
`6 The nail in systemic diseases and drug-induced changes, 223
`A. Tosti, R. Baran & R.P.R. Dawber
`
`7 Occupational abnormalities and contact dermatitis, 330
`R.J.G. Rycroft & R. Baran
`
`8 Cosmetics: the care and adornment of the nail, 358
`E. Brauer & R. Baran
`
`9 Hereditary and congenital nail disorders, 370
`L. Juhlin & R. Baran
`
`10 Nail surgery and traumatic abnormalities, 425
`E.G. Zook, R. Baran, E. Hancke & R.P.R. Dawber
`(with the participation of G.J. Brauner)
`
`11 Tumours of the nail apparatus and adjacent tissues, 5 15
`R. Baran, E. Haneke, J.-L. Drapk & E.G. Zook
`(with the participation of J.F. Krcusch)
`
`Index, 631
`
`V
`
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`

`
`Contributors
`
`R.J. Hay MA, DM, FRCP, MRCPath
`Mary Dunhill Professor of Cutaneous Medicine,
`St John’s Institute of Dermatology,
`St Thomas’s Hospital,
`London. UK
`L. Juhlin MD
`Professor and Head, Department of Dermatology,
`University Hospital,
`S-751 85 Uppsala, Sweden
`J.F. Kreusch PhD, MD
`Dermatological Clinic,
`University of Luebeck,
`23538 Luebeck, Germany
`B. Richert MD
`Department of Dermatology,
`Polyclinique Lucien Brull,
`4200 Liege, Belgium
`R.J.G. Rycroft MA, MB, BChir, MD, FRCP
`Consultant Dermatologist,
`St John’s Institute of Dermatology,
`St Thomas’s Hospital,
`London, UK
`A. Tosti MD
`Professor of Dermatology,
`Istituto di Clinica Dermatologica
`dell’ Universita di Bologna,
`40138 Bologna, Italy
`E.G. Zook MD
`Professor of Surgery and Chairman,
`Southern Illinois School of Medicine,
`Institute of Plastic Surgery,
`Springfield,
`IL 62708, USA
`
`R. Baran MD
`Nail Disease Centre, Le Grand Palais,
`42 rue des Serbes,
`06400 Cannes, France
`
`D.A.R. de Berker MB, BS, MRCP
`Consultant Dermatologist and Honorary Senior Lecturer,
`Department of Dermatology,
`Bristol Royal Infirmary,
`Bristol. UK
`
`E. Brauer MD (Deceased)
`Formerly Associate Professor of Clinical Dermatology,
`New York University School of Medicine,
`New York,
`NY. USA
`
`G.J. Brauner MD
`Associate Clinical Professor of Dermatology,
`New York Medical College,
`Valhalla,
`NY, USA
`
`R.P.R. Dawber MA, MB, C ~ B , FRCP
`Consultant Dermatologist and Clinical Senior Lecturer,
`Department of Dermatology,
`The Churchill Hospital,
`Oxford, UK
`
`J.-L. Drapi MD, PhD
`C.I.E.R.M.,
`HBpital de BicPtre,
`Universitk Paris Sud,
`Le Kremlin-BicPtre. France
`
`E. Haneke Prof Dr Med
`Klinikk Bunas, 1337
`Sandvika, Oslo, Norway
`
`vi
`
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`

`
`Preface to the Third Edition
`
`It is now over 20 years since we first conceived the idea of a
`detailed reference book on all aspects of nail science, nail dis-
`orders and their treatment. By that time in our lecturing and
`teaching commitments around the world we had been privil-
`eged to work with a vast array of great experts in the field, all
`beginning to move across traditional specialty boundaries-one
`saw podiatrists with great operating skills working with derma-
`tological and plastic surgeons; beauticians showing doctors
`that aesthetic and ‘functional’ remedies may at times be more
`relevant than formal medical therapeutics; geneticists seeing
`that the nail apparatus may give more specific insight into
`mechanisms of hereditary diseases than other sites. . . and so
`on. Blackwell Science accepted the project and the first edition
`appeared in 1984.
