Global prevalence of onychomycosis in general and special populations: An updated perspective.

BACKGROUND: Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge. OBJECTIVE: To provide an updated estimate on the prevalence of toenail onychomycosis. METHODS: We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients. RESULTS: A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture. CONCLUSION: Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.

Retrospective Analysis of Liver Enzyme Abnormalities in Patients Prescribed Terbinafine and Itraconazole for Onychomycosis.

Introduction Onychomycosis (OM) is defined as a nail fungal infection. Its prevalence increases with advancing age. Human-to-human transmission makes it a serious public health risk. Although OM is not a life-threatening disease, it has a detrimental effect on patients' quality of life. Due to the long therapy duration and potential side effects of systemic antifungal medicines, physicians may be reluctant to treat OM orally. In this study, we aimed to evaluate the effect of terbinafine and itraconazole on liver transaminases, the side effects of these treatments, and patients' adherence to systemic treatment of OM. Methods This is a retrospective study conducted in our dermatology department (Ordu University, Ordu) between June 2020 and October 2021. Hospital records were analyzed, and patients with the diagnosis of tinea unguium (ICD code B35.1) were investigated. Patients who were prescribed terbinafine or itraconazole were included in the study. Following a clinical diagnosis of OM, the researchers first tried to confirm it through direct microscopic examination with potassium hydroxide (KOH). If the direct microscopic examination was negative but the suspicion about OM continued, confirmation was done through a fungal culture. Results This study included 735 patients, of whom 409 (55.6%) were female and 326 (44.4%) were male. The research covered all of the patients who were given one of these two medications. To find patients who could apply to other hospitals, the Turkish National Healthcare System was checked in addition to hospital information. To identify patients who could apply to other healthcare institutions, all hospitals share their data with this national healthcare system. Terbinafine was used by 433 patients (76.4%), 75 patients (13.2%), and 37 patients (6.5%), respectively, for one, two, and three months. A total of 119 patients (70.8%) took itraconazole for a month, 32 patients (19%) took it for two months, and four patients (2.33%) took it for three months. At the end of the first month, the proportion of the patients with elevated aspartate transaminase (AST) levels was 5.2% for terbinafine and 0% for itraconazole. Eighteen (8.4%) patients with terbinafine had elevated alanine aminotransferase (ALT) levels, and four patients (7.5%) who were on itraconazole treatment had high ALT levels. None of the patients reported cutaneous adverse drug reactions, gastrointestinal disturbances, or headaches due to OM treatment. Also, no patients discontinued treatment because of hepatotoxicity. Conclusion In this study, none of the patients discontinued the treatment because of hepatotoxicity. According to the results of this study, oral terbinafine and itraconazole can be used with close follow-up. Baseline and regular laboratory monitoring for AST and ALT should be done to monitor liver toxicity with terbinafine and itraconazole. Besides, we did not observe other side effects like cutaneous or cardiac side effects or drug-drug interactions.

Dermatophyte antigen kit: A useful diagnostic tool for onychomycosis.

A dermatophyte antigen kit (DQT) was released in Japan as an in vitro diagnostic tool to identify tinea unguium in June 2022. From July 2022 to February 2023, we examined 75 potassium hydroxide (KOH)-negative patients (male, n = 23; female, n = 52; mean ± SD age, 63.6 ± 13.9 years) and determined the accuracy in confirming the fungal element with ZoomBlue™ staining at 400× magnification. The DQT results were classified into three categories. DQT-positive onychomycosis was detected in 27 patients with tinea unguium and two with non-dermatophyte onychomycosis. Fungal cultures were positive in 14 (51.8%) patients (Trichophyton rubrum [n = 11], T. interdigitale [n = 1], Fusarium solani [n = 1], and Talaromyces muroii [n = 1]). DQT-negative onychomycosis included ten patients with cured tinea unguium and 3 with Candida onychomycosis. Twenty-three patients had DQT-negative mimics for onychomycosis (onychauxis [n = 11], traumatic onycholysis [n = 8], yellow nail syndrome [n = 5], pincer nail deformity [n = 3], brittle nail syndrome [n = 2], contact dermatitis [n = 2], lichen planus [n = 1] and psoriasis [n = 1]). Because sparse, atrophic and/or fragmented mycelia are invisible in direct microscopy with potassium hydroxide (KOH) at 100× magnification, DQT was beneficial for diagnosing onychomycosis.

