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7/28/2019 Tinea Unguium Dhiah
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Arisal
(1102070049)
Nahdhiah Zainuddin
(1102090114)
ADVISOR :
dr. Fitri Kadarsih Bandjar
SUPERVISOR :
dr. Widya Widita, Sp.KK, M.Kes
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Onychomychosis infection of the nail
caused by dermatophytes, yeast or
moulds.
Tinea unguium refers to infection of
the nail caused by a dermatophyte
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The incidence of onychomycosis 2-13%
in North America.
A multicenter survey in Canada showed 6.5%
Age : incidence increase with advancing
age, range 40-60 years old assosiatedwith tinea pedis & tinea manus
Sex : affects males > females
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Risk facktor :
Diabetes mellitus
Suppresed immune system
Increasing age
Trauma to the nail
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Most frequent etiologic :
Trichophyton rubrum Trichophyton mentagrophytes
var.interdigitable
Very rare etiologic : Epidermophyton floccosum
Trichophyton violaceum
Trichophyton schoenleinii
Trichophyton verrucosum (generally only at
nail finger)
Trichophyton tonsurans
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Dermatophyte infections involve three
main steps :
Adherence to keratinocytes
Penetration through and between cells
Development of a host response
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Patients usually first present for
cosmetic.
Patients may report pain, discomfort,
permanent damage to the nail.
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Dermatophyte infections occur in pattern :
Distal Lateral Subungual Onychomycosis
(DLSO)
White Superficial Onychomycosis (WSO) Proximal Subungual Onychomycosis
(PSO)
Endonyx Onychomycosis
Total Dystrophic Onychomycosis
True Candida Onychomycosis
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DLSO:
- Hyperkeratosis- Yellow-white in
color
- Usually causedby T.rubrum
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Onychomycosis of toe :
distal subungual hyperkeratosis and
onycholysis
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WSO :
White spot
The nail becomesroughened and
crumbles easily.
Most frequentlycauses by T.
mentagrophytes
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The nail plate in
WSO present
numerous white,
opaque, and friablespots
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Mainly from
the proximal
nailfoldHyperkeratosis
Proximal
onycolisisThe usual cause
is T.rubrum
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PSO : the proximal shows an area of
leukonychia. The nail surface isnormal
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milky whitediscoloration of
the nail plate
Very rare type ofonychomychosis
Caused by
T.soudanense &T.violaceum
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Milky-white discoloration of the nail platein endonyx onychomychosis in the absence
of subungual hyperkeratosis and
onycholysis
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The secondary evolution of untreated DLSO or
PSO
Presents as a thickened, opaque, and yellow-brown
nail
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Assosiated with chronic mucocutaneus candidiasis orimmunodepression
The nail is diffusely thickened and crumbled, and the
periungual tissues are inflamed with pseudoclubbing
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The clinical features of onychomycosismay mimic a large number of other nail
disorders.
Therefore, laboratory diagnosis of
onychomycosis must be confirmed
before beginning a treatment regimen.
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Potassium hydroxide (KOH) preparation
of subungual debris
The simplest and quickest method Culture of nail bed or nail plate debris
Inoculated on Mycosel and Saborauds
media
Histology of nail plate and/or nail bed
Periodic acid Schiff (PAS)
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most commonly
characterized by pits
salmonpathches,
onycholysis. Pits develop from tiny
psoriatic lesions
located in the mostproximal matrix
region.
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longitudinal ridging.pterygium formation
thick nail plate.
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Debridement
Debride dystrophic nails; patients should
debride weekly.
Topical antifungals
Amorolfine nail lacquer
Ciclopirox (Penlac) nail lacquer
Oral Therapy
Patient Educatient
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Oral Therapy
Griseofulvin is no longer consideredstandart treatment for onychomychosis
because is adverse effect
Terbinafine is an allylamine and is
prescribed of 250mg daily for 6 weeksfor fingernails and 12 weeks for toenails
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Itraconazole is fungistatic against
dermathophytes, nondermathophytes molds,
and yeast. Pulse dosing 400 mg daily for 1week per month or a continuous dose of 200
mg daily, both of which require 2 months for
fingernails and 3 months for toenails. For
children 5mg/kg/day.
Fluconazole. The usual dosage is 150-300mg once per week for 3 to 12 month, altough
450mg weekly may be used in refractory
onychomycosis.
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Combination Therapy
Combination therapies have been
shown to have a more effective
clearence rate than either oral or topical
treatment alone.
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Without effective therapy,
onychomycosis does not resolve
spontaneously; progressive involvementof multiple toenails is the rule.
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