ONYCHOMYCOSIS

Synonyms.—When due to ringworm fungus: Onychomycosis trichophytina;
Tinea trichophytina unguium; Trichophytia unguium; Ringworm of the Nails; Fr.,
Onychomycose trichophytique; Trichophytie unguéale; Ger., Onychomycosis tonsurans.
When due to favus fungus: Onychomycosis favosa; Tinea favosa unguium; Favus of the
nails; Fr., Onychomycose favique; Favus des ongles; Ger., Favus des Nagels.

Definition.—A crumbly, friable, grayish-colored, granular-looking
condition of the nail, due to invasion by the ringworm or favus fungus.

Symptoms.—Rarely more than one or two nails are involved,
and most commonly the finger-nails. The invasion is, as a rule, in­
sidious, and the development of the malady extremely slow. Usually
the lateral distal edge shows the first signs, the part becoming somewhat
brittle and friable, grayish or grayish-yellow in color, and often some­
what crumbly. It may be thus limited, scarcely involving more than
one-fourth of its substance, and remain so sometimes almost indefinitely.
In other instances the greater part of this nail is sooner or later invaded,
and it may encroach upon the posterior portion, although most com­
monly involving the anterior half or two-thirds. In exceptional cases,
however, the whole nail is implicated. Beneath the distal portion there
is often a variable accumulation of epithelial matter and débris, of a
dirty-gray or grayish-yellow color, and in some instances sufficiently
great in quantity to lift this part of the nail up from its bed in an irregular

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DISEASES OF THE APPENDAGES

manner. In occasional cases the malady seems to be more or less re­
stricted to this underlying part, the horny, or nail substance proper,
showing, at first at least, but little involvement, although usually slightly
changed in color. While the free edge or the immediately adjacent side
more commonly shows the earliest effects, not infrequently the first
involvement is with the lateral or posterior portion, and this probably
more frequently from the ringworm fungus than from the favus fungus.
The changes produced by these fungi vary but little, although in the dis­
ease due to that of favus the evidences first presenting consist in some
cases of yellowish, pin­point to pin-head, grain-like bodies. While the
nail of any finger or fingers may be attacked, the thumb, the first, and the
second are apparently most frequently involved, and this is especially so
in favus. The toe-nails are relatively seldom invaded, but much more
commonly by the ringworm fungus than with that of favus; Vidal,
Zeisler, and a few others have noted instances in which the latter attacked
these parts primarily. In exceptional instances the affected nails, more

Fig. 242.—Onychomycosis due to the favus fungus—favus of the nails—in a Russian
girl aged seventeen. One year’s duration; favus of the scalp since twelve years old
(courtesy of Dr. F. J. Leviseur).

especially those of the toes, are increased in volume and become quite
hard and horny, sometimes gryphotic and distorted (Geber, Censi) ,¹
Etiology and Pathology.—The cause, as already stated, is
either the ringworm or favus fungus; the latter much less frequently,
and when etiologic, the malady is, as a rule, contracted from the erup­
tions elsewhere on the surface, usually from the disease on the scalp.
This is true in great measure also with that due to the ringworm fun­
gus, although it is not uncommon to find the nails the primary and sole
part involved, having been contracted from others who may have the
disease on the non-hairy or hairy parts. It may itself be the source
of contagion to others.² Both the nail and subjacent derma are in­
vaded by these fungi. According to Sabouraud, only the trichophyton
endothrix (almost always trichophyton acuminatum or trichophyton

¹ Geber, Ziemssen’s Handbook of Skin Diseases, p. 487; Censi, “Clin. dermosif. d.
R. Univ. di Roma,” abs. in Brit. Jour. Derm., 1898, p. 423, records 2 instances of
onychomycosis trichophytina of the toe-nails, in which the nail was thickened, curved,
and nodular, shaped like a bird’s claw or a ram’s horn.

² Fournier, Jour. mal. cutan., 1889, p. 3, has recorded an instance of contraction of
ringworm by several members of a family from a servant who had onychomycosis.