Tinea Unguium and Tinea Pedis and Their Correlation With Diabetes Mellitus in the General Population in the Hail Region, Saudi Arabia: A Cross-Sectional Study.

Background Tinea pedis or foot ringworm is an infection of the feet affecting the soles, interdigital clefts of toes, and nails, with a dermatophyte fungus. It is also called athlete's foot. Onychomycosis of the nail is caused by dermatophytes called Tinea unguium. An abnormal nail not caused by a fungal infection is a type of dystrophic nail. Onychomycosis can infect both fingernails and toenails, but onychomycosis of the toenail is much more prevalent. Aim The study aimed to assess the knowledge, perception, and awareness among a sample from Ha'il City, Saudi Arabia, of the definitions, risk factors, symptoms, diagnosis, complications, and treatment of both Tinea pedis and Tinea unguium, along withtheir correlation with diabetic patients. Material A cross-sectional survey was distributed throughout Ha'il City. An online questionnaire was designed and distributed via various social media apps, which included questions concerning participants' sociodemographic information, alongside questions regarding the risk factors, signs, symptoms, complications, and management of both Tinea pedis and Tinea unguium. Methods SPSS for Windows v22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for statistical analysis. Results The overall awareness of the study's participants about Tinea Pedis and Tinea unguium infection was low (34.82%).

Nail Society of India (NSI) Recommendations for Pharmacologic Therapy of Onychomycosis.

Onychomycosis (OM) is the commonest cause of dystrophic nails, responsible for upto 50% of cases. Apart from significantly damaging the nails, quality of life, and self-image of the sufferer, it also acts as a reservoir of fungal infections carrying important implications for emerging recalcitrant dermatophytoses. Treatment of OM is based on guidelines released almost a decade back, in addition to published literature and personal preferences. Hence, an expert group of nail society of India (NSI) worked towards drafting these guidelines aimed at compiling recommendations for pharmacologic treatment of OM, based on scientific evidence, along with practical experience. The group did an extensive analysis of available English language literature on OM published during the period 2014-2022. The evidence compiled was graded and discussed to derive consensus recommendations for practice. Special focus was placed on combination therapies and adjunct therapies, including experience of members, to improve treatment outcomes.

Metagenomics of Toenail Onychomycosis in Three Victorian Regions of Australia.

Onychomycosis is a fungal disease of the nail that is found worldwide and is difficult to diagnose accurately. This study used metagenomics to investigate the microbiology of 18 clinically diagnosed mycotic nails and two normal nails for fungi and bacteria using the ITS2 and 16S loci. Four mycotic nails were from Bass Coast, six from Melbourne Metropolitan and eight from Shepparton, Victoria, Australia. The mycotic nails were photographed and metagenomically analysed. The ITS2 sequences for T. rubrum and T. interdigitale/mentagrophytes averaged over 90% of hits in 14/18 nails. The high abundance of sequences of a single dermatophyte, compared to all other fungi in a single nail, made it the most likely infecting agents (MLIA). Trichophyton rubrum and T. interdigitale/mentagrophytes were found in Bass Coast and Shepparton while only T. interdigitale/mentagrophytes was found in Melbourne. Two nails with T. interdigitale/mentagrophytes mixed with high abundance non-dermatophyte moulds (NDMs) (Aspergillus versicolor, Acremonium sclerotigenum) were also observed. The two control nails contained chiefly Fusarium oxysporum and Malassezia slooffiae. For bacteria, Staphylococcus epidermidis was in every nail and was the most abundant, including the control nails, with an overall mean rate of 66.01%. Rothia koreensis, Corynebacterium tuberculostearicum, and Brevibacterium sediminis also featured.

