Curved toenails, Be careful to separate the ingrown toenails
Onychomycosis is suspected by appearance in patients who also have tinea pedis; predictive clinical features include involvement of the 3rd or 5th toenail, involvement of the 1st and 5th toenails on the same foot, and unilateral nail deformity. Subclinical onychomycosis should be considered in patients with recurrent tinea pedis.
Differentiation from psoriasis or lichen planus is important because the therapies differ, so diagnosis is typically confirmed by microscopic examination and, unless microscopic findings are conclusive, culture of scrapings or PCR of clippings. Scrapings are taken from the most proximal position that can be accessed on the affected nail and are examined for hyphae on potassium hydroxide wet mount and cultured. Although more expensive, PCR has become a more common technique to confirm the diagnosis of onychomycosis, especially if cultures are negative or a definitive diagnosis is required (1, 2, 3). Histopathologic examination of PAS-stained nail clippings and subungual debris may also be helpful.
Obtaining an adequate sample of nail for culture can be difficult because the distal subungual debris, which is easy to sample, often does not contain living fungus. Therefore, removing the distal portion of the nail with clippers before sampling or using a small curette to reach more proximally beneath the nail increases the yield.