Clinical Dermatology Review

: 2021  |  Volume : 5  |  Issue : 1  |  Page : 43--48

Clinical, dermoscopic, and mycological association in onychomycosis in a tertiary care hospital

Daksha Vasava, Hita Mehta, Twinkle Patel, Milan Jhavar, Rahul Lakhotia 
 Department of Dermatology, Venereology and Leprosy, Government Medical College, Bhavnagar, Gujarat, India

Correspondence Address:
Hita Mehta
Department of Dermatology, Government Medical College, Bhavnagar - 364001, Gujarat


Background: Onychomycosis (OM) refers to fungal infection of the nail unit. It is one of the most common nail disorders, accounting for 50% of all nail disorders and about 30% of all cutaneous 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, dermoscopic, and mycological patterns of OM. Materials and Methods: A total of 200 patients with clinical suspicion of OM were included in the study. All patients underwent clinical examination, dermoscopic examination with a handheld dermoscope Dermlite II pro (3 Gen, San Juan, Capistrano, CA, USA) with a ×10 magnification, KOH assessment, and culture analysis. The most frequent dermoscopic patterns were identified and their associations with the clinical subtype of OM were 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 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.

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;5:43-48

How to cite this URL:
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 [serial online] 2021 [cited 2021 Sep 21 ];5:43-48
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Full Text


Dermoscopic (DS) is a quite simple, noninvasive tool used for the diagnosis of pigmentary and inflammatory disorders and infectious diseases.[1] “Onychoscopy” is a dermoscopic examination of nails.[2] Onychomycosis (OM) is a fungal infection of the nail unit which occurs all over the world. The prevalence of OM seems to vary across the world because of various socioeconomic and cultural factors. Various Indian studies reported an incidence in the range of 0.5%–5%.[3],[4] It is one of the most common nail disorder accounting 50% of all nail disorders and about 30% of all cutaneous fungal infections.[3],[5] Various clinical types of OM are distolateral subungual OM (DLSO), proximal subungual OM, white superficial OM, and total dystrophic OM (TDO).[3],[4],[5] Many dermoscopic patterns such as distal irregular termination, superficial transverse striation, spike pattern, longitudinal striae, linear edge, and subungual keratosis with ruin appearance are associated with specific clinical types of OM.[3],[6]

Accurate diagnosis is important since the treatment of OM can be long-standing, expensive, and may be accompanied by severe adverse effects. Dystrophic nails can cause embarrassment, affecting a patient's self-esteem and may have a greater impact on quality of life than the severity of the disease itself.[7],[8]

The purpose of our study was to identify clinical, mycological, and dermoscopic pattern of OM and to notice their association between clinical types and dermoscopic features of OM.

 Materials and Methods

In our study, 200 new patients with clinically suspected OM, attending the outpatient department of dermatology, venereology, and leprosy of a tertiary care hospital from January 2016 to 2017, were enrolled in our study after approval by the institutional ethics committee.

After obtaining written consent from all patients, complete history and skin, nail, and systemic examinations were carried out. Patients who were not willing to participate in the study and patients who had undergone systemic or topical treatment for fungal infections were excluded from the study.

Macroscopic images of the affected nails were obtained 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 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 using Chi-square test in GraphPad software. P < 0.05 was considered statistically significant.


A total of 200 clinically diagnosed cases of OM were included in the study. Out of the 200 cases, 65 (32.5%) were male and 135 (62.5%) were female, which makes the male: female ratio of 1:2.1. Majority of patients were in the age group of 40–50 years (69) followed by 30–40 year (55) [Table 1] and [Table 2]. The duration of the nail disease ranged from 2 months to 22 years [Graph 1].{Table 1}{Table 2}[INLINE:1]

On clinical examination, out of 200 patients, 104 (52%) showed involvement of fingernails, 59 (29.5%) showed involvement of toenails, and 37 (18.5%) showed involvement of both hand and feet. Distolateral OM in 145 (72.5%) patients was the most common clinical type, followed by TDO and proximal superficial OM [Figure 1]. White superficial type of OM was not found in any patient. The most common findings seen on clinical examination of nails were discoloration of nail plates (89%) and onycholysis (54.5%) and the least common findings were Beau's lines (9%) and pitting (2.5%) [Table 3].{Figure 1}{Table 3}

In our study, we found many interesting dermoscopic (DS) findings such as distal irregular termination (45.5%) as the most common dermoscopic finding, followed by spike pattern (38%), superficial transverse striation, longitudinal striae, linear edge, splinter hemorrhage, and subungual keratosis with ruin appearance [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]. A significant association was seen between dermoscopic patterns such as superficial transverse striation and spike pattern with different types of clinical OM (P < 0.05) [Table 4].{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Table 4}

On direct microscopic examination, out of 200 patients, 82 (41%) patients were KOH positive and 68 (34%) patients were culture positive. Most commonly isolated organisms in culture were yeast (17.5%), followed by nondermatophytes (9%) and dermatophytes (8%) [Table 5] and [Figure 8] and [Figure 9].{Figure 8}{Figure 9}{Table 5}


The most common causative organisms of OM are dermatophytes, followed by yeasts and non dermatophytic molds (Aspergillus, Fusarium, Onychocola canadensis, Scopulariopsis brevicaulis, and Scytalidium dimidiatum).[4],[5],[9] There are many diagnostic tests available for the diagnosis of OM such as direct microscopy (KOH examination), culture, biopsy, and other newer modalities 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 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 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]

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 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]


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


Conflicts of interest

There are no conflicts of interest.


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