education & debate fortnightly review

5
EDUCATION & DEBATE Fortnightly Review Fungal nail disease: a guide to good practice (report of a Working Group of the British Society for Medical Mycology) D W Denning, E G V Evans, CC Kibbler, M D Richardson, M M Roberts, T R Rogers, D W Warnock, R E Warren Department of Infectious Diseases and Tropical Medicine (Monsall Unit), North Manchester General Hospital, Manchester MS SRB D W Denning, senior lecturer PHLS Mycology Reference Laboratory, Department of Microbiology, University of Leeds E G V Evans, head Department ofMedical Microbiology, Royal Free Hospital, London C C Kibbler, consultant Regional Mycology Reference Laboratory, Department of Dermatology, University of Glasgow M D Richardson, head University Department of Dermatology, Hope Hospital, SalfordM6 SMD M M Roberts, consultant Department ofInfectious Diseases and Bacteriology, Royal Postgraduate Medical School, London T R Rogers, professor PHIS Mycology Reference Laboratory, Public Health Laboratory, Bristol D W Warnock, head Public Health Laboratory, Royal Shrewsbury Hospital R E Warren, director Correspondence to: Dr Roberts. BAM 1995;311:1277-81 The term onychomycosis refers to fungal infection of the nails whether this is a primary event or a secondary infection of a previously diseased or traumatised nail. Infection may be due to dermatophyte (ringworm, tinea unguium), yeast, or other non-dermatophyte (mould) species, and the clinical appearance may indicate the nature of the infecting organism. In paronychia chronic infection of the nail fold is most often caused by Candida species, but bacterial infection with Gram negative species such as Pseudo- monas may coexist. Acute paronychia (whitlow) due to staphylococcal infection may also occur, and the presence of these bacterial infections will influence management. Invasion of the nail plate by Candida species may occur in the presence of paronychia, immune deficiency states (including chronic muco- cutaneous candidiasis), Raynaud's disease, or endocrine disorders. This paper reviews the clinical features of onycho- mycosis and the differential diagnosis of nail dystrophy, gives the reasons for appropriate mycological investi- gation, and discusses guidelines for appropriate treatment on the basis of laboratory findings and particular clinical situations. Epidemiology Treating onychomycoses is difficult but is important because they do not resolve spontaneously. About 30% of all superficial fungal infections affect the nail.'2 A Box 1: Causes of fungal nail infection Common Dermatophytes Tichophyton rubrum Trichophyton interdigitale Yeasts Candida albicans Candida parapsilosis Uncommon Trichophyton erinacei Trchophyton soudanense Trichophyton tonsurans Tichophyton violaceum Epiderinophytonfloccosum Microsporum canis Candida glabrata * Candida guillermondii Candida krusei* Candida tropicalis Non-dermatophytes (moulds) Fusarium spp Aspergillus spp Scopulariopsis brevicaulis Acremonium spp Scytalidium dimidiatum (Hendersonula) Scytalidium hyalinum *Primanly causes of paronychia. recent population survey of dermatophyte onycho- mycosis has suggested a prevalence of 2-8% for men and 2-6% for women in the United Kingdom.' Earlier surveys of swimming pools,4 schools,5 hospital patients,6 and office workers7 have shown a prevalence of tinea pedis of 8-40%. Of those people with tinea pedis, 20-30% also have affected nails.8 This suggests that the prevalence of onychomycosis in adults could therefore be about 3-8%. This is difficult to assess, however, since some reports do not distinguish between dermatophytosis and other forms of onycho- mycosis or between infection of fingernails and toe- nails. Toenails are more commonly infected than finger- nails.' This applies particularly to dermatophyte and mould infections, whereas Candida infections are more likely to affect the fingernails and fingernail folds.'" Mixed infection can account for up to 5% of onycho- mycotic infections.' 12 There is wide geographical and ethnic variation in the causative species, but in Britain about 5% of cases are due to non-dermatophyte moulds such as Scopulariopsis (see box 1) and these almost exclusively affect nails. There are many cases of patients who have been inappropriately treated for years because the correct diagnosis has not been established. Nail infection due to Scopulariopsis will not respond to the standard treatments for dermato- phyte or yeast onychomycosis. The increase in foreign travel has led to the intro- duction of some exotic species. In addition fungi previously considered to be non-pathogenic may now be found as pathogens in patients with immune BMJ VOLUME 311 1 1 NOVEMBER 1995 Summary points * Onychomycosis is usually caused by dermatophytes (85-90%), but several fungi that are difficult to treat affect toenails * Paronychia is caused by many Candida species, some resistant to azole drugs * Samples for mycology should be taken as proximally as possible in the nail * Demonstration of hyphae in a nail specimen by microscopy is sufficient to start treatment * Choice of treatment depends on many factors including patient's age and preference, infecting fungus, number of nails affected, degree of nail involvement, whether toenails or fingernails are infected, and other drugs being taken 1277