`The ‘cross-fertilization’ between specialists has continued
`apace during the last 17 years to the extent that expanding
`knowledge and better medical and surgical treatments have led
`to the Third Edition being 50% larger than the First Edition.
`This expansion has been controlled and enhanced by the edi-
`torial team increasing to five-David de Berker, Antonella Tosti
`and Eckart Haneke have great breadth of experience in the sci-
`entific and clinical aspects of the nail apparatus and those used
`to the Second Edition will recognize this input well beyond their
`
`specific contributions to many chapters. There has been consid-
`erable enlargement of the sections on nail apparatus tumours
`and nail surgery; this is due almost entirely to the new contribu-
`tions by Elvin Zook and Jean-Luc Drap6. Last but not least we
`welcome Bernard Richert; his clinical experience has been care-
`fully applied to the physical signs section. Significant changes
`have occurred in the understanding and treatment of ony-
`chomycosis since the Second Edition and this is reflected in the
`fungal diseases section.
`Many clinical figures included in this edition have been con-
`tributed by colleagues from all over the world and we offer
`them our most grateful thanks; we hope that all their contribu-
`tions have been acknowledged in the text and apologise if inad-
`vertently we have failed to do so at any point. After three
`editions of this book it is time for a very particular acknow-
`ledgement to be made to Nicole Baran. Those directly involved
`will know of her immense administrative commitment far
`beyond the call of duty! One can truly say that she is the great
`catalyst that has made the book gel.
`
`Robert Baran
`Rodney Dawber
`
`vii
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`
`Preface to the First Edition
`
`Since the earliest publication by Heller there have been several
`books written on diseases of the nail: in particular the works of
`Alkiewicz and Pfister; Pardo-Castello and Pardo; Samman,
`Sertoli and Zahs must be mentioned as they are of high quality
`and extremely useful, mainly to dermatologists.
`For many years we have felt that there is a need for a compre-
`hensive reference book on all aspects of the nail in health and
`disease. It is evident that in different cultures nail abnormalities
`are often seen by a variety of specialists, e.g. traumatic and
`genetic dystrophies are rarely seen initially by dermatologists
`whilst cosmetic and industrial problems may be handled by
`dermatologists, industrial health experts, cosmetologists or chi-
`ropodists. These are a few examples of the need for a reference
`book to ‘cross’ speciality, and even more important, parochial,
`national medical barriers. We believe that a satisfactory book
`on the nail must do this. The world is small! We have both trav-
`elled widely in recent years and do hope that the content and
`style of the book succeeds in this aim.
`Some people may be surprised to find a Frenchman and
`Englishman apparently having agreed with each other for long
`enough to produce a book of this nature-not all French and
`English are enemies! We have worked diligently to benefit from
`our language differences and to combine the differences in
`training and interests and hope that this first truly international
`book, including authors from France, Germany, Sweden, UK
`and USA, will be of use world-wide.
`Though the chapters have been contributed by specific
`authors, we must point out that the book is very much a group
`activity; in particular, the editors have contributed much from
`
`their own files to every section. This applies to the script, refer-
`ences and figures, and therefore any errors of fact, emphasis or
`quality of picture may be the fault of the editors rather than the
`named chapter writers!
`The inclusion of colour pictures has obviously made the
`book more expensive than with black and white pictures alone.
`We gave considerable thought to this and decided to include
`them as important diagnostic aids because of the photogenic
`nature of the nail; and the fact that between the ten authors we
`had a unique opportunity to pool material collected over many
`years.
`
`Acknowledgements
`
`An undertaking of this kind is quite impossible without the help
`of a vast number of colleagues the world over who have encour-
`aged, cajoled and constructively disagreed with us over the
`many years that we have been interested in nails; and more
`specifically we must thank those who have provided details and
`pictures of their patients-these are acknowledged in the script.
