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Onychomycosis: modern diagnostic and treatment approaches

Onychomykose: Moderne Diagnostik und Behandlungsansätze

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Summary

The medical term onychomycosis should be understood as chronic infection of the nails caused by a fungus. The most common causative agents are the dermatophytes and Candida species. The less common are certain types of moulds (nondermatophyte moulds or NDMs). In approximately 60–80 % of the cases, onychomycosis is due to dermatophytes. Among dermatophytes, the most often isolated causative pathogen is Trichophyton (T.) rubrum. Other common species are T. interdigitale (formerly T. mentagrophytes), Epidermophyton floccosum, and T. tonsurans. The most significant yeasts causing onychomycosis are Candida albicans and Candida parapsilosis. Predisposing factors for onychomycosis include mainly diseases such as diabetes mellitus, peripheral vascular arterial disease, chronic venous insufficiency, polyneuropathies of diverse etiologies, and immunosuppression, e.g., myeloproliferative diseases (such as lymphoma and paraproteinemia), HIV/AIDS, etc. Other factors facilitating the fungal infection are frequent trauma in professional sportsmen, often accompanied by excessive perspiration. The diagnostic methods that are often applied in different dermatologic departments and ambulatory units are also different. This precludes the creation of a unified diagnostic algorithm that could be used everywhere as a possible standard. In most of the cases, the method of choice depends on the specialist’s individual experience. The therapeutic approach depends mostly on the fungal organism identified by the dermatologist or mycologist. This review hereby includes the conventional as well as the newest and most reliable and modern methods used for the identification of the pathogens causing onychomycosis. Moreover, detailed information is suggested, about the choice of therapeutic scheme in case whether dermatophytes, moulds, or yeasts have been identified as causative agents. A thorough discussion of the schemes and duration of the antifungal therapy in certain groups of patients have been included.

Zusammenfassung

Der medizinische Terminus Onychomykose steht für eine chronische Infektion des Nagelapparates durch einen Pilz. Zu den häufigsten verursachenden Erregern zählen Dermatophyten sowie Candida-Arten. Zahlenmäßig weniger bedeutsam sind bestimmte Schimmelpilze (nicht-Dermatophyten-Schimmelpilze oder engl. non-dermatophyte moulds). In etwa 60–80 % der Fälle wird die Onychmoykose jedoch durch Dermatophyten verursacht. Der am häufigsten isolierte Dermatophyt ist Trichophyton (T.) rubrum, weitere relevante Spezies für eine Onychomykose sind T. interdigitale (früher T. mentagrophytes, Epidermophyton floccosum) und T. tonsurans. Die wichtigsten, eine Onychomykose verursachenden Hefepilze sind Candida albicans und Candida parapsilosis. Zu den disponierenden Faktoren, die eine Onychomykose begünstigen, zählen vor allem Stoffwechselerkrankungen, wie Diabetes mellitus, aber auch Gefäßerkrankungen, wie periphere arterielle Verschlusskrankheit, chronisch-venöse Insuffizienz, Polyneuropathien unterschiedlicher Ätiologie und immunsupprimierende Krankheiten, z. B. myeloproliferative Neoplasien (wie z. B. Lymphome und Paraproteinämien), HIV/AIDS, etc. Weitere Faktoren, die der Entstehung einer mykotischen Nagelinfektion Vorschub leisten, sind lokale Traumen bei Profi-oder Leistungssportlern, oft vergesellschaftet mit starker Hyperhidrose. In dermatologischen Kliniken und Praxen kommen verschiedene diagnostischen Methoden zur Anwendung Ein einheitlicher diagnostischer Algorithmus wäre wünschenswert, nach wie vor ist jedoch die persönliche Erfahrung des Untersuchers entscheidend für die eingesetzten Methoden. Entscheidend ist, dass der gewählte therapeutische Ansatz im Wesentlichen vom nachgewiesenen Erreger abhängt. In dieser Übersicht wird die konventionelle Diagnostik von Onychomykosen dargestellt. Außerdem wird auf moderne und neu entwickelte labordiagnostische Methoden, die zum direkten Nachweis und zur Identifizierung der nachgewiesenen Erreger der Onychomykose Einzug in die Dermatologie und Mikrobiologie gefunden haben, eingegangen. Darüber hinaus wird auf die Auswahl der erfolgversprechendsten lokalen und systemischen Therapieformen erläutert, abhängig davon, ob Dermatophyten, Hefepilze oder Schimmelpilze nachweisbar waren. Die verschiedenen Schemata der Onychomykosetherapie für bestimmte Patientenkollektive werden ausführlich dargestellt.

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Authors and Affiliations

  1. Polyclinic for Dermatology and Venerology, University Hospital Lozenetz, Academic Educational Hospital of the Saint Kliment Ohridski University, Medical Faculty, Koziak Street 1, 1407, Sofia, Bulgaria

    Georgi Tchernev &  Teodora Taneva

  2. Department of Dermatology and Venerology, Trakia University, Medical faculty, Armeiska Street 11, 6000, Stara Zagora, Bulgaria

    Plamen Kolev Penev MD

  3. Haut- und Laborarzt/Allergologie, Andrologie, Labor für medizinische Mikrobiologie, Straße des Friedens 8, 04579, Mölbis, Germany

    Pietro Nenoff

  4. Department of Dermatology and Venerology, Medical University Plovdiv, Vasil Aprilov 15A Street, Plovdiv, Bulgaria

    Liliya Georgieva Zisova MD, PhD, Reni Hristova MD & Desislava Nocheva MD

  5. Dermatology and Venerology Department, University Hospital of Coimbra, Praceta Mota Pinto, 3000-075, Coimbra, Portugal

    José Carlos Cardoso

  6. Department of Dermatology and Venerology, Medical University of Graz, Auenbruggerplatz 8, 8036, Graz, Austria

    Gabriele Ginter-Hanselmayer MD

  7. Department of General and Clinical Pathology, Medical Faculty, Trakia University, Armeiska Street 11, 6000, Stara Zagora, Bulgaria

    Julian Ananiev &  Maya Gulubova MD, PhD

  8. Department of Social Territorial Medicine, Section of Dermatology, University of Messina, via Consolare Valeria, Gazzi, 98125, Messina, Italy

    Claudio Guarneri MD &  G. Martino

  9. Department of Dermatology, Wakayama Medical University, Wakayama, Japan

    Nobuo Kanazawa MD, PhD

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  1. Georgi Tchernev
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Tchernev, G., Penev, P., Nenoff, P. et al. Onychomycosis: modern diagnostic and treatment approaches. Wien Med Wochenschr 163, 1–12 (2013). https://doi.org/10.1007/s10354-012-0139-3

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