Suspected Onychomycosis in a 34-Year-Old Male
Case at a Glance
A 34-year-old male presents with chronic toenail changes on his right foot, suspected to be onychomycosis (nail fungus), with a history of successfully treated tinea pedis.
Patient's Story
The patient is a 34-year-old male, 188cm tall, weighing 80kg, who is an ex-smoker with no current medical issues. He presents with concerns about his right toenail, which has been abnormal in appearance for several years. He reports a previous history of athlete's foot (tinea pedis) which was successfully treated. The affected toenail is painless, and no other nails appear to be involved. The patient is seeking clarification on the diagnosis and potential treatment options.
Initial Assessment
Physical examination reveals changes consistent with onychomycosis affecting a single toenail on the right foot. The nail shows characteristic fungal infection appearance with less than 50% of the nail plate involved. No pain or discomfort reported. No other nails appear affected at this time.
The Diagnostic Journey
Based on clinical presentation and history of previous fungal infection (tinea pedis), the working diagnosis is onychomycosis. The localized involvement of a single nail and previous fungal infection history support this diagnosis. Mycological confirmation with KOH preparation and culture would be recommended for definitive diagnosis.
Final Diagnosis
Suspected onychomycosis (nail fungus) of the right great toenail, likely secondary to previous tinea pedis infection.
Treatment Plan
Treatment options discussed include: 1) Topical antifungals - efinaconazole being most effective for limited nail involvement, with alternatives including ciclopirox, amorolfine, and tavaborole showing lower efficacy. 2) Oral terbinafine 250mg daily for 90 days - most effective systemic treatment with 70% mycological cure rate and 38% complete clinical cure rate at 48 weeks post-treatment. 3) Alternative oral agents (itraconazole, fluconazole) available but less effective. Laser treatment noted to have limited evidence for complete cure.
Outcome and Follow-up
Patient counseled on treatment expectations, including potential for reinfection and the definition of treatment success (clearance for one or more years). Discussed rare but serious risk of hepatotoxicity with oral antifungals (1 in 400,000 for terbinafine) and the need for monitoring. Patient to consider treatment options and return for mycological confirmation and treatment initiation.