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Risk factors associated with onychomycosis

Article  in  Journal of the European Academy of Dermatology and Venereology · February 2004

DOI: 10.1111/j.1468-3083.2004.00851.x · Source: PubMed

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 JEADV (2004) 18, 48–51

OR IG INAL AR T ICLE

Risk factors associated with onychomycosis

Blackwell Publishing Ltd.

B Sigurgeirsson,†* Ó Steingrímsson‡
Departments of †Dermatology and ‡Microbiology, University of Iceland and Landspitali, University Hospital, Reykjavik, Iceland. *Corresponding author,
Hú,læknastö,in, Smáratorg 1, 200 Kópavogur, Iceland, E-mail: bsig@simnet.is

ABSTRAC T
Objective To examine possible risk factors related to onychomycosis.
Background Onychomycosis is a common disease with multifactorial aetiology, but little is known about
the risk factors for this disease.
Patients and methods Questions related to signs, symptoms and possible risk factors associated with
onychomycosis were sent to 3992 persons aged 16 years and older selected randomly from the Icelandic
National Registry. Patients with suspected onychomycosis, based on photographs, were offered mycological
examination. Data from the questionnaire and the results of mycological examination were used to calculate
the odds ratio (OR) for several factors that might be associated with onychomycosis.
Results Two thousand four hundred and eighty-six subjects responded to the questionnaire. Prevalence for
mycologically determined onychomycosis was 11.1% in the Icelandic population. A history of the following
factors more than doubled the risk of onychomycosis: cancer (OR 3.44; 95% CI 1.15–10.35), psoriasis (OR
2.44; 95% CI 1.61–3.72), tinea pedis interdigitalis (OR 3.93; 95% CI 3.11–4.95), the moccasin form of tinea
pedis (OR 4.26; 94% CI 3.34–5.45), parents with onychomycosis (OR 2.59; 95% CI 1.89–3.53), children
with onychomycosis (OR 3.48; 95% CI 2.05–5.88), spouse with onychomycosis (OR 2.53; 95% CI 1.72–
3.72), regular swimming activity (OR 2.57; 95% CI 2.00–3.30) and age 50 years or older (OR 2.74; 95% CI
2.19–3.42).
Conclusions Several risk factors are associated with onychomycosis. Knowledge of these risk factors is
important when treating and educating patients with onychomycosis.
Key words: onychomycosis, risk factors, prevalence

Received: 19 July 2002, accepted 13 February 2003

and treatment of onychomycosis if further risk factors for this

Introduction
Onychomycosis is a common disease of the nail. The pre-
valence in population-based studies ranges from 2 to 11%.1–3
For many years griseofulvin was the only available oral
therapy. The newer azoles and allylamines have dramatically
improved cure rates.4 Recent studies have demonstrated
that recurrence, either by reinfection or relapse of previous
infection, is seen in up to 50% of cases.5 It has also been
demonstrated that patients who fail standard therapy
regimens can in many cases be successfully treated with
an individualized treatment regimen.5 It is known that
onychomycosis is associated with several risk factors such as old
age,6 psoriasis,7 diabetes8 and individuals involved with
sport activities.9 It would be of great value in the prevention
disease could be identified. The objectives of this study were to
examine the risk factors, known and unknown, for onycho-
mycosis in a large population-based sample of individuals.
Patients and methods
Questions related to signs and symptoms of onychomycosis,
detailed in a questionnaire, were sent to 3992 persons aged
16 years and older, selected randomly from the Icelandic
National Registry. The Registry includes information about
all living Icelanders. The questionnaire included photographs
of nails infected with dermatophytes, normal nails and also
other nail diseases. The respondents were asked to compare
these with their own nails. To ensure the reliability of this

