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Prolonged treatment of the fungal nail infection – Ruling out immunological disease?

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Prolonged treatment of the fungal nail infection – ruling out immunological disease?

Introduction: Onychomycoses represent the most frequently seen nail diseases. They are rare in children and increase in incidence with age. Most cases are caused by dermatophytes, but can also be caused by yeasts and molds. The infections are believed to occur when predisposing factors are present such as impaired blood circulation, peripheral neurophaty, diabetes mellitus, repeated minor trauma and immune defects. Clinically onychomycoses have to be differentiated from noninfectious onychodystrophy that can be caused by psoriasis, lichen planus and chronic nail eczema.

Case report: We report a case of 36-year-old woman who presented with waxing and waning discolorations of her fingernails for over ten years. For the first time, ten years ago, she reported with visible discolorations of three fingernails.

•Nail clippings - KOH  – negative,

•Culture – negative.

Discolorations appeared on her other fingernails.

•Repeated tests – Candida infection.

Topical antifungals were applied locally – improvement. The patient stopped the treatment because of pregnancy. After the birth the patient was breastfeeding for longer period of time so oral antifungal drugs couldn’t be administered. Topical antifungals were applied. The discolorations didn’t disappear but weren't as extensive.

Three years ago she reported with dark discolorations of the same fingernails. She also reported pain in her fingertips.

•P. aeruginosa and yeasts were isolated.
•Antibiotics and fluconazole were administered – no improvement.
•Itraconazole – three pulse doses à improvement.

Growth of healthy nail plate was visible. No pain was present.

Two years ago the discolorations reappeared on the same nail plates. The pain along with edema also reappeared.

Topical antifungal drug was administered.

•The dark discolorations disappeared.
•The pain persisted.

Because of persisting pain and edema the patient was referred to specialist of immunology. Work up has not been concluded.

Conclusion: Onychomycosis should be verified before noninfectious onychodystrophy is diagnosed.  The infections it selves are hard to treat; the treatment is usually long and the progress in terms of visible growth of the heathy nail is very slow. Although fungal nail infections can reoccur, even on the same nail, repeated discolorations and negative mycological findings should implicate to exclude other nail diseases, especially when accompanied by the pain and swelling of the fingertips. Immunological work up should be performed so, if necessary, the adequate therapy is given.

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