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Page 1: EDUCATION & DEBATE Fortnightly Review

EDUCATION & DEBATE

Fortnightly Review

Fungal nail disease: a guide to good practice (report ofa WorkingGroup ofthe British Society for Medical Mycology)

DW Denning, E GV Evans, C C Kibbler,MD Richardson,MM Roberts, TR Rogers,DWWarnock, RE Warren

Department ofInfectiousDiseases and TropicalMedicine (Monsall Unit),North Manchester GeneralHospital, ManchesterMS SRBDW Denning, senior lecturer

PHLS Mycology ReferenceLaboratory, Department ofMicrobiology, UniversityofLeedsE GV Evans, head

Department ofMedicalMicrobiology, Royal FreeHospital, LondonC C Kibbler, consultant

Regional MycologyReference Laboratory,Department ofDermatology, University ofGlasgowMD Richardson, head

University Department ofDermatology, HopeHospital, SalfordM6 SMDMM Roberts, consultant

Department ofInfectiousDiseases and Bacteriology,Royal PostgraduateMedical School, LondonT R Rogers, professor

PHIS Mycology ReferenceLaboratory, Public HealthLaboratory, BristolDW Warnock, head

Public Health Laboratory,Royal Shrewsbury HospitalRE Warren, director

Correspondence to:Dr Roberts.

BAM 1995;311:1277-81

The term onychomycosis refers to fungal infection ofthe nails whether this is a primary event or a secondaryinfection of a previously diseased or traumatised nail.Infection may be due to dermatophyte (ringworm,tinea unguium), yeast, or other non-dermatophyte(mould) species, and the clinical appearance mayindicate the nature of the infecting organism. Inparonychia chronic infection of the nail fold is mostoften caused by Candida species, but bacterialinfection with Gram negative species such as Pseudo-monas may coexist. Acute paronychia (whitlow) due tostaphylococcal infection may also occur, and thepresence of these bacterial infections will influencemanagement. Invasion of the nail plate by Candidaspecies may occur in the presence of paronychia,immune deficiency states (including chronic muco-cutaneous candidiasis), Raynaud's disease, or

endocrine disorders.This paper reviews the clinical features of onycho-

mycosis and the differential diagnosis ofnail dystrophy,gives the reasons for appropriate mycological investi-gation, and discusses guidelines for appropriatetreatment on the basis of laboratory findings andparticular clinical situations.