48 © 2004 European Academy of Dermatology and Venereology

 Risk factors for onychomycosis 49

method, a preliminary quality control study was carried out Table 1 Possible risk factors associated with onychomycosis based on a
on patients with onychomycosis. Out of 55 patients seen for questionnaire

onychomycosis at our clinic, 50 (91%) identified themselves

Odds ratio 95% Confidence interval
with photographs of nails with confirmed onychomycosis
rather than other nail disorders or normal nails. Included in Atopic disorders
the questionnaire were questions about nail status, duration Atopic eczema 0.69 0.44–1.10
of disease and localization of nail disease, and several questions Angioedema 1.65 1.12–2.42*
on possible risk factors for onychomycosis. The part of the Urticaria 1.36 1.06–1.73*
Asthma 1.52 1.07–2.17*
study that relates to the prevalence of onychomycosis in
Iceland has already been published.1 Chronic disorders
Cancer 3.44 1.15–10.35*
At the time of the study there were 229 263 persons aged
Heart 1.63 0.91–2.92
16 years or older in the National Registry, so 1.74% of the Lung 1.34 0.69–2.59
Icelandic population aged 16 years and older were included Gastrointestinal 1.86 1.03–3.36*
in the study. Endocrinological 1.48 0.73–2.97
Patients with suspected nail changes based on photo- Rheumatological 1.88 1.25–2.83*
Neurological 0.62 0.08–4.86
graphs were offered a clinical examination with mycological
sampling. Direct examination of specimens was performed Skin disorders
after nail scrapings had been immersed in 5% KOH solution Psoriasis 2.44 1.61–3.72*
Eczema 0.91 0.58–1.44
containing dimethyl sulfoxide. Specimens were inoculated
Other 1.28 0.88–1.87
on Sabouraud’s glucose agar containing chloramphenicol
Fungal infections of the skin
0.05 g/L and on mycobiotic agar. Plates were incubated at
Tinea pedis (interdigitalis) 3.93 3.11–4.95*
30°C for 3 weeks and examined at weekly intervals. Risk Tinea pedis (moccasin type) 4.26 3.34–5.45*
calculations were based on the individual’s response after Dry palms 1.60 1.11–2.32*
studying the accompanying photographs. Information regarding
Genetic factors
concomitant disorders was derived from the questionnaire, Parents with onychomycosis 2.59 1.89–3.53*
but no attempt was made to further verify this information. Children with onychomycosis 3.48 2.05–5.88*
We calculated the odds ratio (OR) for each risk factor with Spouse with onychomycosis 2.53 1.72–3.72*
a 95% confidence interval (CI).10 Results with the lower CI Others living in same household 0.98 0.51–1.87
with onychomycosis
> 1 were considered significant.
Lifestyle
Regular swimmer 2.57 2.00–3.30*
Results University education 0.99 0.73–1.34
Nursing home 1.62 0.73–3.60
Of the 3992 subjects, 2486 responded (62.3%): this included Aged 50 or older 2.74 2.19–3.42*
1117/1964 (56.9%) males and 1369/2028 (67.5%) females. Smoking 1.13 0.90–1.42
The estimated prevalence based on positive mycology was
*A significant association with onychomycosis.
11.1% in the Icelandic population. When only patients with
a positive growth of a dermatophyte were considered the
prevalence was 8.4%.1 Fungal infections were strongly associated with onychomy-
The questionnaire included questions related to other skin cosis. High risk was found in patients with the interdigital
disorders, signs and symptoms suggestive of fungal infections (OR 3.93; 95% CI 3.11–4.95) and the moccasin form (OR
of the skin, genetic factors, lifestyle, chronic disorders and 4.26; 95% CI 3.34 –5.45) of tinea pedis. Slightly elevated risk
atopic diseases (Table 1). was even associated with a history of dry palms (OR 1.60;
Onychomycosis was more common in males than females, 95% CI 1.11–2.32), which might be suggestive of an id reac-
with an OR of 1.28 (95% CI 1.03 –1.59). tion in some of these patients.
Of the atopic disorders the risk of onychomycosis was Genetic factors seem to play a role, as elevated risk was
slightly increased in patients with a history of angioedema found in patients who had children (OR 3.48; 95% CI 2.05–
(OR 1.65; 95% CI 1.12–2.42), urticaria (OR 1.36; 95% CI 5.88) or parents (OR 2.59; 95% CI 1.89 –3.53) with ony-
1.06 –1.73) and asthma (OR 1.52; 95% CI 1.07–2.17). chomycosis. Direct transmission to members of the same
When chronic disorders were examined, patients with a household cannot be excluded as slightly elevated risk was
history of cancer had a high risk of developing onychomycosis found in patients whose spouse (OR 2.53; 95% CI 1.72–3.72)
(OR 3.44; 95% CI 1.15 –10.35). In patients with gastrointestinal had onychomycosis.
(OR 1.86; 95% CI 1.03 –3.36) and rheumatological disorders (OR The risk in regular swimmers was increased (OR 2.57;
1.88; 95% CI 1.25 –2.83) the associated risk was low. 95% CI 2.00–3.30) and age obviously played a role, with