Transmission of Onychomycosis and Dermatophytosis between Household Members: A Scoping Review.

Onychomycosis is a common fungal infection of the nail, caused by dermatophytes, non-dermatophytes, and yeasts. Predisposing factors include older age, trauma, diabetes, immunosuppression, and previous history of nail psoriasis or tinea pedis. Though many biological risk factors have been well characterized, the role of the environment has been less clear. Studies have found evidence of transmission in 44% to 47% of households with at least one affected individual, but the underlying mechanisms and risk factors for transmission of onychomycosis between household members are incompletely understood. A scoping literature review was performed to characterize and summarize environmental risk factors involved in the transmission of onychomycosis within households. A total of 90 papers met the inclusion criteria, and extracted data was analyzed in an iterative manner. Shared household surfaces may harbor dermatophytes and provide sources for infection. Shared household equipment, including footwear, bedding, and nail tools, may transmit dermatophytes. The persistence of dermatophytes on household cleaning supplies, linen, and pets may serve as lasting sources of infection. Based on these findings, we provide recommendations that aim to interrupt household transmission of onychomycosis. Further investigation of the specific mechanisms behind household spread is needed to break the cycle of transmission, reducing the physical and social impacts of onychomycosis.

High Frequency of Self-Diagnosis and Self-Treatment in a Nationally Representative Survey about Superficial Fungal Infections in Adults-United States, 2022.

Data about the prevalence, diagnosis, treatment, and public knowledge of superficial fungal infections in the United States are scarce. These infections are a growing concern given the emergence of antifungal drug resistance. We analyzed data from a national survey of nearly 6000 U.S. adults. Overall, 114 (2.7%) participants reported having ringworm and 415 (10.0%) reported a fungal nail infection in the past 12 months; 61.4% of participants with any superficial fungal infection were self-diagnosed. Most patients (55.5%) used over-the-counter antifungals. The common nature of superficial fungal infections and the high rates of self-diagnosis and treatment indicate that community education about these infections should be considered a public health priority.

Real-Time PCR Assay for the Detection of Dermatophytes: Comparison between an In-House Method and a Commercial Kit for the Diagnosis of Dermatophytoses in Patients from Dakar, Senegal.

BACKGROUND: PCR assays have been developed for the diagnosis of dermatophytes, yet data in African populations are scarce. OBJECTIVE: This study aimed to compare two PCR assays for the diagnosis of dermatophytosis in outpatients at the Aristide Le Dantec University Hospital in Dakar, Senegal. PATIENTS AND METHODS: A total of 105 samples, including 24 skin, 19 nail and 62 hair samples collected from 99 patients were included in this study. Each sample was subjected to conventional diagnosis (CD), including direct microscopy and culture, and two real-time PCR assays: one in-house (IH)-PCR, used at the University Hospital of Marseille and the Eurobio Scientific commercial kit (CK): designed for the specific detection of six dermatophytes not including Microsporum audouinii. RESULTS: Of the 105 specimens, 24.8%, 36.2% and 20% were positive by CD, IH-PCR and CK-PCR, respectively. The IH-PCR and CK-PCR exhibited 88.9% and 65.4% sensitivity, respectively. With a 36.6 diagnostic odd ratio and 1.41 needed to diagnose, the IH-PCR displayed better diagnostic indices than the CK-PCR. It is notable that, when considering the species that it claims to detect, when it came to skin and nail samples, CK-PCR sensitivity increased to 77%. CONCLUSIONS: The pan-dermatophyte IH-PCR performed better in the diagnosis of dermatophytosis in this African population than the CK-PCR, which is not designed to detect M. audouinii. Nevertheless, both assays exhibited similarly good diagnostic indices for tinea corporis and tinea unguium, both of which are localisations where M. audouinii is more rarely involved than in tinea capitis.

Chronological evaluation of treatment effect for tinea unguium with efinaconazole: Possibility of an early estimation of treatment effects.

