1. Introduction Nail dystrophy can be the result of a number of insults and conditions like Fungal infection, Trauma, Psoriasis, Hand eczema, Lichen Planus and Inherited disorders. 50% or more of cases are due to fungal infection (onychomycosis). dermatophytes account for approximately 90% of cases. Less than 10% of cases of onychomycosis are due to yeasts or non-dermatophyte molds.

2. Onychomycosis any infection of the nail caused by Dermatophyte fungi Non dermatophyte fungi, or yeasts. Tinea unguium----strictly to dermatophyte infection of the nail plate. 3. Epidemiology 2 % -8%. prevalence of onychomycosis in Europe at approximately 27 %, North American ---- 13.8% 4. It occurs worldwide. Is frequently associated with chronic tinea pedis. Toenail infections are more common than fingernail infections. rarely fingernail onychomycosis occur without concurrent toenail infection. 5. A single nail may be involved , but more commonly, multiple nails on one or both hands or feet are affected. 6. 3.Yeasts Approximately 5 %of onychomycosis. the majority of which is caused by Candida albicans. most common cause of chronic paronychia and occasionally there is associated nail involvement. occurs in conjunction with chronic mucocutaneous candidiasis. 7. Anatomy of the nail The nail apparatus consists of a horny dead product the nail plate. Four specialized epithelial cells- the proximal nail fold. the nail matrix the nail bed the hyponychium 8. Anatomy of the nail 9. clinical types of onychomycosis 1. Distal & lateral subungual onychomycosis(DLSO) 2. Proximal subungual onychomycosis(PSO) 3 .White superficial onychomycosis(WSO) 4 Candidal onychomycosis. 10. Distal & lateral subungual onychomycosis(DLSO) Hyperproliferation of the nail bed in response to the infection creates subungual hyperkeratosis . Later, subungual hyperkeratosis becomes prominent and spreads until the entire nail is affected. Gradually the entire nail becomes brittle and separated from its bed as a result of the piling up of subungual keratin. 11. progression of infection, there is yellowing and thickening of the distal nail plate as well as onycholysis. which is an ideal environment for further proximal invasion and growth of the fungus. Fingernails and toenails present a similar appearance, and the skin of the soles is likely to be involved, with characteristic scaling and erythema. 12. proximal subungual onychomycosis 13. The infection spread to the proximal ventral nail plate. white opacity on the proximal nail plate. This opacity gradually enlarges to affect the entire nail plate. may develop to produce a white nail with only marginal increase in thickness . 14. subungual hyperkeratosis ,leukonychia & proximal onycholysis. destruction of the entire nail unit may be seen. Discoloration ,friable ,subungual debris ,provides a secondary infection by bacteria, molds and yeast. 15. White superficial onychomycosis HIV-positive population, it is commonly caused by T . rubrum. infection generally begins with scaling of the nail under the overhanging cuticle and remains localized to a portion of the nail. 16. Candidal onychomycosis. Candida species invade via the hyponychial epithelium to affect the entire thickness of the nail plate . destruction of the nail and massive nail bed hyperkeratosis. It caused by C. albicans 17. There are three main manifestations of Candida infection of the nail apparatus . onycholysis associated with paronychia. Complete destruction of the nail plate . erosion of the distal and lateral nail plate of the fingernails. 