EpidemiologyTreating onychomycoses is difficult but is important

because they do not resolve spontaneously. About 30%of all superficial fungal infections affect the nail.'2 A

Box 1: Causes offungal nail infectionCommonDermatophytesTichophyton rubrumTrichophyton interdigitale

YeastsCandida albicansCandida parapsilosis

Uncommon

Trichophyton erinaceiTrchophyton soudanenseTrichophyton tonsuransTichophyton violaceumEpiderinophytonfloccosumMicrosporum canis

Candida glabrata *Candida guillermondiiCandida krusei*Candida tropicalis

Non-dermatophytes (moulds)Fusarium spp Aspergillus sppScopulariopsis brevicaulis Acremonium spp

Scytalidium dimidiatum(Hendersonula)

Scytalidium hyalinum*Primanly causes ofparonychia.

recent population survey of dermatophyte onycho-mycosis has suggested a prevalence of 2-8% for menand 2-6% for women in the United Kingdom.' Earliersurveys of swimming pools,4 schools,5 hospitalpatients,6 and office workers7 have shown a prevalenceof tinea pedis of 8-40%. Of those people with tineapedis, 20-30% also have affected nails.8 This suggeststhat the prevalence of onychomycosis in adults couldtherefore be about 3-8%. This is difficult to assess,however, since some reports do not distinguishbetween dermatophytosis and other forms of onycho-mycosis or between infection of fingernails and toe-nails.

Toenails are more commonly infected than finger-nails.' This applies particularly to dermatophyte andmould infections, whereas Candida infections are morelikely to affect the fingernails and fingernail folds.'"Mixed infection can account for up to 5% of onycho-mycotic infections.'12 There is wide geographical andethnic variation in the causative species, but in Britainabout 5% ofcases are due to non-dermatophyte mouldssuch as Scopulariopsis (see box 1) and these almostexclusively affect nails. There are many cases ofpatients who have been inappropriately treated foryears because the correct diagnosis has not beenestablished. Nail infection due to Scopulariopsis willnot respond to the standard treatments for dermato-phyte or yeast onychomycosis.The increase in foreign travel has led to the intro-

duction of some exotic species. In addition fungipreviously considered to be non-pathogenic may now

be found as pathogens in patients with immune

BMJ VOLUME 311 1 1 NOVEMBER 1995

Summary points

* Onychomycosis is usually caused bydermatophytes (85-90%), but several fungi thatare difficult to treat affect toenails* Paronychia is caused by many Candidaspecies, some resistant to azole drugs* Samples for mycology should be taken asproximally as possible in the nail* Demonstration of hyphae in a nail specimenby microscopy is sufficient to start treatment* Choice of treatment depends on many factorsincluding patient's age and preference, infectingfungus, number of nails affected, degree of nailinvolvement, whether toenails or fingernails areinfected, and other drugs being taken

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deficiency and are often associated with a highmortality. For example, Fusarium species may cause

onychomycosis, usually with a solitary toenailinfection and sometimes with paronychia. Thismay provide a portal of entry leading to dissemi-nated infection in immunocompromised patients,particularly those with haematological conditionsand AIDS.

Clinical appearanceThe clinical picture of a fungal nail infection varies

according to the nature of the infecting organism (seebox 2). Involvement of adjacent skin should be noted,since ifthis is due to fungal infection the treatment maybe different. If fungal infection is included in thedifferential diagnosis then mycological examination isessential, even if another disease exists. Non-dermatophyte moulds may be present as a secondaryinvader if a nail has previously been diseased ortraumatised. This may account for the fact that such

infections often affect only one nail.Distal or lateral involvement of the nail plate

occurring at the free end of the nail and spreadingproximally is particularly associated with Trichophytonrubrum infection or some non-dermatophyte infections.Eventually the whole nail may be affected, and theremay be proximal subungual nail dystrophy withseparation of the nail from the bed. In superficialwhite onychomycosis, crumbly white areas are evidenton the nail surface particularly in patients withAIDS. T interdigitale causes this type of appearance.Paronychia is seldom present in a dermatophyteinfection, but Candida infection often begins in theproximal nail plate and paronychia is common. Inchronic mucocutaneous candidosis, a rare T cell dis-order with disabling mucosal candidiasis, total naildystrophy is usual.

Differential diagnosisSeveral conditions may be associated with nail

dystrophy, including bacterial and fungal infection(see box 3). Sometimes bacterial infection may coexistwith fungal infection and may require treatment in itsown right. Many other conditions can cause a change inthe appearance ofthe nail, but the nail surface does notusually become soft and friable as in a fungal infection.If there is any doubt a specimen should be taken formycological examination.