`We are deeply indebted to Georges Achten, Peter Samman
`and Nardo Zai’as who at various times have stimulated our
`interest in this field; without their help in our careers this book
`would not have materialized in any shape or form.
`We are very grateful to Dr Gerald Godfrey and Chris Gum-
`mer who gave great assistance in formulating the final text.
`
`Robert Baran
`Rodney Dawber
`
`...
`Vlll
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`
`640
`
`INDEX
`
`nutritional disorders lzroririimedl
`vitamin Budcficiczicy 95, 262
`vitamin C deficient)‘ 262
`zinc deficiency 95, 262-3
`
`oblique lines 64. 106
`occupatioiial disorders
`aetiology 331
`bacterial infections 342-4
`clinical reaction patterns 331
`definition 331
`diagnosis 33]
`fungalinfectiotis 345
`handicap, impairment and disability 331
`systemic 345
`v ira I in factions 344 -5
`taccttpational stigmata 332, 333
`uculo-dento-digital [ODDIODODJ syndrome
`383
`-:ieulo—tricl1o-dysplasia tO'l'Dl syndrome 383
`Odlatid bodies .9
`0dt>nto—trichume|ic hypohidrotic ectodcrrnal
`dysplasizt 383
`ndonto-trichriungual digital palmar
`syndrome 383
`odonrimiicroriychial tlysplasia 383
`odunroonyehodermal dysplasia 3 79
`oduntoonychodysplasia with alopccia .383
`oilspot
`psoriasis 76, 175, I76
`systemic lupus crythemzitosus 2.40
`old age 123-7
`aetiology of changes I24
`fungalinfcctiuri 127
`ingrowing toenail 126
`linear nailgmwth 124
`mechaniczilfacttirs I26
`nail contour variations l‘23, 124
`nailthickness F25
`tumours in nailarea. 126
`()l1ier‘s chonclrodysplasia 586
`Oltrisrei_l’s syndrome 379
`omega nail 54, 496-7
`one—hand ftwo-foot tinea sg.-ridroine I31
`onions J38
`oiiychalgia 318
`onychattophy 60
`rxnychauxis SPO pach ycinychia
`O|"l)«'Cl1l3
`puncrata 67
`sicca 164
`syphilis 163
`oi'iychoatr<:ph_v 306
`nitychnclavus 126
`onychocryprnsis 126
`()l'i)v'Cl'lOdC‘rlT1al band 1, 2
`t>ii}'ch<id§'s:ruph}' 300
`on}-chc'sgr}rphosis 61, 62, 40-?-
`eauses 63‘
`circulation disorders 228
`hereditary 62
`old age 61, I25, [26
`psoriasis 62
`rheumatoid arthritis 244
`spinal cord itiiuries Z74
`syphilis l65—4
`systemic sclerosis Z40
`tneiiails 489
`traumatic 62
`vein:-us stasis 233
`onyehnhetercgtopia 399, 409, 410
`onychtvlemnixil horn SIR
`
`U-I‘1}’Cl10l}iSiS 76. 7?