ON YCHOM YCOSIS

963

violaceum) is found in the nails, the other varieties of ringworm fungus
not attacking these structures; but this statement is, it is believed, too
absolute. The fungus can, as a rule, be readily demonstrated in the
scrapings of the affected nail substance by placing on a slide in some
liquor potassæ, allowing it to soften for several minutes to an hour or
more, and then examining with a power of 400 to 500 diameters. Ex­
ceptionally, as noted by Hutchinson and Crocker, the parasite is not easily
found, the scrapings requiring sometimes a soaking of ten to twenty
hours in the liquor potassæ.

Diagnosis.—With the presence of either ringworm or favus
patches elsewhere upon the surface the nail involvement would permit
usually of a ready diagnosis. A similar, or closely similar, condition
of the nails is, however, seen in connection with psoriasis, eczema, and
other chronic inflammatory dermatoses; and, moreover, not infrequently
occurs independently, sometimes as the result of impaired general nutri­
tion or trophic disorders, and likewise in those of gouty or rheumatic
tendency. The diagnosis, therefore, must often be based upon micro­
scopic examination of the scrapings. It is true, however, that in the
parasitic disease rarely more than one or several nails are affected, while
in association with or as a result of the maladies mentioned, in most
instances, many or all are apt to be more or less involved.

Prognosis and Treatment.—The malady is extremely obsti­
nate, although finally responsive to persistent treatment. If let alone,
it continues indefinitely, showing no tendency to spontaneous cure.¹
It usually remains limited, however, to one or two nails; more than several
are rarely involved.²

In the treatment the parts are to be repeatedly closely pared, pumiced,
or scraped. If very hard and brittle, and often also with advantage in
other instances, an occasional soaking in an alkaline solution will
serve to soften; or liquor potassæ or a stronger solution of caustic potash
can be painted on several times. Another method (Pellizzari) of soften­
ing and removing the involved nail tissue is by enveloping it with sapo
viridis, covering it with a rubber finger-stall, and allowing it to remain
for one to several days, during which time it can be renewed. These
mildly caustic applications require some care that the surrounding tissue
is not unnecessarily acted upon. Along with the removal of the dis­
eased nail substance from time to time in the manner described parasiti­
cide applications are to be made. One of the best plans is to dip the
affected finger-ends in a solution of mercuric chlorid, from 1 to 3 grains
(0.066-0.2) to the ounce (32.), for five to ten minutes twice daily, allow­
ing it to dry in, and then enveloping the parts with an ointment of white
precipitate or calomel, a dram (4.) to the ounce (32.); or the finger-ends
may be soaked in a 15 to 20 per cent, solution of sodium hyposulphite,
subsequently enveloping them with an ointment of precipitated sulphur,
1 dram (4.) to the ounce (32.). In cases in which the parts are not sen-

¹ Crocker, Brit. Jour. Derm., 1899, p. 331, mentions an instance in which one nail
had apparently been affected by the ringworm fungus for forty to fifty years; Pernet,
ibid., 1902, p. 16, one case in which it had existed for twenty to thirty years.

² Sabouraud, Annales, 1896, p. 33 (describes a case due to ringworm fungus, involv­
ing all the nails of the right hand).

964                     DISEASES OF THE APPENDAGES

sitive or easily irritated enveloping the nail over night in an application
consisting of the following may be advised:

R. Sulphur præcip.,                                                        3ij (8.);

Ac. salicylici,                                                             gr. xxx (2.);

Saponis viridis,                                             q. s. ad 3 j (32.)-

Sabouraud commends a lotion composed of 15 grains (1.) iodin, 30
grains (2.) potassium iodid, and a quart (1000.) of water; this is ap­
plied on absorbent cotton, and kept covered with a rubber finger-stall,
and renewed frequently. It is, as all other plans, slow, but the fungus
development is completely inhibited, the new-growing nail substance
remaining unaffected, and gradually replacing the morbid structure.
Crocker has had the most success with Harrison’s plan of treating
ringworm of the scalp (q. v.). Norman Walker keeps the nails soak­
ing in a bath of Fehling’s solution by means of lint and finger-stall,
for a day or two, removing the softened nail, and following with a
continuous dressing of a 3 per cent, copper sulphate solution; Cranston
Low¹ found both this and the Harrison method successful. In per­
sistently obstinate cases complete avulsion of the affected nail, followed
by the use of the above remedies, may be required.

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