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

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.


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,