`acmcyanosis 23]
`aniyloidosis 27']
`bronchial carcinoma 253
`cancer cheitiothcra pcutic agents 322
`Cmrtzfidiz 76, I32, 151, 155
`chlotamphenicol 310
`circulation disorders Z27
`classification 78
`Cl0f£l?_ll11II1E 310-11
`congenital 403
`Cronkhite-Canada syndroinc 260
`diuretics 328
`DLSCJ sccondarym 134
`elderly 125
`graiI—ver5us-host disease 281
`hacmodialysis 254
`lichen planus 200
`long nails 363
`lungrii.-uplasm 294
`nail cosmetic proccdu res 367
`occupational 332, .348, .349
`pellagra 261
`porphyria 2-69
`p0st—cryosurgi:r_\' 448, 449
`Psemiomrmasirifection 76
`psoriasis 76, 1'73, 175
`retinoicl therapy 306
`syphilis 163
`systemic lupus Cl"';»'[l'I£I!13E(lSL1S 240,
`241
`S';lStC).'I1lL‘ sclerosis 239
`tabes dorsalis 278
`thyroid disease 265
`toenail 154,489
`traumatic T’
`ongrchramadesis 74, 73, 76, 276
`anticonvulsanttherapy 304
`arsenic 317
`circulation disorders 227
`Cronkhite-Canada syndrome 260
`graft-versus-hosrdiseasc 281
`histiocytosis X 290
`lead 318
`paraneoplasticdisorders 292
`parathyroid extracts 320
`reversible 304
`sulphonamides 310
`systemic lupus crythemarosus 240
`rabesdnrsalis Z78
`0l‘1';»'L'l‘l0l'!‘Iatl'lL'(Jl'l1£1 535, 536, 537
`or-)'chornycosis 16, 130-59
`AIDS 283
`Candida 314,155
`culture 14l,i42
`diabetes 266
`differential diagnosis 146
`distal and lateral suhiingual {DLSO}
`l3l—4
`endunyx 13-5, I36. I44
`gre1Ft—vcrsus-host disease 28f
`histopathnlogy I42-6
`HIV 114
`infants H4
`laboratoryiiwestigation 140-6
`IT1:lCr0SCOP}’ 140. Mi‘
`nailrcmtwzil 152
`non—dt-rnizirnphytc moulds 154-5
`oldage 127
`pC'(llL'Lll0S‘lS 169
`priniargr
`l3l—4
`Pl'OXifI!alSUl)l.1HgLl;1l{PSO} 136-9
`
`proximal white subungual (l’WSO]
`136 -7, 144
`superficial black l35, 136
`superficial white 134, I35, I44
`T. rubmm l I4
`therapeutic immunosupptession 281
`toenails 489
`topical treatment 127, 147
`total dystrophic {TDD} I35‘, }40,14§
`transungual drug delivery systems 14?— 8
`treatment H4, 146-55
`trcatnient failure 154
`unychupa pillotna
`nail bed 528, 530, 563
`siibimguzil tissue 80
`nnychoptosisdelluvium 74
`onychorrhexis 83,2}!
`graft—vcrsus—host disease 281
`rheumatoid arthritis Z44
`thallium 318
`011}’L'l.’10$Chi?.iE1
`graft—vcrsus—host disease 281
`lamelliua 69-70, 68, 255
`pcnicillamine 328
`pcriarteriris nodosri 246
`retirioid therapy 307
`in systemic ariiyloidnsis 272
`onychutillnmrznia l 16, Z79
`onychorrichodysplasia with ricutropenia 386
`I;-1'l}'X1lS cr-.1queIe' 163
`l'>f21lC()IIl‘I‘aCCp‘El\.'€5 320
`orf virus .344
`organic solvents 341,342
`orthonyx 498
`Osler syndrome 289
`Oslt-r’s nodes 227
`0SfC0~On}’<Il"i0(l}'SplCl.Si1 4:’)!
`osteoarthritis 248, 497
`osteochondroma 582-3
`osteoid osteoma 58 7- 8
`ostcoljrsis, resorptive I 86
`<35teom}'t‘liti.\ 281
`osteopoikilosis 422
`oto—onycho-peronenl syndrome 405
`overcurvatu re of nails
`[20, I23, 408
`oxalategraiiuloina 604
`oxalic: acid 342
`
`paclwdcrtnopcriostosis .50, 405
`paehyonyehia 61,4-I2
`cervical rib syndrome 276
`graft-versus-host disease 281
`haemodizilysis 254
`hypognizadism 263
`pachyoiiycltia congcnitei 13, 61,380, 389,
`490. 491
`with zm-iyloidosis and hyperpigmeritatimi
`.380
`hard nails‘ 81
`laser siirgery 452
`with lL’L1C()nya:l1lJ
`paclitaxel .32.}
`paiiiftil nail 511-13
`l’fllllSl’c1'—l"‘l.'.lllS}'ndr()m¢ 401
`pttlmarareh I9
`palmardigital arteries 19
`I87
`palmoplanmr pusttilosiz;
`papilloma, subungual S28
`papuloerythroderma 296
`para—atr1inns3lic;¢-lic acid 91
`parakerzttosis pusnilosa (Hi(JI[h-Sab0ur;[L[d)
`I00, .796, 19?