In some cases of psoriasis and eczema there may befungal superinfection of the nails. Yeasts and bacteriaare often found in subungual debris from psoriatic

Box 3: Non-fimgal conditions particularly associated with nail dystrophyBacterial nail infectionPseudomonas aeruginosa-green or black dis colour-ationStaphylococcus aureus may present as acute paronychia(whitlow)

OnychogryphosisGrossly thickened and distorted horn-like appearanceofnailOvercurvature ofnailGreat toenails most commonly affectedMay follow trauma

PsoriasisYellow friable nails with pitting and onycholysis(lifting ofnail from bed)Distal subungual hyperkeratosisUsually several nails affectedUsually evidence of psoriasis elsewhere, not necessarilyon adjacent skin

EczemaIrregularly pitted nail dystrophyIrregular transverse ridging and thickeningCuticles usually maintained (unless associated withchronic paronychia)History ofeczema on adjacent skin

Beau's linesTransverse lines across nails corresponding to episodesof illness

Lichen planusPterygium formation from cuticleLongitudinal ridging ofnailsTotal nail loss, usually permanentMay be lichen planus elsewhere

Alopecia areata and alopecia totalisSolitary or multiple nail dystrophyVariable severity ofnail dystrophyDiffuse fine pitting, often in transverse linesFrequent onychorhexis (fragmented nails) and ridgingOnset ofnail dystrophy may not coincide with hair loss

Yellow nail syndromeSlow growing nailsSmooth overcurved thickened yellow nailsAll nails affectedNo skin involvementLeg oedema and pleural effusions may be present

Twenty nail dystrophyRoughened nail surface, brittle free nail edgeMay not involve all 20 nailsMay resolve spontaneouslyVariable association with autoimmune disorders(lichen planus, alopecia areata)

LeuconychiaCongenital or acquiredPartial, total, or striate formsMay be associated with general diseaseUsually occurs spontaneously or with minor trauma

BMJ VOLUME 311 1 1 NOVEMBER 1995

Box 2: Typical cHnical appearance offungal nail dystrophy

DermatophyteDistal and lateral nail involvement spreadingproximally orProximal subungual dystrophy orSuperficial white dystrophyWhite or yellow thickened nails, crumbling of nailplateAdjacent web or skin involvement may be present

CandidaChronic paronychiaShiny red bolstered nail foldAlmost exclusively affects fingernail foldsLoss of cuticlePus exuding from under nail foldUsually proximal nail involvementDistal nail dystrophy-associated with circulatorydisordersTotal dystrophic onychomycosis-chronic muco-cutaneous candidosisNails white, green, or occasionally black

Non-dermatophyteSuperficial white onychomycosisOften solitary nail involvement-more often toenailColour of nail may be influenced by nature of infectingmould. For example:Acremonium spp-superficial white onychomycosisScopulariopsis spp-white, yellow, brown, or greenScytalidium spp-white or blackFusatium spp-whiteAlternaria spp-brownAspergillus spp-green or black

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FIG 1-Patterns offungal nailinvolvement

Distal and lateralsubungualonychomycosis

Proximal whitesubungualonychomycosis

Superficial whiteonychomycosis

Total dystrophiconychomycosis(all three sitesaffected)

nails,"3 but dermatophyte infection is seldom foundand is more likely to affect the toenails. Chronicparonychia due to Candida infection is commonlyassociated with psoriasis and eczema of the finger-nails.'4 It is important to detect coexisting infectionsince treatment will ensure a more rapid improvementin the appearance ofthe nails in these conditions.

Mycological diagnosisWhen fungal infection is suspected, specimens for

confirmation of the diagnosis should be obtainedbefore treatment is started. As mentioned above,several dermatological conditions can produce nailchanges that mimic fungal infection, and these canaccount for apparent failure of treatment with anti-fungal drugs.

