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153]

Original Article

Clinical, Dermoscopic, and Mycological Association in Onychomycosis in

a Tertiary Care Hospital

Abstract Daksha Vasava,

Background: Onychomycosis (OM) refers to fungal infection of the nail unit. It is one of the most Hita Mehta,
common nail disorders, accounting for 50% of all nail disorders and about 30% of all cutaneous Twinkle Patel,
fungal infections. OM is mostly diagnosed clinically, but Dermoscopic (DS)  examination aids
in diagnosis. Objectives: The purpose of the study is to study the association between clinical, Milan Jhavar,
dermoscopic, and mycological patterns of OM. Materials and Methods: A total of 200 patients with Rahul Lakhotia
clinical suspicion of OM were included in the study. All patients underwent clinical examination, Department of
dermoscopic examination with a handheld dermoscope Dermlite II pro (3 Gen, San Juan, Capistrano, Dermatology, Venereology
CA, USA) with a  ×10 magnification, KOH assessment, and culture analysis. The most frequent and Leprosy,Government
dermoscopic patterns were identified and their associations with the clinical subtype of OM were
Medical College,
analyzed. Results: Out of the 200 cases, 65 cases were male and 135 cases were female. The most
common findings seen on clinical examination of nails were discoloration of nail plates  (178) and Bhavnagar, Gujarat, India
onycholysis  (109). Distal irregular termination  (91) was the most common dermoscopic finding
seen followed by spike pattern  (76). A  significant association was seen between dermoscopic
patterns such as superficial transverse striation, spike pattern, and different types of OM  (P < 0.05).
Eighty‑two cases were positive for fungal elements by direct microscopy, 68 were positive by
culture, and 18 patients showed positive result for both. The most common causative organism found
on culture examination was Candida albicans (24). Conclusion: Dermoscopy is an easy‑to‑perform,
noninvasive, and cost‑effective method which aids in early diagnosis of OM.

Keywords: Dermoscopy, distolateral subungual onychomycosis, onychomycosis

Introduction striation, spike pattern, longitudinal striae,

linear edge, and subungual keratosis with
Dermoscopic (DS) is a quite simple,
ruin appearance are associated with specific
noninvasive tool used for the diagnosis of
clinical types of OM.[3,6]
pigmentary and inflammatory disorders
and infectious diseases.[1] “Onychoscopy” Accurate diagnosis is important since the
is a dermoscopic examination of nails.[2] treatment of OM can be long‑standing,
Onychomycosis (OM) is a fungal infection expensive, and may be accompanied by
of the nail unit which occurs all over the severe adverse effects. Dystrophic nails can
world. The prevalence of OM seems cause embarrassment, affecting a patient’s Address for correspondence:
to vary across the world because of self‑esteem and may have a greater impact Dr. Hita Mehta,
various socioeconomic and cultural on quality of life than the severity of the Department of Dermatology,
disease itself.[7,8] Government Medical College,
factors. Various Indian studies reported an Bhavnagar - 364001,
incidence in the range of 0.5%–5%.[3,4] It The purpose of our study was to identify Gujarat, India.
is one of the most common nail disorder clinical, mycological, and dermoscopic E-mail:hitamehta88@gmail.com
accounting 50% of all nail disorders pattern of OM and to notice their
and about 30% of all cutaneous fungal association between clinical types and Submission: 11-02-2020
infections.[3,5] Various clinical types of OM dermoscopic features of OM. Revision: 03-06-2020
are distolateral subungual OM (DLSO), Acceptance: 02-07-2020
proximal subungual OM, white superficial Published: 19-02-2021
Materials and Methods
OM, and total dystrophic OM (TDO).[3‑5]
Many dermoscopic patterns such as distal In our study, 200 new patients with Access this article online

irregular termination, superficial transverse
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the
new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
clinically suspected OM, attending the Website: www.cdriadvlkn.org
outpatient department of dermatology,
DOI: 10.4103/CDR.CDR_49_20
venereology, and leprosy of a tertiary care Quick Response Code:
How to cite this article: Vasava D, Mehta H,
Patel T, Jhavar M, Lakhotia R. Clinical, dermoscopic,
and mycological association in onychomycosis in a
tertiary care hospital. Clin Dermatol Rev 2021;5:43-8.