`
`.380
`
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`

`
`CHAPTER 4
`
`Fungal (onychomycosis) and
`other infections involving the
`nail apparatus
`
`R.J. Hay, R. Baran & E. Haneke
`
`Onychomycosis
`Distal and lateral subungual onychomycosis
`Primary distal and lateral subungual onychomycosis
`Distal and lateral subungual onychomycosis secondary to
`onycholysis
`Superficial onychornycosis
`Superficial white onychomycosis
`Superficial black onychomycosis
`Variants of superficial white onychomycosis
`Endonyx onychomycosis
`Proximal subungual onychomycosis
`Proximal white subungual onychom ycosis
`Proximal subungual onychomycosis secondary to
`paronychia
`Total dystrophic onychomycosis
`Laboratory investigation
`Direct microscopy
`Culture
`Histopathology for demonstrating fungi in the nail
`Differential diagnosis
`Treatment
`Topical treatment
`Transungual drug delivery system
`Clinical studies
`Oral antifungal treatment
`Nail removal
`Chemical avulsion
`Rationale for a new approach to therapy
`Management of various subtypes
`Non-dermatophyte mould onychomycosis
`Candida onychomycosis
`Onycholysis with Candida colonization
`Chronic Candida paronychia
`Complications associated with the treatment of onychomycosis
`Other fungal infections
`Sporotrichosis
`Blastomycosis
`
`Other infections
`Herpes simplex
`Differential diagnosis
`Treatment
`Herpes zoster
`Gonorrhoea
`Syphilis
`Pinta
`Leprosy
`Leishmaniasis
`Trichinosis
`Scabies
`Pediculosis
`Tungiasis
`Larva migrans
`Subungual myiasis
`Infection in other chapters
`Chapter 3
`Impetigo
`Veillonella
`Nursery staphylococcal infection
`Blistering distal dactylitis
`Chapter 6
`Malaria
`Acute febrile infection
`Mucocutaneous lymph node syndrome
`Chapter 7
`Tetanus
`Erysipeloid
`Prosector’s wart (TB verrucosa cutis)
`Mycobacterium marinum
`Tularaemia
`Orf
`Milker’s nodule
`Chapter 10
`Acute paronychia
`Lectitis purulenta et granulomatosa
`
`129
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`
`130 C H A P T E R 4
`
`In this chapter the onychomycoses are considered in detail,
`together with a variety of infections occasionally seen in and
`around the nail apparatus; some infections (see chapter contents
`above) are discussed, where appropriate, in other chapters.
`Onychomycoses occur throughout the world but there are
`regional differences in incidence. Precise data as to their preval-
`ence have only recently become available and the results again
`vary from country to country (Baran et al. 1999). The results
`also vary with the method of calculation of the prevalences. For
`instance Roberts (1992) found that by using a photographic
`identification method in randomly selected individuals, about
`2.3% of subjects in the UK had changes in their nails compat-
`ible with onychomycosis. However, larger numbers have been
`found by direct examination of populations attending derma-
`tologists in the USA and in Finland. Specific groups such as
`diabetics have also been found to have a higher prevalence
`than normal individuals (Gupta et al. 1998a). Sociocultural
`and occupational factors play an important part in the increase
`as well as the spread of organisms such as Trichophyton
`rubrum. In rural areas in Zaire, the incidence was found to be
`0.89%, whereas in city dwellers it was 4% in men and 2.8% in
`women (Vanbreuseghem 1977). Fungal infections of the nails
`have been reported in 6.5-27% of miners (Gotz & Hantschke
`1965). Some 1.5% of all patients attending dermatological
`centres have onychomycosis (Achten & Wanet-Rouard 1981).
