The patient whose feet are shown in Figures 5.12-5.16 was suffering from onychomycosis and the nails and nail beds were completely destroyed by fungus as shown in Figure 8.7. Onychomycosis per se does not cause foot problems, but when it affects the proximal nail (proximal subungual onychomycosis) it may cause chronic paronychia and serve as a portal for bacteria, resulting in deep tissue infection. It often co-exists with mycosis of the web spaces and it may be superinfected by bacteria, leading to deep tissue infection as well.

This patient was treated with terbina-fine hydrochloride, both systemic (tablets 250 mg once daily) and topical (cream), for 3 months and was instructed in the appropriate foot care.

Chronic Onychomycosis
Figure 8.7 Fungal infection affecting all nails in addition to claw toes. Patient whose feet are shown in Figures 5.12-5.16

Chronic onychomycosis is classified into three clinical types: distal subungual onychomycosis is the most common form. The distal edge of the nail becomes infected and a yellow discoloration, onycholysis and subungual debris develop. In proximal subungual fungal infection, the second commonest form, Trichophyton rubrum accumulates hyperkeratotic debris under the nail plate and loosens the nail, eventually separating it from its bed. This fungus infects the underlying matrix and nail plate leaving the nail surface intact. Leuconychia mycotica, caused by Trichophyton metagrophytes, infects the nail superficially. The nail surface becomes dry, soft and friable but the nail remains attached to its bed. In addition to these fungi Epidermophyton floccosum may also be isolated from infected areas.

Itraconazole and fluconazole are also effective in the treatment of chronic ony-chomycosis.

Keywords: Onychomycosis; distal subun-gual onychomycosis; proximal subungual fungal infection; leuconychia mycotica; Tri-chophyton metagrophytes, Trichophyton rubrum or Epidermophyton floccosum; ter-binafine; itraconazole; fluconazole

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