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Vasava, et al.: Onychoscopy in onychomycosis

hospital from January 2016 to 2017, were enrolled in our Table 1: Age & gender distribution of study population.
study after approval by the institutional ethics committee. Age groups Gender Total (%)
After obtaining written consent from all patients, complete (years) Male Female
history and skin, nail, and systemic examinations were >20 4 4 8 (4)
carried out. Patients who were not willing to participate 20-30 9 15 24 (12)
in the study and patients who had undergone systemic or 30-40 14 41 55 (27.50)
topical treatment for fungal infections were excluded from 40-50 18 51 69 (34.50)
the study. 50-60 14 18 32 (16)
>60 6 6 12 (6)
Macroscopic images of the affected nails were obtained Total 65 135 200
with a single‑lens reflex digital camera  (canon‑EOS 50D).
Dermoscopic examination was performed using a handheld
dermoscope Dermlite II pro (3 Gen, San Juan, Capistrano,
CA, USA) with a ×10 magnification.
Mycological examination including KOH mount using 20%
KOH and culture was performed by collecting samples of
subungual debris at the proximal border of the onycholytic
area. Sabouraud’s dextrose agar and dermatophyte
test media were used for isolation, Then the clinical,
dermoscopic and mycological results of every patients a b
were compared.
After collection of clinical specimens, the patients were
treated with appropriate local and oral antifungal based on
clinical diagnosis.
Statistical analysis
The data collected were analyzed by frequency and
percentage. P value for each dermoscopic pattern in
relation to different clinical types of OM was calculated c
using Chi‑square test in GraphPad software. P < 0.05 was Figure 1: Clinical types of onychomycosis. (a) Distolateral subungual
considered statistically significant. onychomycosis, (b) proximal subungual onychomycosis, (c) total
dystrophic onychomycosis
Results
A total of 200 clinically diagnosed cases of OM were pattern  (38%), superficial transverse striation, longitudinal
included in the study. Out of the 200 cases, 65 (32.5%) striae, linear edge, splinter hemorrhage, and subungual
were male and 135 (62.5%) were female, which makes keratosis with ruin appearance  [Figures  2‑7].  A significant
the male: female ratio of 1:2.1. Majority of patients association was seen between dermoscopic patterns such
were in the age group of 40–50 years (69) followed as superficial transverse striation and spike pattern with
by 30–40 year (55) [Tables 1 and 2]. The duration of the different types of clinical OM (P < 0.05) [Table 4].
nail disease ranged from 2 months to 22 years [Graph 1]. On direct microscopic examination, out of 200 patients,
On clinical examination, out of 200 patients, 104 (52%) 82 (41%) patients were KOH positive and 68 (34%)
showed involvement of fingernails, 59  (29.5%) showed patients were culture positive. Most commonly isolated
involvement of toenails, and 37 (18.5%) showed organisms in culture were yeast (17.5%), followed by
involvement of both hand and feet. Distolateral OM in nondermatophytes (9%) and dermatophytes (8%) [Table 5
145 (72.5%) patients was the most common clinical type, and Figures 8 and 9].
followed by TDO and proximal superficial OM  [Figure 1].
White superficial type of OM was not found in any patient. Discussion
The most common findings seen on clinical examination The most common causative organisms of OM
of nails were discoloration of nail plates (89%) and are dermatophytes, followed by yeasts and non
onycholysis  (54.5%) and the least common findings were dermatophytic molds (Aspergillus, Fusarium, Onychocola
Beau’s lines (9%) and pitting (2.5%) [Table 3]. canadensis, Scopulariopsis brevicaulis, and Scytalidium
In our study, we found many interesting dermoscopic (DS) dimidiatum).[4,5,9] There are many diagnostic tests available
findings such as distal irregular termination  (45.5%) as for the diagnosis of OM such as direct microscopy (KOH
the most common dermoscopic finding, followed by spike examination), culture, biopsy, and other newer modalities