`Between 18% and 40% of all nail disorders are onychomycoses
`(Pardo-Castello & Pardo 1960; Achten & Wanet-Rouard 1978)
`and 30% of all dermatomycoses are nail infections (Langer 1957).
`
`Onychomycosis
`Fungal infections of the nail apparatus may be classified as
`superficial, distal or proximal according to the site of fungal
`invasion (Fig. 4.1). In this chapter a new classification (Baran
`et al. 1998b) is used, which expands on previous schemes to
`include mycoses involving the whole nail apparatus as well as
`a new form, endonyx onychomycosis. The appearance of the
`lesion may provide clues to the likely identity of the infecting
`organism, although it is seldom possible to identify the species
`on clinical grounds alone: for instance, irrespective of right
`or left handedness, unilateral hand involvement is a common
`feature of dermatophytosis caused by Trichophyton rubrum;
`in such patients both feet are commonly infected (Vazquez et al.
`1998) (Fig. 4.2). Similarly onychomycosis confined to the
`fingernails is more suggestive of a Candida infection, especially
`in paronychia and onycholysis, although infections caused by
`either Scytalidiurn dirnidiaturn (Hendersonula toruloidea j or
`S. hyalinum may both produce identical nail lesions. These
`observations contribute to the process of making the diagnosis,
`but this will depend ultimately on the laboratory identifica-
`tion of the fungus. Invasive onychomycosis can also be proved
`convincingly by histology. A search for infections at other sites
`such as the hands, feet (soles and webs) or groins, or the scalp
`in infants, should be instituted when there is a suspicion of ony-
`chomycosis. Discoloured dyschromic nail changes caused by
`fungi are considered in the section on chromonychia (page 89).
`
`Fig. 4.1 Diagram to show the site of invasion and types
`of onychornycosis. DLSO, Distal and lateral subungual
`onychomycosis; EO, endonyx onychornycosis; PSWO,
`proximal subungual white onychomycosis; SWO.
`superficial white onychornycosis.
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`FUNGAL A N D OTHER INFECTIONS 131
`
`Fig. 4.3 Distal and
`lateral subungual
`onychomycosis due to
`Jrichophyton rubrum.
`
`Fig. 4.4 Distal and
`lateral subungual
`onychomycosis restricted
`to the medial edge due
`to Jrichophyton
`(mentagroph ytes va r .)
`interdigitale.
`
`nail becomes opaque. Fungal invasion leads to orthokeratosis
`of the nail bed epithelium. In advanced nail disease a more
`severe inflammatory reaction affects the nail bed with penetra-
`tion of mononuclear cells and polymorphonuclear leucocytes
`into the subungual keratin, sometimes mimicking Munro’s
`microabscesses. Parakeratotic foci, often containing inspis-
`sated serum, may appear (Haneke 1991). In time, tunnels pro-
`duced by dermatophytes and containing air, described by
`Alkiewicz (1948) as a transverse net, appear as opaque streaks
`in the nail plate. Occasionally, this may be seen more clearly
`
`Fig. 4.2 (a) Distal and lateral subungual onychomycosis presenting as one hand/
`two-foot tinea syndrome. (b) Involvement of the palm of the same hand.
`
`Distal and lateral subungual onychomycosis (Figs 4.3-4.10)
`
`Primary distal and lateral subungual onychomycosis
`(Table4.1)
`
`In this pattern of infection the onychodermal band is disrupted
`by infection and the fungus reaches the underside of the nail via
`the hyponychium, the nail bed, or the lateral nail fold where the
`stratum corneum is invaded. The nail bed infection in distal and
`lateral subungual onychomycosis (DLSO) caused by T. rubrum
`is the result of the fungus spreading from the plantar (Evans
`1998) and palmar surface of the feet and hands, a pattern seen
`in the one-hand/two-foot tinea syndrome (Daniel et al. 1997).
