الفهرس 
Epidemiology and incidenceOnly 14 pages are availabe for public view
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Abstract
Onychomycosis is the infection of the nail unit or any of its components by fungi, either dermatophytes, yeasts and or non-dermatophytic molds.
It can have significant negative effects on patients, emotional, social and occupational functioning and consume a sizable proportion of health care financial budget.
Clinical patterns of onychomycosis include: distal and lateral subungual onychomycosis ( DLSO), superficial white onychomycosis (SWO), proximal subungual Onychomycosis (PSO), candidal Onychomycosis and total dystrophic Onychomycosis (TDO).
Onychomycosis can be diagnosed by clinical examination, direct microscopy using potassium hydroxide 20% (KOH), cultures, confocal microscopy, flow cytometry and PCR.
There are several treatment choices for Onychomycosis: oral, topical, mechanical or chemical removal of the nail plate.
Newer systemic antifungal drugs appear to have high cure rates and excellent safety profiles as itraconazole, terbinafine, and fluconazole which offer shorter treatment regimens and fewer adverse effects.
Topical antifungals as ciclopiroxolamines, sodium pyrithione, imidazoles and allylamines, alone are not able to cure onychomycosis because of insufficient penetration but they may be useful as adjuvant therapy in combination with oral therapy.
Combination of two or more drugs can result in increased efficacy and speed of a broader spectrum of activity and better patient tolerability. These benefits can be the result of drug synergy i.e. the combination is more effective than the additive effects of each drug alone.
Surgical or chemical nail avulsion may be useful in patients with severe onycholysis, extensive nail thickening, longitudinal streak or spikes in the nail that can be caused by a granulated nidus of infection (dermatophytoma), which responds poorly to standard courses of medical therapy, Contraindications to the use of systemic antifungal agents, and the presence of drug – resistant pathogens.
Combined surgical and medical treatment provided clinical and economic benefits over monotherapy.
In our study, we decided to compare between the efficacy of total nail avulsion in combination with oral and / or topical antifungal therapy of finger nail Onychomycosis versus oral and topical antifungal therapy.
Patients were subdivided into 5 groups; each group consists of five patients as follows:
Group I: (systemic + topical + surgical)
Group II: (systemic +surgical)
Group III: (topical +surgical)
Group IV: (systemic +topical)
Group V: (systemic only)
Systemic antifungal drug therapy was in the form of itraconazole 200 mg twice daily for one week per month for three successive months and topical antifungal therapy was in the form of tioconazole nail solution 28% twice daily for 3 months or started one week after surgery. Surgical nail avulsion was done using proximal or distal techniques.
After three months from the start of treatment, we found that Group I and Group II had the highest mycological and clinical cure rates (80%) followed by Group IV (60%) and finally Group III and Group V (40%).
Patients were followed up at 6, 9 and 12 months after treatment and careful records including photographs were kept of the re-growth of new normal nails, as well as of any evidence of relapse or resistance to therapy.
The avulsing technique is of paramount importance, not only the entire nail plate must be removed but also all the underlying keratinous debris should be thoroughly curetted off the nail bed and from beneath lateral nail folds to remove all possible foci of re-infection.
Conclusively, our results demonstrate that combined surgical and medical treatment had synergistic effect, leading to mycological and clinical cure.
Our recommendation is that in order to successfully manage patients who apparently fall into the poor, non responders or patients with treatment relapses, consideration should be given not only to medical oral and topical antifungal treatment, but also to the concomitant application of surgical nail avulsion.
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