18. Thickened , rough ,opaque or darkened pseudoclubbing . Paronychial inflammatory response 19. Dx 1.clincally 2. Laboratory --KOH examination, 3-Histiologic Examination with PAS 4- Biopsy 5- Fungal Culture 20. Prognosis Fingernail has good prognosis than toenail. Nail growth in fingernails 1.5 to 2mm monthly and normal nail growth after one year of treatment. Nail growth < 1mm in toenails monthly. Recurrent nail dystrophy after Lab.cure at 12mo is 8% and at 36mo is 22% 21. Oral antifungal Terbinafine Toenail --250 mg PO qd 12wks Pulse therapy: 500 mg PO qd for 1 wk/mo for 4 mo wt 12-20kg-62.5mg/d / 20-40 kg: 125mg/d >40 kg: 250mg/d Fingernail 250mg for 6wks Pulse therapy: 500 mg PO qd for 1 wk/mo for 2 mo 22. Itraconazole pulse dosing at 400 mg daily for 1week per month for2mo for fingenails and 3mo for toenail. Dose of 200 mg daily, 2mo for fingenails and 3mo for toenail. for children 5mg/kg/day 23. Fluconazole 400 mg once per week for 3 to 12mo. 24. In refractory cases surgical avulsion. chemical removal of the nail with 40 %urea A combination of oral , topical , and surgical therapy are effective and reduce costs 25. Pytriasis versicolor Definition : ** a mild chronic infection of the skin caused by hyphal form of malassezia yeasts, and characterized by discrete, scaly, discolored areas mainly on the upper trunk . 26. Epidemiology. Incidence *40-60% in tropical and subtropical zones. *2% in temperate zone. M : F - 1:1. Peaks at late adolescence and early adult hood. Rarely children and elderly affected. 27. Malassezia species M. furfur M. globosa M. sympodialis M. restricta M. sloffiae M. obtusa M. dermatis, pachydermatis M. equi, M. japonica,M.nana,M.yomaton 28. The vast majority of lesions are associated with M. globosa. 29. .pathogenesis Factors responsible for mycellial transformation and over growth include : *warm; humid environment. *Heredity, low immunity. *Hyperhidrosis. *OCPs. *Pregnancy, systemic steroids. *Cushings syndrome, malnutrition. 30. Path.. it is a non communicable opportunistic infection . 31. Clinical features. The most common presentation is hyper pigmented or hypo pigmented oval / annular macules with characterstic dust like / branny/ furfuraceous scale . Common in chest, back, abdomen and proximal extremities. Scalp, face, genitals, intertrignous areas, and rarely palm and soles could also be involved. Pruritis is mild or abscent 32. Inverse Tinea versicolor Encountered in flexural areas Sharply demarcated, confluent erythematous patch that may confuse with SD, erythrasma . 33. Lab findings Scales scrapped or taken by cellophane tape and treated with 10% KOH, look like spaghetti and meat balls 34. Diagnosis. Clinical appearance is characteristic. KOH is confirmatory. Woods lump may show yellowish fluorescence of involved skin 35. Treatment. Depends on the degree of skin involvement. Localized :- *Most respond to topicals. *Selenium sulfide 2% shampoo applied 1x/d for 2wks. Then 1 -2x/month. *Ketoconazole 2% shampoo applied and left for 5 minutes for 3 consecutive days. 36. .treatment Topical terbinafine 1% solution applied 2x/d for 7 days has cure rate of 80%. 50% propylene glycol in water Systemic treatment. - Indications :- *Extensive lesions *Frequent recurrence *Failure of topical treatments. 37. Systemic treatment. Oral ketokonazole 200mg/d for 7 days. Itraconazole 200-400mg/d for 3-7days. Itraconazole 400mg stat. has more than 75% efficacy and even found to be comparable with Itraconazole of a weeke course. Fluconazole 400mg po stat is effective. 38. Recurrence. Known for high rate of recurrence. 80% recurrence rate in two years of cessation of treatment. Treatment. - Ketoconazole shampoo 1x a wk as soap. - ketoconazole 400mg 1x/month - Fluconazole 300mg 1x/month - Itraconazole 400mg 1x/ month. 39. Candidiasis Introduction A divers group of infection with variable clinical presentation cause by a members of the gene Candida . The clinical manifestations may be acute , subacute &chronic or episodic. 40. The involvement may be localized to the skin ,nail , mucous membranes & GIT or become systemic. 41. C.albicans C.glabrata C. tropicalis. C. krusei C.dubliniensis C. parapsilosis 42. C.albicans dimorphic. most common cause70-80% 50% --colonized the oropharynx. 