TAKING SPECIMENS

An adequate specimen is required for microscopyand culture. Having a specimen taken should bepainless apart from occasional slight discomfort whensubungual specimens are taken. Figure 2 shows theappropriate sites from which nail specimens should beobtained. Scrapings taken with a blunt scalpel orclippings should be transported in a folded square ofpaper, preferably fastened with a paper clip, butcommercial mycological packs are also available (suchas Dermapak, Dermaco, Toddington, Bedfordshire,and MycoTrans, MycoTrans, Biggar, Lanarkshire).

MICROSCOPY AND CULTURE

In the laboratory 20-30% potassium hydroxidesolution is added to part of the specimen to maceratethe nail keratin so that the specimen can be examinedfor fungal elements by direct microscopy. The rest ofthe specimen is inoculated on to several different mediato test for the presence ofnon-dermatophytes as well as

dermatophytes and yeasts. This is important becauseinfection with most non-dermatophyte species-suchas Scopulaniopsis, Scytalidium, Fusarium, andAcremonium-will not usually respond to oraltreatment.The results of culture can be positive even if

microscopy is negative, but it is more common formicroscopy to be positive while culture is negative (30-50%). Specimens from nails (subungual debris andclippings) should be taken as proximally as possiblesince this increases the probability of obtaining apositive culture result as well as positive microscopy.Although fungal elements may be seen in material fromthe distal end of the toenail, the culture may benegative. This probably reflects the slow rate of toenailgrowth, so that the fungal elements seen are no longerviable. Subungual material may yield helpful positiveculture results since dermatophyte infection is

primarily a disease of the nail bed. It is desirable toshow the presence of fungal hyphae or spores withinnail keratin by microscopy to confirm that the nail isactually affected. In chronic paronychia culture of pusfrom the nail fold is extremely helpful.When the clinical diagnosis of a dermatophyte

infection is suspected, it may sometimes be necessaryto repeat scrapings to confirm the presence ofinfection. It may also be helpful to repeat cultures aftertreatment has started to ensure that the infection isresponding to treatment. However, susceptibilitytesting is rarely appropriate unless a treatment failsunexpectedly in a proved infection. Sometimes a

fungus may be resistant to a treatment in vivo but notin vitro. In a particular patient drug interactions orfailure of absorption may also account for apparentunresponsiveness to treatment.

Full laboratory mycological diagnosis is justifiablefor the following reasons:

* Confirmation of fungal infection before startingprolonged oral treatment with antifungal drugs since anon-fungal dermatological condition may be present* To optimise treatment as certain fungi are lessresponsive to treatment, especially toenail infectionscaused by Trichophyton rubrum and non-dermatophytes* On epidemiological grounds to identify contacts(for example, tinea pedis in families or institutions,identification ofunusual fungi, animal contacts in casesof animal ringworm)* To test for mixed infection (important fortreatment).

The results of direct microscopy should be reportedas soon as possible, with an indication of the nature ofthe fungal elements found. A positive microscopyresult is an indication for starting treatment. Results ofculture should be available in two to three weeks butare sometimes available earlier. While treatment forchronic toenail infection can await the result of culture,it may be desirable to start treatment immediately formore inflammatory conditions such as Candidaparonychia. Candida should be speciated if isolated-rather than reported as "Candida species" or "yeastsisolated"-because some species do not causeonychomycosis. In the past only Candida albicans hasbeen assumed to have a pathogenic role, but it is nowevident that other Candida species, especially Candidaparapsilosis, may, be playing an active rather thanpassive role. A Candida species isolated in culture ismuch more likely to be clinically important if directmicroscopy shows the presence of yeast cells orpseudohyphae within the nail keratin. In paronychiaother Candida species are pathogenic, and someisolates are resistant to imidazole and triazole drugs.

