Talc Over The Toenails

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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.

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.

Management:

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 insufficiency.

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 fingernails.

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.

References:

Shirwaikar AA, Thomas T, Shirwaikar A, Lobo R, Prabhu KS. Treatment of onychomycosis: an update. 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 Parekh
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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