Onychomycosis: Burden of Disease and the Role of Topical Antifungal Treatment
November 2013 | Volume 12 | Issue 11 | Original Article | 1263 | Copyright © November 2013
Ralph C. Daniel MD
Department of Medicine (Dermatology), University of Mississippi Medical Center, Jackson, MS
Abstract
Onychomycosis is not just a cosmetic problem. It is a common disorder that may be a reservoir of infection and lead to significant
medical problems. In addition, onychomycosis may cause a substantial decrease in quality of life. An understanding of the disorder and
updated management is important for all health care professionals. Onychomycosis is the most common nail disorder in adults.
1 It is
four to seven times more frequent in toenails, where it often involves several nails.
2-4 It is a progressive disease, and although not life
threatening it is inappropriately considered purely a cosmetic problem, with some physicians still believing there is no need to treat. The
fungal infection usually begins in the nail bed, and often extends to the nail plate. Onychomycosis is unsightly and can be uncomfortable;
with discoloration of the nail plate and more severe disease resulting in loss of the nail plate altogether. Onychomycosis may become a
source of more widespread fungal lesions, spreading to other nails, body sites (groin, skin, scalp), and even to family members.
5, 6
J Drugs Dermatol. 2013;12(11):1263-1266.
INTRODUCTION
The Burden of Onychomycosis
Patients with onychomycosis often initially seek medical
intervention because of its aesthetic impact. A significant
portion feels unattractive and stigmatized by their
onychomycosis; conscious people are staring at their nails and
wondering if the disease is contagious.7
The impact of onychomycosis upon an individual can be
significant.8 Although an accurate estimate of its burden is
unknown, in a telephone survey 70% of toenail onychomycosis
patients considered their nail disease to be at least a
moderate problem, and the embarrassment caused was more
prevalent and severe in women (44% of subjects compared to
26% of men).9 In another study in Poland, more than 20% of
patients had a severely decreased quality of life (QoL), with
another 30% reporting moderately decreased QoL.10 In an earlier
QoL self-assessment survey where subjects responded
to a newspaper advertisement, 92% stated they had negative
psychosocial or physical effects related to their onychomycosis,
44% reported a negative effect on self-image, and 41%
reported pain or discomfort.11
Studies have reported a vast majority (93%) of subjects suggesting
that other people found it unpleasant to look at their
infected nails, 31%-96% feared the disease would spread to others,
and 44%-74% were generally embarrassed.9,11,12
But many patients also suffer significant pain and discomfort,
varying degrees of physical impairment, and loss of dexterity
that can get worse without treatment. An observational study of onychomycosis patients treated by dermatologists
and podiatrists highlighted large numbers of condition-related
embarrassment (67%), toenail discomfort (54%), and painful
walking (36%).13 Studies suggest toenail pain was present in
41–60% of subjects, and nearly one-fifth avoided various social
activities due to onychomycosis. 9,11,12 Most patients with toenail
onychomycosis had problems wearing shoes (82%), and difficulties
in cutting their nails (75%–86%).9,11,12 Other discomforts
related to onychomycosis reported included tingling, burning,
numbness, pressure, or discomfort.9
The large scale Achilles Project surveyed foot diseases in
over 43,000 patients visiting their primary care physician
or dermatologist.14 They found 37% of patients with onychomycosis
had discomfort on walking, 29% suffered pain, 30%
were embarrassed by their condition, and 19% were limited
in their daily activities.14
The aesthetic impact of onychomycosis can have a negative
effect on patient’s social and professional life, and sense
of well-being.15 Not surprisingly, these effects are especially
pronounced in women, who are more concerned about the
appearance of their affected nails and report greater interference
with their daily activities,13 and younger people where
appearance is of greater importance for them in establishing
interpersonal relationships.11 Severe cases appear to even have
a negative influence of patients’ sex lives, and the self-esteem
of female subjects is significantly affected by an unsightly and
contagious-looking nail plate.12 Socks and stockings may frequently
be damaged due to the constant rubbing against sharp,