`The thickened horny layer raises the free edge of the nail plate
`with disruption of the normal nail plate-nail bed attachment
`(Baran et al. 1998a). The disease spreads proximally and the
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`132 C H A P T E R 4
`
`Fig. 4.7 Onycholysis due
`to Trichophyton rubrum.
`
`Fig. 4.5 Distal and
`
`lateral subungual
`onychornycosis due to
`Trichophyton rubrum
`nigricans presenting
`with longitudinal
`rnelanonychia.
`
`Fig. 4.8 Onycholysis due
`to Candida albicans.
`
`Fig. 4.6 Onycholysis due
`to Trichophyton rubrum.
`
`with the aid of a lens, after the nail plate has been treated
`with cedar oil to render it translucent. Where the network is
`sufficiently dense, it appears as an opaque white or yellowish
`zone or streak, a clinical feature often seen in dermatophyte or
`mould infections. Such lacunae often contain masses of fungi
`as well as keratin debris and their existence provides a difficult
`target for treatment as persistence of infection may occur at this
`site, possibly due to poor drug penetration. Often there is nail
`
`invasion in a longitudinal narrow band which follows the
`ridges of the nail bed. In addition according to Zaias (1972), a
`variety of microorganisms may coexist in the ecological niche
`created by an area of onycholysis and these are responsible
`for colour changes which vary from grey to chestnut brown.
`Negroni (1976) has reported on nail erythrasma. With progres-
`sive infection, the nail becomes friable and eroded at the lateral
`and distal borders.
`The clinical appearances of nail dystrophies caused by differ-
`ent fungi are seldom diagnostic, but there may be some useful
`and potentially distinctive features apart from the differences in
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`FUNGAL A N D O T H E R I N F E C T I O N S 133
`
`Fig. 4.10 Black nail due
`to Candida parapsi/osis.
`(Courtesyof 0. Binet,
`France.)
`
`Table 4.1 Causes of distal and lateral subungual onychomycosis (DLSO)
`
`Derrnatophytes Trichophyton rubrum. T interdigitale, Epidermophyton
`floccosum, T. shoenleinii, T tonsurans, T soudanense, T.
`erinacei, 7. verrucosum, T concentricum, T. violaceurn, M. canis
`
`Yeasts
`
`Moulds
`
`Candida albicans, C. pXapsi/OSiS
`
`5copulariopsis brevicau/is, 5cytalidium dimidiatum, 5. hyalinum
`
`Fig. 4.9 (a) Distal and lateral subungual onychomycosis (DLSO) due to5cfla/idium
`dimidiarurn in a Caucasian patient. (Courtesy of D. Jones UK.) (b) DLSO associated with
`paronychia due to5. dimidiarum.
`
`the overall pattern of nail involvement discussed previously.
`For example hyperkeratosis accompanying onycholysis is a
`common feature of dermatophyte infections, which are the
`commonest causes of DLSO, whereas in Cundidu onycho-
`mycosis, gross hyperkeratosis is mainly seen in total nail plate
`involvement in patients with chronic mucocutaneous candidia-
`sis; in other cases of true Cundida onychomycosis thickening of
`the nail plate may be minimal. There has been some debate
`about the role of Candidu as a cause of DLSO. Cundidu species
`are said not to produce specific keratinases and therefore they
`cannot invade the healthy nail plate. There does appear to be a
`group of patients in whom there is genuine distal and lateral
`invasion of the nail plate with erosion, confirmed histologic-
`
`ally, but without significant thickening. This is mainly seen
`in women, patients with endogenous or exogenous Cushing’s
`syndrome or those with Raynaud’s phenomenon (Hay et ul.
`1 9 8 8 ~ ) . It may also occur in some tropical countries. While it is
`possible that some invasion is secondary to pre-existing ony-
`cholysis (see below), this is seldom possible to establish. There
`is often a distinctive brown- or cinnamon-coloured discoloration
`of nails, mainly toenails, affected by Scopulariopsis brevicuulis.
