Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, India.
Indian J Dermatol Venereol Leprol. 2011 Nov-Dec;77(6):659-72. doi: 10.4103/0378-6323.86475.
Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Increased prevalence in the recent years is attributed to enhanced longevity, comorbid conditions such as diabetes, avid sports participation, and emergence of HIV. Dermatophytes are the most commonly implicated etiologic agents, particularly Trichophyton rubrum and Trichophyton mentagrophytes var. interdigitale, followed by Candida species and non dermatophytic molds (NDMs). Several clinical variants have been recognized. Candida onychomycosis affects fingernails more often and is accompanied by paronychia. NDM molds should be suspected in patients with history of trauma and associated periungual inflammation. Diagnosis is primarily based upon KOH examination, culture and histopathological examinations of nail clippings and nail biopsy. Adequate and appropriate sample collection is vital to pinpoint the exact etiological fungus. Various improvisations have been adopted to improve the fungal isolation. Culture is the gold standard, while histopathology is often performed to diagnose and differentiate onychomycosis from other nail disorders such as psoriasis and lichen planus. Though rarely used, DNA-based methods are effective for identifying mixed infections and quantification of fungal load. Various treatment modalities including topical, systemic and surgical have been used.Topically, drugs (ciclopirox and amorolfine nail lacquers) are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include terbinafine, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis. Despite good therapeutic response to newer modalities, long-term outcome is unsatisfactory due to therapeutic failure, relapse, and reinfection. To combat the poor response, newer strategies such as combination, sequential, and supplementary therapies have been suggested. In the end, treatment of special populations such as diabetic, elderly, and children is outlined.
甲真菌病是一种常见的指甲疾病，与显著的身体和心理发病率有关。近年来发病率的增加归因于寿命的延长、糖尿病等合并症、热衷运动以及 HIV 的出现。皮肤癣菌是最常见的致病因子，尤其是红色毛癣菌和须癣毛癣菌变种。指间，其次是念珠菌和非皮肤癣菌霉菌（NDM）。已经认识到几种临床变异。念珠菌甲真菌病更常影响手指甲，并伴有甲周炎。对于有创伤史和相关甲周炎症的患者，应怀疑 NDM 霉菌。诊断主要基于 KOH 检查、培养和指甲屑的组织病理学检查以及指甲活检。充分和适当的样本采集对于确定确切的致病真菌至关重要。已经采用了各种改进措施来提高真菌分离率。培养是金标准，而组织病理学通常用于诊断和区分甲真菌病与其他指甲疾病，如银屑病和扁平苔藓。尽管很少使用，但基于 DNA 的方法对于识别混合感染和真菌负荷的定量是有效的。各种治疗方式，包括局部、系统和手术，都已被用于治疗甲真菌病。局部治疗时，药物（环吡酮和阿莫罗芬指甲漆）通过专门的经皮药物输送系统给药，以确保高浓度和长时间的接触。常用的口服治疗药物包括特比萘芬、氟康唑和伊曲康唑。特比萘芬和伊曲康唑都可以连续或间歇性给药。连续给予特比萘芬似乎是治疗皮肤癣菌甲真菌病最有效的方案。尽管新方法的治疗反应良好，但由于治疗失败、复发和再感染，长期结果仍不理想。为了应对这种不佳的反应，已经提出了新的策略，如联合、序贯和补充治疗。最后，概述了特殊人群（如糖尿病、老年和儿童）的治疗方法。