TreatmentTOPICALTREATMENTS

Localised dermatophyte onychomycosis may betreated with nail paints such as 28% tioconazole withundecylenic acid (Trosyl) twice daily"5 or amorolfine

FIG2- Where to take samplesfrom nails

BMJ VOLUME 311 11NOVEMBER1995

Distal and lateral onychomycosis:Scrape or take adequate

- - - - - - chippings fromSuperficial white subungual material andonychomycosis: proximal part of

Scrape from diseased naildiseased nail

surface ,Proximal whiteonychomycosis:Scrape fromnail surface

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Page 4: EDUCATION & DEBATE Fortnightly Review

(Loceryl) once weekly'° provided that there is onlylocalised involvement of the distal ends of nails (seebox 4). These preparations have superseded 8-ciclopiroxpaint in clinical practice. A 40% cure rate with Trosylmay be possible, especially with dermatophyte andCandida species,5 but treatment needs to be continuedfor at least six months for fingernails and 12 months orlonger for toenails. A similar cure rate for toenails canbe obtained with amorolfine, but a rather better curerate of 50% after six months is likely with affectedfingernails.'0

Proximal nail disease or severe nail bed involvementis extremely unlikely to respond to topical treatment,even if this is preceded by chemical dissolution of thediseased nail with 40% urea paste.'6 Urea paste shouldnormally be applied by a chiropodist. Nail avulsionmay occasionally be necessary for non-dermatophyte(mould) disease but is undesirable since it may result indamage to the nail matrix and subsequent permanentdamage to the nail. Some non-dermatophyte infectionsmay respond to systemic treatment. When the skin isaffected as well as the nails this will require treatmentin its own right and, if extensive, may be an indicationfor systemic treatment.

Topical treatment with an imidazole cream or painttwice daily for up to six months will often cure chronicparonychia, especially when this is localised to finger-nail folds, which is the common clinical situation.From a practical viewpoint, paint formulations may beeasier to use than creams. Measures to reducemaceration ofthe nail folds should be incorporated intothe management of such cases. The associatedproximal nail dystrophy will often improve with treat-ment of the nail fold. Localised distal infection of thenail by Candida species requires use of Trosyl nailpaint twice daily or weekly use of amorolfine nail paint.Severe Candida onychomycosis or paronychia is likelyto require systemic treatment, especially since suchcases are usually associated with an immune deficiencystate.

SYSTEMIC TREATMENTSTerbinafineThe allylamine terbinafine (Lamisil) is now the

treatment of choice for dermatophyte onychomycosis.Terbinafine has fungicidal activity against all dermato-phytes and various Candida species, including Candidaparapsilosis. However, it shows only fungistatic activityagainst Candida albicans.'7 It is therefore inappropriatefor a mixed dermatophyte and Candida albicansinfection unless the C albicans infection is localised andcan be treated topically. With more extensive mixedinfection, itraconazole would be more appropriate.

Infection of fingernails requires terbinafine 250 mgdaily for between six weeks and three months, whereastoenail infection requires treatment for three monthsor possibly up to six months. A repeat culture at threemonths may be useful in patients undergoing treat-ment with terbinafine, since a positive culture at thisstage would indicate whether a longer course wasrequired. From a clinical viewpoint, it may be difficultto assess whether a fingernail or toenail is completelyfree of infection at three months since the distaldystrophic part of the nail may not have grown out.Treatment with oral terbinafine will also clear anyassociated skin infection without the need foraddtiional topical treatment. Although it is not yetlicensed in Britain for use in young children, it may beused in children aged 12 and over when other optionsare unsuitable or have failed.Cure rates of 80-95% in dermatophyte nail infec-

tion'8 and of about 95% in dermatophyte skin infectioncan be expected with terbinafine. This drug has theadditional advantages that it interacts with relativelyfew other drugs and is generally well tolerated.

Although it shows some in vitro activity againstScytalidium dimidiatum, its activity in vivo is limited.Its place in the treatment of non-dermatophyte(mould) onychomycosis is not as well defined as that ofitraconazole,'7 and itraconazole may be preferable forsome ofthese infections.

