European Geriatric Medicine 5 (2014) 172174

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Research paper

Epidemiological prole of onychomycosis in the elderly living in the

nursing homes
T. Gunduz a,1, K. Gunduz b,*,1, K. Degerli c,1, M.E. Limoncu a,1
a
Department of Microbiology, School of Vocational Health, Celal Bayar University, Manisa, Turkey
b
Department of Dermatology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey
c
Department of Microbiology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Few data is available about the prevalence and the causative microorganisms of
Received 17 September 2013 onychomycosis in the elderly. The aim of this study was to determine the prevalence and types of
Accepted 25 November 2013 onychomycosis in the elderly people living in the nursing homes and to determine the responsible fungal
Available online 19 December 2013
agents.
Methods: Elderly people living in nursing homes were examined for onychomycosis. Nails with color and
Keywords: structure changes were suspected of onychomycosis. Scraping materials were evaluated by direct KOH
Diabetes mellitus
examination and fungal cultures were performed.
Elderly
Results: Totally, 214 elderly persons (59 female, 155 male) from nursing homes were studied.
Fungal infection
Geriatry Onychomycosis was suspected clinically in 102 cases and scraping materials were obtained from 122
Onychomycosis nails. Clinical types of onyhomycosis were distal subungual in 87, proximal subungual in 21 and white
supercial in 14 cases. Fungal spores were seen in 81 (37.8%) samples (3 hand nails, 78 toenails) with
direct KOH examination and fungal culture was positive in 54 (25.2%) (3 hand nails, 51 toenails) of them.
Trichophyton rubrum was the most frequently isolated fungus (75.9%) followed by Candida glabrata
(12.9%).
Conclusions: In the elderly, onychomycosis is more common than the general population. However
causative fungi are similar; dermatophytes are the most common causative organisms followed by
yeasts.
2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

1. Introduction
As the improvement of medical treatment modalities and
general care conditions, the population over age 65 years
increases. With progressive aging of populations, geriatric health
care has become a major international issue for health authorities.
Elderly people are more susceptible to infections due to decreased
cellular immune response and also due to degenerative and
metabolic changes during the aging process. Although limited,
there are studies investigating the skin conditions in the geriatric
population. Fungal infections were the most frequently diagnosed
skin disease (49.7%) in 300 elderly patients living in nursing homes
[1]. In another study conducted on 4099 elderly people, fungal
infections were reported to be the second most common skin
* Corresponding author. Department of Dermatology, Faculty of Medicine, Celal
Bayar University, UncubozkoyMah, 5501 Sok. No: 29/5, Manisa, Turkey.
Tel.: +90 536 354 7822; fax: +90 236 234 8931.
E-mail address: kamergunduz@gmail.com (K. Gunduz).
1
Each author participated sufciently in the work. The manuscript has been read
and approved by all authors.
disease (15.8%) [2]. Onychomycosis, tinea pedis, tinea cruris, and
candidiasis are common in the geriatric population [3].
Nail diseases are frequent problems in the geriatric population;
they may be associated with the disturbed peripheral circulation or
disturbed biological mechanisms. With aging, the rate of growth,
color, contour, surface, thickness, chemical composition and
histology of the nail unit change [4]. Senile nails are susceptible
to fungal infections [1,5]. Onychomycosis is caused by dermato-
phytes in the majority of cases, but can also be caused by Candida
and non-dermatophyte molds (NDM). There are four types
of onychomycosis: distal subungual, proximal subungual, white
supercial and candidal onychomycosis [6].
The aims of this study were to determine the prevalence and
clinical characteristics of onychomycosis in the elderly people
living in the nursing homes and to determine the causative fungal
agents.
2. Methods
The study design was approved by the Local Ethics Committee
and informed consent was obtained from the cases. None of the