20-25% of the normal flora Vx. 30% of pregnant women. the organism is infrequently found in skin of normal flora , soil , vegetation ,&air samples. 43. temperature > 35 c. low oxygen tension . functional integrity of the SC. age of the pt . Immune status interaction with microbial flora medication. 44. Clinical features Cutaneous candidiasis Predilection for colonizing moist , macerated fold of skin. the most commonly presentation as intertrigo (flexor Candida )- genitocrural , axillary , gluteal , interdigital , inframammary & b/n folds of skin in abdominal well. 45. Predisposing factors --obesity , wearing of occlusive clothing ,Dm , CF -pruritic , erythematous , macerated skin in intertriginous area ,satellite vesicopustules. erythematous base with a collarette of easily detach able necrotic epidermis. 46. Confluent & discrete erythematous eroded area with pustular & erosive satellite lesion. 47. Dx by typical appearance of skin lesion & presence of satellite vesicopustules. confirmed by ---KOH culture of skin scraping. 48. Sabouraud's dextrose agar with antibacteria. Blood agar 49. DDx Tinea infections, Eczema, Seborrheic dermatitis, Intertriginous psoriasis, Bacterial intertrigo, 50. Treatment Avoidance or correction of the underlying predisposing factors is an important aspect of treatment in all forms of candidiasis. 51. Nystatin cream or powder Miconazole powder Adding mild potency topical steroid helps in relieving symptoms Systemic azoles as required 52. Erosio interdigitalis blastomycetica. interdigital candidal or polymicrobial infection of the hand or feet . affect the third & fourth interspace . 53. Erythematous eroded area in b/n the 54. Candida paronychia typically several fingers are chronically affected. Common in individuals -- hand habitually wet work. 55. CF redness, swelling & tenderness of paronychial area with prominent retraction of the cuticle to word the proximal nail fold. secondary nail changes onycholysis & transverse depressions of the nail plate with brownish or green discoloration along the lateral borders. 56. Dx-----clinically. confirmed by ---KOH culture of skin scraping 57. Treatment Are more resistant to therapy. All wet work should be minimized A topical imidazole in solution form is the ideal treatment Oral Ketoconazole 58. Acute pseudomembranous candidiasis or thrush is the most common form of oral candidiasis. Predisposing factor Dm ,systemic steroid use, antibiotics use , pernicious anemia , malignancies , radiotherapy & cell mediated immunodeficiency. 59. 1/3 of pt with HIV infection . > 90% of pt with ADIS. Sharply defined patch of creamy , crumbly , curd like ,white pseudomembrane , which leaves an underlying erythematous base up on removal. It consist of desquamated epithelial cells , fungal element ,inflammatory cells fibrin & food debarment. 60. Acute atrophic candidiasis (erythematous) occur after sloughing of the pseudo membrane. is specifically associated with prolonged use of antibiotics. Patchy depapillated areas with minimal pseudo membrane formation are seen at the dorsal surfaces of the tongue. 61. Chronic atrophic candidiasis (denture stomatitis ) common form 24-60 % of wearing denture . chronic erythema & edema of the palate mucosa that contains the dentures as well as angular cheilitis are present . 62. Angular cheilitis is perhaps best considered as an intertrigo in which different organisms may play a part, Candida being the commonest. CF erythema , fissuring , maceration & soreness at the angle of the mouth. 63. Dx-----clinically. confirmed by ---KOH culture of skin scraping 64. Treatment Topical antifungals Nystatin suspension (400,000 to 600,000 U qid) held in the mouth and then swallowed Clotrimazole troches (10 mg dissolved in the mouth five times per day) 1 to 2% gentian violet Chlorhexidine rinse. 65. Systemic antifungals Ketoconazole 200mg po/d for 12 weeks Fluconazole 50-100mg po/d for 1 wk Itraconazole 100mg po/d for 3 weeks