The topical antifungal efinaconazole was applied to 27 nails (17 patients), and the treatment effects were monitored over a stipulated period (after 3, 6, and 12 months). Fourteen nails were observed for 18 months. Effects of the treatment were determined on the basis of the improvement rate of the turbidity ratio compared with that before treatment. After 12 months, five nails were cured and marked improvement was noted, whereas moderate and marked improvements were noted in 11 and six nails, respectively. The cured patients exhibited a significantly better improvement rate at 6 months (68.8%) than the other groups. Only 10.6% improvement was observed at the same point in time for the mild improvement group. Thus, in cases where the improvement rate after 6 months of treatment was 10% or less, it was judged that oral treatment should be considered. Furthermore, of the nails monitored for 18 months, those that exhibited further growth in improvement rates at 12 months was 51.6%, suggesting that an improvement rate of 50% at 12 months after starting treatment could be used as an indicator to determine switching to oral treatment.

Topical efinaconazole: A sequential combination therapy with oral terbinafine for refractory tinea unguium.

Efinaconazole is a topical antifungal drug approved in Japan for tinea unguium. Although topical treatments generally have low cure rates with a prolonged therapy period, a Cochrane review confirmed that high-quality evidence supports the effectiveness of efinaconazole for the complete cure of tinea unguium. Combination therapy is a way to improve the cure rate of onychomycosis. In this study, topical efinaconazole was administrated to 12 patients who had been treated with oral terbinafine (125 mg daily) for more than 20 weeks with little expected effect. Because terbinafine accumulates for a long time in the nail, treatment immediately followed by other drugs can be considered sequential combination therapy. During terbinafine monotherapy, the percentage involvement decreased from 53.5% to 44.0% after 37.4 weeks and the effective and cure rates were 16.7% and 0%, respectively. During sequential topical efinaconazole therapy combined with lasting terbinafine in the nail, the percentage involvement decreased from 44.0% to 18.7% after 28.4 weeks, and the effective and cure rates were 66.7% and 16.7%, respectively. The improvement rate per month of combination therapy (12.6%) was higher than that with monotherapy (2.1%) (p = 0.002). There were no serious side-effects. This sequential combination therapy with efinaconazole was effective in poor terbinafine responders, making it a promising regimen for improving the cure rate of tinea unguium.

A Case of Tinea Faciei, Tinea Corporis, and Tinea Unguium with Dermatophytoma Successfully Treated with Oral Fosravuconazole L-lysine Ethanolate.

We present a 76-year-old Japanese male with tinea faciei, tinea corporis, and tinea unguium with dermatophytoma. We performed fungal culture and confirmed the causative fungus to be Trichophyton rubrum. We treated the patient using oral fosravuconazole l-lysine ethanolate (F-RVCZ). More than one year has passed since the end of treatment, but there has been no recurrence. This case suggests that F-RVCZ is effective for tinea other than tinea unguium.

A cross sectional study to observe the diversity of fungal species in Onychomycosis isolated from a tertiary care hospital in Karachi.

OBJECTIVE: To study the frequency and diversity of fungi involved in onychomycosis. METHODS: The cross-sectional study was conducted from February 2018 to February 2019 at the Department of Microbiology, Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi, and the University of Karachi. Specimens were taken from patients suffering with onychomycosis attending the Dermatology Department of Jinnah Postgraduate Medical Centre and were processed for the isolation of fungi. Specimens were processed for the diagnosis by potassium hydroxide mount for microscopic evaluation and mycological culture to determine the type of fungus involved in onychomycosis. Fungi were isolated using Sabouraud Dextrose Agar with antibiotics cycloheximide and chloramphenicol, and without antibiotics. Plates were observed for the growth periodically until 4th week. Appearance of any colony was studied further for identification on the basis of cultural characteristics and microscopy. Precise identification of Candida species was done. RESULTS: Of the 230 samples, 85(36.96%) were from males and 145(63.04%) from females. Potassium hydroxide mount showed fungal element in 134(58.26%) specimens, while in 111(48.26%) patients the fungal culture was positive. Nine (3.9%) cases were culture-positive but potassium hydroxide-negative, while among the 134(58.26%) potassium hydroxide-positive cases, 32(23.9%) were culture-negative.