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Vasava, et al.: Onychoscopy in onychomycosis

Table 2: Gender distribution in various type of onychomycosis

Clinical type
DLSO (%) PSO (%) TDO (%) DLSO + TDO (%) P
Total number of cases 145 (74) 6 (2.97) 40 (19.6) 9 (4.45)
Gender
Male 40 (20) 1 (0.49) 23 (11.38) 1 (0.49) 0.0014
Female 105 (52.5) 5 (2.47) 17 (8.41) 8 (3.96)
DLSO: Distolateral subungual onychomycosis, PSO: Proximal subungual onychomycosis, TDO: Total dystrophic onychomycosis

Table 3: Clinical findings in onychomycosis

Clinical findings Number of patients (%)
Discoloration of nail plate 178 (89)
Color, total number of patients (%)
Mix 81 (40.5)
Brown 62 (31)
Yellow 34 (17)
Black 2 (1)
Green 0 (0.00)
Onycholysis 109 (54.5)
Subungual keratosis 39 (19.5)
Paronychia 27 (13.5)
Beu’s lines 18 (9) Graph 1: Distribution of cases in relation to duration of illness

Pitting 5 (2.5)
such as polymerase chain reaction (PCR), optical coherence
tomography (OCT), and confocal laser scan microscopy, but
none can be considered as a standard test for diagnosis.[10,11]
The present cross‑sectional study was conducted to
evaluate the association between clinical, mycological, and
dermoscopic pattern of OM. OM is a disease of middle
age people. It is uncommon in pediatric and older age.[5] In
the present study, OM is found to be most common in the
age group of 30–50 years (65%). Higher incidence of OM
was present among females (135) compared to males (65).
Occupation wise, higher incidence of OM was found in
homemakers followed by laborers. Women are affected
more because of the constant submerging of their hands in
water and their early consultation to the doctor for cosmetic
reason.
Fingernail (52%) was more commonly affected than
toenails  (29.5%). Increased incidence of fingernail OM
may be because of higher chances of occupational trauma
and fingernail infection is easily noticed by the patients
driving them to seek medical attention.
OM can be a differential diagnosis of nail involvement
in several dermatoses such as psoriasis, lichen planus,
alopecia areata, viral warts, chronic paronychia, and
traumatic onycholysis. To differentiate the above conditions
from OM, it requires mycological examinations which
are time‑consuming and not all dermatology clinics have
a microbiology laboratory. Potassium hydroxide smear
and fungal culture are confirmatory diagnostic technique
but having only acceptable sensitivity of 48%–80% and
25%–80%.[12] Newer diagnostic methods such as PCR and
OCT are expensive and not routinely done.
In our study, KOH mount and culture were performed
in all patients. Direct microscopic examination (KOH)
was positive in 41% of cases and culture on Sabouraud’s
dextrose agar was positive in 34% of cases [Table 5]. These
findings were consistent with previous studies.[3,5]
The most common clinical finding in our study was
discoloration of nail plates  (89%) and similar finding was
also observed in other studies like Kaur et  al. and Yadav
et al.[5,13] A study carried out by Ramesh found onycholysis
and subungual keratosis as the most common clinical
findings, which was similar to the findings described
by Kilinc et  al.[14,15] DLSO was the most common
clinical type of OM in our patients (50.60%), which is
consistent with many previous studies.[3,16,17] The greater
prevalence of DLSO can be explained by the structure of
hyponychium: It is the space where nail plate separates
from underlying tissue which makes it the weake, st area of
nail apparatus thereby allows pathogen as well as act as a
reservoir for them.[18]
Various dermoscopic patterns of OM described in
literature are distal irregular termination, spike pattern,
ruin appearance, smooth demarcation, longitudinal stria,
superficial transverse striation, and splinter hemorrhage.[3,6]
Distal irregular termination corresponds to the “distal
pulverization” characteristic of the thickening of the nail
plate, which is due to accumulation of dermal debris.[3]
The presence of “spikes” at the proximal edge of the
onycholytic area is an important indicator of OM. Spike