`It is caused by the presence of large numbers of pigmented co-
`nidia produced in situ (Belsan & Fragner 1965). Likewise brown
`pigmentation appearing as an irregular streak in the nail plate,
`often at the lateral border of the great toenail, is also a feature of
`infections caused by Trichophyton interdigitale and T. rubrum
`may sometimes present with
`longitudinal melanonychia
`(Higashi 1990; Perrin & Baran 1994). In this case the cause
`of the pigmentation is unknown. The nail dystrophies caused
`by Scytulidium dimidiatum (Fig. 4.9) or Scytulidium hyalinum
`are similar to dermatophyte onychomycosis (Moore 1978;
`Gugnani et ul. 1986) and may be found in Caucasians (Jones
`et ul. 1985). However, secondary paronychia appears to be
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`134 C H A P T E R 4
`
`Table 4.2 Organisms found in distal lateral subungual onychomycosis (DLSO) with
`pre-existing onycholysis.
`
`Dermatophytes
`
`Trichophyton rubrum, T. interdigitale, Epidermophyfon
`floccosurn
`
`Yeasts
`
`Mould
`
`Candida albicans, C. parapsilosis, C. tropicalis
`
`Various species have been reported including Aspergillus
`and Penicillium
`
`commoner in fingernail infections and extensive onycholysis
`may also be a prominent feature of these infections. This may
`lead to a transverse fracture of the nail plate near the proximal
`nail fold and subsequent shedding of the distal plate.
`
`Distal and lateral subungual onychomycosis secondary to
`onycholysis (Table 4.2)
`
`On occasions dermatophytes may be isolated from nails, such
`as the big toenail, which show idiopathic or primary onycholy-
`sis. Davies (1968) reported on 3955 samples of nails infected
`with T. rubrum. Nine per cent of the normal, healthy looking
`nails were positive for fungus on direct microscopy, culture or
`both. This was confirmed by Baran and Badillet (1982), who
`examined 46 samples of normal nails from patients infected in
`other sites with T. rubrum (35 cases), T. interdigitale (10 cases)
`(one patient having a mixed infection), and Epidermophyton
`floccosum (one case). T. rubrum was found in the nails of four
`of these patients, T. interdigitale in two and E. floccosum in one
`only. A subsequent control study was carried out on 52 out-
`patients seeking medical advice for reasons other than big
`toenail dystrophy. Dermatophytes were isolated from clinically
`normal big toenails in two patients, T. rubrum in one case and
`E. floccosum in the other. In these apparently healthy nails,
`the fungi were presumably acting as commensals rather than
`pathogens. However, they are potentially invasive, particularly
`in nails showing onycholysis, and may be transmitted to a differ-
`ent host. On the fingers, primary onycholysis is more frequently
`associated with secondary invasion by Candida and/or Pseudo-
`monas. It is most common in women in whom there is repeated
`contact with water, soap and detergents. Contrary to the class-
`ical pattern of DLSO, which usually starts with distal hyperker-
`atosis, there is a reversal of the usual order of evolution of each
`lesion in secondary onychomycosis. For example, in the finger-
`nails onycholysis precedes any subsequent thickening of the
`distal subungual area, hence the name of DLSO associated with
`onycholysis. Repeated episodes of friction secondary to rubbing
`of the nails against shoes or the repeated episodic trauma
`incurred during running or jogging may also create an area of
`traumatic onycholysis where microorganisms are also poten-
`tially but not invariably pathogenic. A variety of fungi not nor-
`mally considered pathogenic may be isolated from dystrophic
`nails, particularly in the elderly (English & Atkinson 1974).
`
`The usual clinical pattern of nail involvement most closely
`resembles DLSO. Hyperkeratosis and brown or green dis-
`coloration are common and the toenails are most commonly
`affected. The organisms isolated may include Aspergillus species
`such as A. terreus or A. v