© 2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 48 – 5 1

50 Sigurgeirsson and Steingrímsson
increased risk in those 50 years or older (OR 2.74; 95% CI
2.19 –3.42).
Discussion
Knowledge about risk factors for onychomycosis is
important. It is known that patients with psoriasis,7 diabetes8
and immunosupression11 are more prone to onychomycosis.
Onychomycosis also increases with age6 and most studies
have showed higher prevalence among males. It is also known
that sport activity increases the risk of onychomycosis;9
for instance, a high prevalence has been demonstrated in
swimmers.12
In the present study we examined several risk factors. We
found it interesting to examine the atopic disorders, as there
have been several reports of patients with atopic disorders
and onychomycosis. In some of these cases it has been
reported that with treatment of onychomycosis the signs and
symptoms of the atopic disorders have disappeared. This
suggests that in selected cases, patients can have reactive dis-
orders as a result of a fungal infection.13–16 In the present
study we were not able to determine the nature of the asso-
ciation between these disorders and onychomycosis, but
patients with asthma, urticaria and angioedema were more
likely to have onychomycosis. This could be explained by an
allergic reaction to the fungus that causes the atopic disease
or by the fact that patients with these disorders are more
prone to onychomycosis.
Immunosuppressive states such as human immunodefi-
ciency virus (HIV) infection are known to be associated with
onychomycosis.17 To our knowledge the association of can-
cer and onychomycosis has not been demonstrated before. It
is possible that immunosuppression, which often follows
advanced malignant disease, increases the risk of onychomy-
cosis. The treatment of the cancer can also play a role in
making the patient more susceptible to a fungal infection. The
same arguments apply for rheumatological disorders, which
also seem to be associated with increased risk of onychomyco-
sis. We have no ready explanation for the increased risk
associated with gastrointestinal disorders. No risk was seen
with endocrinological disorders, although the association with
diabetes has been clearly demonstrated in the literature.8
The association between onychomycosis and psoriasis
has been reported before7 and is probably more frequent
than previously thought.18 We were not able to demonstrate
an association of eczema or other skin disorders with
onychomycosis.
It is not surprising that patients with a history of other
fungal infections of the feet have a higher risk of onychomy-
cosis. The highest risk was associated with the moccasin
form of tinea pedis. Even patients who described dry fissur-
ing palms had a higher risk of onychomycosis. We believe
that in this case the dry palms can be a sign of an id reaction.19
© 2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 48–51
Genetic factors are thought to play a role in the suscepti-
bility of onychomycosis.20 In this study we found increased
risk in patients whose parents or children had onychomyco-
sis, but elevated risk was not found when other members of
the same household had onychomycosis. The risk was also
increased when the spouse had onychomycosis, which points
to transmission to the subject from the spouse.
We found increased risk in swimmers. This has been dem-
onstrated before12 and also in relation to other sports.9 We
also found that the risk of onychomycosis was higher in
those aged 50 years or older. This has been reported previ-
ously in several studies.6,21 We did not find an association
with smoking. A recent study has shown an increased risk of
onychomycosis in heavy smokers.22 Our study, however,
included too few heavy smokers to make that kind of analysis
possible.
We have demonstrated several important risk factors that
are associated with onychomycosis. Increased risk was
found in patients with a history of atopic disorders, chronic dis-
eases, psoriasis, other fungal infections of the skin, sport and
increased age. A possible genetic link was also demonstrated.
Knowledge about risk factors is important for those who
treat patients with onychomycosis. Many of the risk factors
we have shown to be associated with onychomycosis have
not been reported before. A questionnaire study is in essence
a crude tool and the results must therefore be interpreted
with caution until they have been further investigated in
other studies.
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