Itraconazole and other azole drugsItraconazole is active against most Candida species,

including Candida albicans, and is also effective indermatophyte infection. Up to 5% of cases of onycho-mycoses have mixed cultures," and itraconazole willusually successfully treat those requiring oral treat-ment. Pulsed treatment with itraconazole (in which a

week of treatment is alternated with three weekswithout treatment for several cycles) has been advo-cated, but this drug is also available for continuoustreatment and can be taken for at least three months.Itraconazole 200 mg daily for at least three months isthe most appropriate treatment for severe nail diseaseor for immunocompromised patients, especially whennon-dermatophyte moulds such as Aspergillus speciesare implicated. Itraconazole has superseded keto-conazole in treating nail infection because of its bettersafety profile. Itraconazole persists in nail keratin for atleast six months after the end of treatment. Cure ratesfor dermatophyte and candidal nail infection are about80% and are similar to those with terbinafine. How-ever, itraconazole may interact with several otherdrugs, and this limits its usefulness in certain situ-ations. Fluconazole is not yet licensed for nail disease,but it may be required for severe candidal nail infectionor chronic paronychia in doses up to 400 mg daily inimmunocompromised patients.

Neither itraconazole or fluconazole is currentlylicensed for use in children. In older children

BMJ VOLUME 311 1 1 NOVEMBER 1995

Box 4: Recommended treatments foronychomycosisDermatophyte infectionLocalised distal nail disease28% Tioconazole with undecylenic acid (Trosyl) painttwice dailyAmorolfine (Loceryl) paint weeklyDissolution with 40% urea paste

Proximal or extensive nail diseaseTerbinafine (Lamisil) 250 mg daily for 3-6 monthsItraconazole (Sporanox) 200 mg daily for 3-6 monthsGriseofulvin 1Omg/kg/daily (500 mg twice daily); for6-9 months for fingernails, for 15-18 months fortoenailsPossibly also a nail paint (see above) especially fortoenails

Candida infectionChronic paronychia (localised)Imidazole creams or paintsNystatin ointmentTerbinafine cream (Lamisil)Distal candidal nail infection28% Tioconazole with undecylenic acid paint (Trosyl)twice dailyAmorolfine (Loceryl) nail paint weeklySevere candidal nail infection or severe chronic paronychiaItraconazole 200-400mg daily for 3 months

Non-dermatophyte (mould) onychoomycosisLocalised nail disease28% Tioconazole with undecylenic acid paint (Trosyl)twice dailyAmorolfine (Loceryl) paint weeklyPossibly also dissolution with 40% urea paste oravulsionPersistent nail diseaseItraconazole 200 mg daily for 3-18 months

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(weighing over 20 kg), however, a 100 mg capsule ofitraconazole or 50 mg capsule of fluconazole may beprescribed. In younger children fluconazole suspen-sion of3 mg/kg may be appropriate.

GriseofulvinGriseofulvin is effective only for dermatophyte

infection and is therefore inappropriate in cases ofmixed infection unless it is combined with a nail paintthat has a wider antifungal spectrum. Griseofulvin maycure up to 90% of fingernail infections in four to eightmonths, but its low cure rate of 40% in some toenailinfections'9 means that it is now less appropriate(treatment with terbinafine or itraconazole gives morethan double the cure rate). However, griseofulvin iscurrently the only oral drug licensed in the UnitedKingdom for treating dermatophyte infection inchildren. Other considerations that should be borne inmind include the relative risk of side effects, thecross reaction of penicillin hypersensitivity with griseo-fulvin, and interactions with other drugs alreadyprescribed.

