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.
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.
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