1878-7649/$ see front matter 2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
http://dx.doi.org/10.1016/j.eurger.2013.11.012
 T. Gunduz et al. / European Geriatric Medicine 5 (2014) 172174
elderly people had cognitive troubles and all gave informed
consent themselves. Elderly people living in the nursing homes
were examined for onychomycosis in Manisa, a city located in the
western region of Turkey. Medical follow-up was performed by a
dermatologist and a microbiologist in the nursing home. Nails with
color and structure changes were suspected of onychomycosis.
Dermatological examination of each case was performed in order
to exclude any dermatoses, like psoriasis, eczema or lichen planus
that might produce dystrophic nails. None of the cases had
antifungal medication. Scraping materials from the nails were
evaluated by potassium hydroxide (KOH) examination for the
presence of fungal elements in the mycology laboratory of Celal
Bayar University Hospital. Specimen cultures were performed on
Sabourauds dextrose agar with/without Dermasel, which contains
chloramphenicol and cycloheximide in order to inhibit the growth
of saprophytic fungi and bacterial skin ora. Cultures on 26 8C were
maintained for 4 weeks and checked periodically for growth.
Fungal colonies were evaluated according to the growth patterns,
color and macro- and microconidia formation by using lactophenol
cotton blue stain.
The medical histories and accompanying systemic diseases of
the study group were also recorded.
SPSS 15.0 was used for statistical analysis. Chi2 test was used for
comparison. Values P < 0.05 were evaluated as signicant.
3. Results
Totally, 214 elderly persons (59 female, 155 male) from 3
distinct nursing homes were included into the study. The mean age
of the study group was 76.9  7.6 (range 6597). Onychomycosis
was suspected clinically in 102 cases and scraping materials were
obtained from 122 nails (4 from ngernails, 118 from toenails); one
nail sample from 51 cases, 2 nail samples from 22 cases and 3 nail
samples from 9 cases were obtained. Clinical types of onyhomycosis
were distal subungual in 87, proximal subungual in 21 and white
supercial in14 cases.
Fungal spores were seen in 81 (37.8%) samples (3 ngernails, 78
toenails) with direct KOH examination and fungal culture was
positive in 54 (25.2%) samples (3 ngernails, 51 toenails). Table 1
summarizes the isolated fungi. Trichophyton rubrum was the most
frequently isolated fungus (75.9%) followed by C. glabrata (12.9%).
Of 214 elderly cases, 125 (58.4%) had at least one chronic
systemic disease. The most commonly encountered systemic
diseases were hypertension, chronic obstructive pulmonary
disease and diabetes mellitus (DM). Prevalence of onychomycosis
was 2.5 times higher in patients with DM (P < 0.001). None of the
cases used immunosuppressive medications.
4. Discussion
Fungal infections are common in the geriatric population [18].
Because of impaired host defenses and a favorable environment at
specic anatomic sites, there is an increased prevalence of
seborrheic dermatitis, mucosal and cutaneous candidiasis, tinea
pedis, and onychomycosis in the geriatric population compared to
other age groups [9].
Table 1
Distribution of the isolated fungi.
Toenails Fingernails
Trichophyton rubrum 38 3 study, the severity of onychomycosis was signicantly associated
Trichosporon spp. 4 with the duration of DM. Peripheral neuropathy, impaired
Candida glabrata 7 peripheral circulation and impaired host defence were reported
Candida tropicalis 1 to be signicant predictors for the development of onychomycosis
Candida parapsilosis 1
173
Onychomycosis affects approximately 5% of the population
worldwide and represents about 30% of cutaneous fungal infections.
Onychomycosis of ngernails may lead to pain, discomfort, and
impaired or lost tactile functions. Toenail dystrophy can interfere
with walking, exercise, or proper shoe t. Increased incidence of
onychomycosis in the elderly may be attributable to risk factors,
such as poor peripheral circulation, repeated trauma, suboptimal
immune function, and inability to maintain good foot care [10].
The fungal infections encountered in a large geriatric