COST BENEFITS

When the relative benefits of a particular drug areconsidered, the advantages-such as shorter length oftreatment, greater efficacy, and lack of side effects ordrug interactions-need to be balanced against thecost. When topical and systemic treatments arecombined to obtain a higher rate of cure, the total costof such a combination may be greater than that of asingle more expensive but more effective drug used fora shorter time. For this reason, terbinafine has becomethe first line treatment of choice for most cases ofdermatophyte infection whereas itraconazole may bepreferred for mixed infection.

Costs can be justified if the most appropriate drugsare chosen according to the nature of the organismisolated. When the diagnosis is not immediatelyobvious it is worth waiting for the final culture result to

avoid unnecessary treatment, especially if thecondition is not life threatening. An exception to thisrule may be made if there is extensive disease or if thepatient is immunocompromised even if the diseaseprocess is localised.

Evaluation of recent drugs such as amorolfine,itraconazole, fluconazole, and terbinafine is stillcontinuing.

Funding: The working group was supported by the BritishSociety ofMedical Mycology.

Conflict ofinterest: None.

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1969;99:567-79.14 Ganor S. Chronic paronychia and psoriasis. BrJ Dermatol 1975;92:685-8.15 Jevons S, Lees L. Trosyl (tioconazole) Pfizer Kent (clinical experince. A

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19 Davies RR, Everall JD, Hamilton E. Mycological and clinical evaluation ofgriseofulvin for chronic onychomycosis. BMY 1967;iii:464-9.

A MEMORABLE PATIENT

Hearing voicesI spent the winter of 1994-5 in Osho CommuneInternational, the largest spiritual health centre in India,where I carried out a research project. A slim, intelligentyet distressed European woman in her early 40s asked mefor a talk. For about five years she had been hearing voicesof several men and women talking to her and each otherin different European languages. She resisted theirinstructions but thought that they influenced her bodyand changed her feelings. Friends' advice to "withdrawher antennas" had been helpful. Recently she had beenhearing plants commenting on her thoughts and actions.These experiences had become so uncomfortable that shewanted to get rid of them. She had never mentioned themto doctors, afraid of being regarded as mad and givenmedicines.She did not seem a risk to herself or others and had no

features of major depression. I explained the benefits ofantipsychotic medication but she declined, afraid of sideeffects and reduction in sensitivity. What to suggest? Shedecided to try meditation, painting, and gardening.A week later the voices were worse and she found it hard

to concentrate. I urged her to consider antipsychoticdrugs. She felt devastated. She was determined to getrid of her experiences without medicine. She attendedpainting classes, meditated, and did gardening. Shebooked craniosacral balancing (soft bodywork) andTibetan pulsing healing (meditative bodywork) sessions.

In the following weeks she flourished. She describedincreasing self worth and dignity, became more lively and

energetic, and the voices did not disturb her any more.She stopped gardening but maintained her progress andreturned to Europe a few months later.

I felt I had not done anything for her and yet shewas grateful. I regard antipsychotic drugs as a mainstay intreating psychosis. But her symptoms reduced withmethods doctors tend to discount. When she left India shewas not symptom free, but confident and cheerful.

Psychosis can fluctuate in severity independent ofantipsychotic treatment. But why had I not seen suchimprovement in patients with chronic psychosis inGermany or in Britain? Do such patients avoid psy-chiatrists? Are they not referred or seen only once in aclinic, never to return again? Do we treat too hastily? Arewe hindering improvement by reducing self respect,sensitivity, and motivation through stigma, neurolepticmedication, or side effects?

I do not expect to find an answer. Osho CommuneInternational discourages people with mental healthproblems, as a visit can be destabilising and psychiatricfacilities for visitors are minimal. So it is unlikely that Iwill have a similar experience there. I feel enriched andgrateful. I became aware of treatment options which Inever considered before and probably would not considerin a Western health service. I learnt to pay attention to thepossibility of improvement without drugs, unusual treat-ments which patients may suggest, and of the value oftheir motivation.-KAmiAA-MAwIA MuELLER is a locumsenior registrar in psychiatry in Colchester

BMJ VOLUME 311 1 1NOVEMBER 1995 1281