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Vasava, et al.: Onychoscopy in onychomycosis
a b
Figure 2: (a) Dermoscopic image of distal irregular termination in total
dystrophic onychomycosis and (b) schematic diagram
a b
Figure 4: (a) Dermoscopic image of smooth demarcation in distolateral
subungual onychomycosis and (b) Schematic diagram of smooth
demarcation
a b
Figure 6: (a) Dermoscopic image of longitudinal yellow white streaks and
(b) schematic diagram
pattern is characterized by longitudinal “indentations” directed
toward proximal nail fold; it results from distal to proximal
progression of dermatophytes through the horny layer of
the nail bed.[19] Longitudinal striae on dermoscopy (aurora
borealis pattern) appear as a yellow‑white alternate band on
nail plate, it results from progression of dermatophytes along
the nail plate, and they are the reflection of color of colonies,
flakes, or subungual debris.[19] The sensitivity of spikes in OM
was 100% and that of longitudinal striations was 82.5%.[20]
Subungual keratosis with ruin appearance in which there
are indented areas on the ventral portion of the nail and
46
a b
Figure 3: (a) Dermoscopic image of spiked pattern in distolateral subungual
onychomycosis and (b) schematic diagram
a b
Figure 5: (a) Dermoscopy of subungual keratosis with ruin pattern and (b)
schematic diagram
a b
Figure 7: (a) Dermoscopic image and (b) schematic diagram of transverse
striation
the ruin appearance on dermoscopy corresponds to fungal
presence, it occurs secondary to the accumulation of
dermal debris reacting to the process of fungal invasion,
characteristically seen in DLSO (17%).[3,7,19]
We observed splinter hemorrhages in 2 patients of DLSO
and 1 patient of TDO. They are less commonly seen in OM
and appear as linear, thin, deep red to black lines in the
distal nail. These occur in the dermis of the nail bed, when
capillaries rupture into linearly oriented epidermal dermal
ridges, they are also seen in psoriasis, traumatic nail and in
healthy individuals.[21]
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Vasava, et al.: Onychoscopy in onychomycosis

Table 4: Dermoscopic patterns and correlation with different type of onychomycosis

Clinical type
DLSO (%) PSO (%) TDO (%) DLSO + TDO (%) P
Distal irregular termination 66 (33) 0 22 (11) 3 (1.5) 0.0718
Spike pattern 65 (32.5) 1 (0.5) 6 (3) 4 (2) 0.0046
Ruin appearance 34 (17) 0 9 (4.5) 2 (1) 0.6112
Smooth demarcation 26 (13) 2 (1) 5 (2.5) 0) 0.2966
Longitudinal stria 24 (12) 1 (0.5) 3 (1.5) 1 (0.5) 0.5360
Superficial transverse striation 5 (2.5) 0 6 (3) 0 0.0294
Splinter hemorrhage 2 (1) 0 1 (0.5) 0 0.9159
DLSO: Distolateral subungual onychomycosis, PSO: Proximal subungual onychomycosis, TDO: Total dystrophic onychomycosis