population were tinea pedis (56%), onychomycosis (31.5%), tinea
corporis (7.2%), tinea versicolor (3%), and candidiasis (1.8%) [2]. In
another study, onychomycosis (34.6%) was found to be the most
frequent fungal infection [1]. In accordance with the previous
reports, the prevalence of onychomycosis was 37.8% in our study
group.
Fungi causing onychomycosis may vary from one geographic
area to another due to different climatic conditions.
Dermatophytes are the most frequently implicated causative
agents in onychomycosis. NDM, such as Scytalidium
dimidiatum and S. hyalinum account for 1.56% of all onycho-
mycosis. Yeasts previously regarded as contaminants, are now
increasingly recognized as pathogens. Candida onychomycosis is
increasingly found in individuals with defective or lowered
immunity consequential to aging, diabetes, vascular diseases,
immunosuppression, and broad spectrum antibiotics [10]. In the
Achilles foot project, covering 80,396 patients from East Asia
and Europe, dermatophytes were found to be the most common
causative organisms for onychomycosis, accounting for about
68% of all cases. This was followed by yeasts (11%) and NDM
(11%) [11]. In a study of 15,000 patients with onychomycosis in
Canada, 90.5% were caused by dermatophytes (Trichophytum
rubrum or T. mentagrophytes), 7.8% by NDM (Aspergillus,
Fusarium), and 1.7% by Candida spp. [12]. Scherer et al. [13]
investigated 450 cases of suspected onychomycosis in a geriatric
population. Samples were taken from the hallux toenail. A total
of 46.4% of the patients had a single fungal organism cultured,
30.4% had a mixed fungal infection cultured, and 23.1% had
no fungal growth. Saprophytes were found in 59.9% of the 526
total fungal organisms cultured while dermatophytes were
found in only 23.8%. The authors concluded that there might be
a shift from isolated dermatophyte infection to mixed
saprophyte infections in a geriatric population with onycho-
mycosis. Dias et al. [14] investigated fungal nail patterns in 108
geriatric individuals. Distal and lateral subungual onychomy-
cosis was the more common clinical pattern followed by total
dystrophic onychomycosis. T. rubrum was the dermatophyte
most frequently isolated (83.3%) followed by T. interdigitale.
Scopulariopsis infection was detected in 3 cases. Fusarium spp.
was identied in 3 cases. No mixed infections with dermato-
phytes were reported. In our study, distal subungual onycho-
mycosis was the more common clinical pattern followed by
proximal subungual type; dermatophytes (83.3%) were the most
frequently isolated fungi, followed by yeasts (13.7%). Two
different studies from Turkey report NDM growth in onycho-
mycosis as 2.9% and 9% [15,16]. However, there were no NDM
growth or mixed infections in our series.
DM is an important predisposing condition for cutaneous
infections, including onychomycosis. Patients with DM are 2.53
times more likely to have onychomycosis than the control
population. Dogra et al. reported that yeasts were the most
common agent in the onychomycosis of patients with DM. In their
[17]. The results of our study were similar; prevalence of
174 T. Gunduz et al. / European Geriatric Medicine 5 (2014) 172174
onychomycosis was 2.5 times higher in the elderly patients with
DM.
KOH examination is a good screening test for determining the
presence of fungi and fungal culture is a more specic conrmatory
test. However, the limitation of our study is that we were not able
to use more sensitive and specic diagnostic laboratory methods.
In conclusion, onychomycosis is more common in the elderly
than the general population. In our geographic and climatic
conditions, dermatophytes are the most common causative
organisms followed by yeasts. DM is an important predisposing
factor for onychomycosis in the geriatric population.
Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.
Acknowledgement
We are grateful to Irfan Saglam for his efforts in the Mycology
Laboratory and to Hakan Baydur for his help in the statistical
analysis of data.
Ethical statemement: The study design was approved by the Local
Ethics Committee and informed consent was obtained from the
cases.
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