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Fungal nail disease (Onychomycosis); Challenges and solutions

Onychomycosis (fungal nail infection) is caused by three groups of fungal pathogens namely dermatophyte molds (DM), non-DM (NDM) and yeasts. It is primarily a cosmetic problem but may induce impact on quality of life. Clinically it is characterized by five morphologically distinctive types; distal lateral subungual onychomycosis (DLSO), superficial white onychomycosis (SWO), proximal subungual onychomycosis (PSO), and endothrix onychomycosis. It is difficult to detect the fungal agent responsible for a particular type of onychomycosis by clinical features alone. Mycological methods like direct demonstration of fungal agents by potassium hydroxide mount or nail plate histopathology with Periodic acid Schiff (PAS) staining are sensitive methods for the detection of pathogens. Fungal culture alone is commonly used as a standard for the detection of etiological agent. Molecular biological techniques are currently used only in research laboratories or epidemiological purposes. Therapy is generally not satisfactory. Both topical and systemic agents are used in the therapy. Topical Ciclopirix and Amorolfine are found to be effective but only in early and limited disease. Terbinafine and Itraconazole seems to be the best drugs for the systemic therapy. Clinical cure rates are generally lower than the mycological cure rates.