Table 5: Association between clinical types and mycological examination

Clinical types
DLSO (%) PSO (%) TDO (%) DLSO + TDO (%) P
Positive direct KOH 56 (28) 3 (1.5) 17 (8.5) 6 (3)
Culture
Positive 54 (27) 3 (1.5) 10 (5) 1 (0.5) 0.4816
Trichophyton rubrum 6 (3) 0 2 (1) 0
Trichophyton mentagrophytes 4 (2) 0 1 (0.5) 1 (0.5)
Trichophyton tonsurans 1 (0.5) 0 1 (0.5) 0
Candida albicans 19 (9.5) 2 (1) 3 (1.5) 0
Candida non albicans 8 (4) 1 (0.5) 2 (1) 0
Aspergillus niger 11 (5.44) 0 1 (0.5) 0
Aspergillus fumigates 5 (2.47) 0 0 0
Negative 91 (45.5) 3 (1.5) 30 (15) 8 (4)
DLSO: Distolateral subungual onychomycosis, PSO: Proximal subungual onychomycosis, TDO: Total dystrophic onychomycosis

a b c
Figure 8: (a) KOH examination shows septate branching hyphae
of Trichophyton tonsurans. (b) Lactophenol cotton blue smear
shows brown black colony of Aspergillus niger in total dystrophic
onychomycosis. (c) Lactophenol cotton blue smear shows conidia
phialoconida of Aspergillus fumigatus in distolateral subungual
onychomycosis
a b c
Figure 9: (a)White colored colony of Candida albicans on Sabouraud’s
dextrose agar in distolateral subungual onychomycosis. (b) Dome-shaped
white colony of Trichophyton rubrum on dermatophyte test medium
in distolateral subungual onychomycosis. (c) Yellowed brown colored
colonies of Trichophyton tonsurans on dermatophyte test medium in
distolateral subungual onychomycosis

We also observed distal irregular termination (45.5%)

as the most common pattern. On the other hand, a study
carried out by Piraccini et  al. and Jesús‑Silva et  al. had
found spike pattern and longitudinal striae as the most
common dermoscopic findings, respectively.[3,19]
As per the data of Piraccini et al., traumatic onycholysis had
a linear edge without sharp spiked border in comparison to
the onychomycotic onycholysis that had jagged proximal
edges with spikes seen as indentation toward the normal
nail.[19] In our study, in all cases of linear edges, we
observed linear edge with little spikes and discoloration
which differentiate onychomycotic onycholysis from
traumatic onycholysis.
The presence of orange discoloration of affected
portion and absence of well demarcated streaks is an
important additional clue for diagnosing psoriatic nail
onycholysis.[12] Therefore, these dermoscopic findings
may be useful to differentiate the diagnosis of OM from
psoriatic nail onycholysis. Hence, dermoscopic patterns
are helpful for the diagnosis of OM and its differentiation
from close mimicking condition. Onychoscopy has also
been utilized as a tool to locate the best primal site for
mycological example.[2]
In our study, longitudinal striae were commonly observed
in DLSO  (12%). We found significant association between

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Vasava, et al.: Onychoscopy in onychomycosis
two DS patterns and clinical findings, namely spike pattern
with DLSO (P = 0.0046) and superficial transverse striation
with TDO (P = 0.0294). Similar association was observed
by Yadav et  al.[12] The DS pattern of subungual keratosis
with ruin appearance was present in 17% of patients with
DLSO, which was in concordant with the study conducted
by De Crignis et al.[6]
Conclusion
We evaluated dermoscopic images of OM, searching
for dermoscopic signs specific for each clinical type that
could facilitate the diagnosis of OM and its differentiation
from other nail disorder. We also conclude that the three
dermoscopic findings which are unique for OM are
longitudinal striae, spike pattern, and distal irregular
termination.
We found a significant association between two DS
patterns and clinical findings, spike pattern with
DLSO (P  =  0.0046) and superficial transverse striation
with TDO (P = 0.0294). This study shows the usefulness of
dermoscopy as a diagnostic tool coupled with mycological
examination for the diagnosis of OM. We recommend large
number of studies to be done to establish more accuracy
of dermoscopic patterns of OM. Dermoscopy has proven
to become an important adjunctive tool in the evaluation of
nail diseases.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient (s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initial s will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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