Tinea Unguium Initial Assessment

Clinical Presentation

Tinea unguium is usually asymptomatic, and patients first consult for cosmetic reasons. Onychomycosis is suspected if there are changes in the third or fifth toenail, involvement of the first and fifth toenails on the same foot, and unilateral nail changes. This can manifest with various nail changes, including discoloration, subungual hyperkeratosis, onycholysis, splitting, and destruction of the nail plate. Patients may complain of numbness, pain, and discomfort affecting manual activities and may cause loss of self-esteem and diminished social interaction. This may manifest as erythematous swelling of the nail fold (paronychia) or separation of the nail plate from its bed.

History

Onychomycosis typically requires prolonged, high-cost therapy; thus, the diagnosis should be confirmed before treatment starts. Tinea can be strongly suspected based on the patient’s history and clinical examination findings. Evaluating suspected onychomycosis starts with a focused history and physical examination in patients presenting with nail dystrophy (eg discoloration, thickening, splitting, or nail plate destruction) to establish the differential diagnosis. If clinical suspicion remains after this assessment, additional diagnostic tests can be used to confirm the infection. Patients should be asked about the duration and progression of nail changes, any preceding trauma, and any history of skin disease. When all nails are affected, further details such as possible systemic illnesses or a family history of nail disorders can help identify individuals at risk for systemic or genetic causes of onychodystrophy.

Physical Examination