Talc Over The Toenails


Superficial fungal infection of the toenails in an HIV positive patient!

A 40-year-old male presented with complaints of nail changes for the past 2 years. The patient’s history revealed infection with the human immunodeficiency virus for the past 10 years for which he was taking antiretroviral drugs. تعليم القمار

On examination, superficial, opaque, friable, powdery
(talc-like) white patches were noticed over the nail plates of all toes
bilaterally. Direct microscopy with 10% KOH of scrapings from the dorsal nail
plate showed translucent, septate hyphae.

A diagnosis of white superficial onychomycosis was made.


Itraconazole pulse therapy was initiated, but at the 1-month
follow-up, no improvement was seen in the patient’s nails.

Onychomycosis is a fungal infection of the nail bed, matrix
or plate. Onychomycosis is more often seen on the toenails than the fingernails,
and it comprises one-third of fungal skin infections. Usually, the patients
affected are those above 60 years or those with immunocompromised states such as
seen in this patient with HIV infection. Other causes of onychomycosis include occlusive
footwear, locker room exposure, poor hygiene, layers of toenail polish, which
doesn’t allow the nail to breathe, chronic diseases like diabetes, and vascular

White superficial onychomycosis (WSO), a less common type of
onychomycosis, is characterized by a superficial localization of fungi on the
dorsal surface of the nail plate. Usually, the nail plate is the primary site
of inoculation. The common culprit fungus of WSO is T. mentagrophytes. Other fungi
include Microsporum persicolor, C. albicans, T. rubrum, Aspergillus terreus,
Fusarium oxysporum, and Acremonium species.

 The acceptable management
approach is to mechanically debride the affected area, followed by topical
antifungal agents. Oral antifungals are always more effective than topical
antifungals, and the toenails require a longer duration of therapy than

Can the toenail fungus heal on its own?

It is very rare for onychomycosis of the toenails to heal spontaneously
without treatment. Such fungal infection requires treatment because even if the
old infected nail falls out, there are high chances that the newly growing nail
may get infected with the fungus too.


Shirwaikar AA, Thomas T, Shirwaikar A, Lobo R, Prabhu KS. Treatment of onychomycosis: an update. لعبة قمار  Indian J Pharm Sci. 2008;70(6):710-714. DOI:10.4103/0250-474X.49088

Krishnegowda SY, Sudhir KN (2015) Talc, over the Nails. Clin Med Img Lib 1:010. doi.org/10.23937/2474-3682/1510010

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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