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Diagnostic assessment of suspected onychomycosis

Diagnostic assessment of suspected onychomycosis
Onychomycosis is common and may be present in conjunction with other nail diseases. Confirmation of onychomycosis does not exclude the possibility of a concomitant nail disorder.

KOH: potassium hydroxide; PAS: histopathologic examination of nail clipping with periodic-acid Schiff stain; PCR: polymerase chain reaction.

* Onychomycosis may be suspected in patients with nail discoloration or nail dystrophy in a pattern consistent with one of the clinical subtypes of onychomycosis. Common features include yellow, white, or brown nail discoloration; subungual hyperkeratosis; onycholysis; spitting of the nail plate; and nail plate destruction. Refer to UpToDate topics on onychomycosis for details on the clinical features of onychomycosis.

¶ PCR testing is utilized by some clinicians as an initial diagnostic test and is a reasonable alternative, where available. However, not all PCR tests assess for all fungal causes of onychomycosis, and familiarity with the coverage and other limitations of the test selected is essential. Advantages of KOH preparation include immediate results and low cost. Advantages of PCR include higher sensitivity and the potential for identification of the causative fungus.

Δ Repetition of the KOH preparation is an alternative next step. A modest increase in sensitivity may occur with repeated testing. Both PAS and PCR are reasonable options; selection between these tests is generally based upon availability and cost. An advantage of some PCR tests is the ability to identify the type of fungus. Refer to the ¶ footnote definition for important PCR considerations.

◊ Options include repetition of the test performed in the previous step or performance of the test not previously performed (ie, PCR after PAS).

§ Refer to UpToDate topics on overview of nail disorders.
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