Continuous terbinafine and pulse itraconazole for the treatment of non-dermatophyte mold toenail onychomycosis.

INTRODUCTION: Although dermatophytes are considered the predominant causative organisms in onychomycosis, non-dermatophyte mold (NDM) infections may be more prevalent than originally thought and may be more difficult to treat. There are limited data of oral antifungal efficacy in treating NDM onychomycosis. METHOD: A retrospective chart review (2009-2016) was conducted in patients receiving continuous oral terbinafine or pulse itraconazole for toenail onychomycosis due to NDMs. Mycology results and percent nail affected were recorded with patient characteristics including demographics and concurrent diseases. Complete, clinical, and mycological cure were tabulated. RESULTS: Data from 176 patients were collected. Mycological and complete cure rates for terbinafine (69.8% and 17%) and itraconazole (67.5% and 22%) were not significantly different from each other. Regardless of oral treatment, age (p = .013), baseline severity (p = .016), and presence of atherosclerosis (p = .040) or hyperlipidemia (p = .033) decreased the likelihood of mycological cure, while age decreased the likelihood of complete cure (p = .001). CONCLUSION: Continuous terbinafine and pulse itraconazole were similar in efficacy for curing NDM onychomycosis. Age was the most consistent prognostic factor affecting likelihood of cure, with factors that may influence drug reaching the site of infection also decreasing likelihood of mycological cure.

Fosravuconazole to treat severe onychomycosis in the elderly.

Fosravuconazole is a novel oral antifungal drug developed in Japan and used to treat tinea unguium since 2018. Its excellent oral absorbability and systemic bioavailability has enabled short-duration therapy of 3 months. Furthermore, no concomitant drugs are contraindicated due to the presence of the mild inhibitor of cytochrome P450 enzyme which is responsible for polypharmacy adverse effects. Therefore, it can be safely administrated to elderly patients. Elderly patients (≥65 years old) with severe onychomycosis (≥50% nail involvement) were treated with oral fosravuconazole 100 mg once daily for 12 weeks. The rate of involvement improved from 86.6% to 28.1% (P < 0.01). The efficacy (i.e. percentage of those rated as "improved" and better) and cure rate was 83.8% (31/37) and 29.7% (11/37), respectively. Furthermore, when focusing on the thin nail group (<3 mm), the efficacy and cure rate was 88.2% (15/17) and 58.8% (10/17), respectively. Although the serum γ-glutamyltransferase levels increased in 21.6% (8/37), all patients recovered without any specific treatments.

Role of Tinea Unguium and Other Factors in Chronic and Recurrent Dermatophytosis: A Case Control Study.

CONTEXT: There is an alarming rise in the incidence of chronic and recurrent dermatophytosis (CRD) in India. Many factors including tinea unguium may be responsible for it. AIMS: To evaluate various epidemiological and clinical factors including the presence of tinea unguium as a risk factor for CRD. SETTINGS AND DESIGN: This was a case-control study in which patients attending the dermatology outpatient department of a tertiary care hospital in February-March 2019 were recruited. A total of 80 consecutive clinically diagnosed patients with CRD as per the case definition (cases) were selected. Another 80 consecutive patients with dermatophytosis other than CRD (controls) were also selected. Patients were clinically evaluated with special attention for the presence of tinea unguium. RESULTS: Among the total of 80 cases, 44 (55%) and 36 (45%) were diagnosed to have chronic dermatophytosis and recurrent dermatophytosis respectively. CRD was relatively uncommon in patients younger than 20 years. Sharing of linen, family history, and topical corticosteroid abuse were also frequent among patients with CRD. Tinea unguium was present in six cases (7.5%) and two controls (2.5%) which was not statistically significant (P = 0.27). CONCLUSIONS: The current epidemic of CRD may be primarily due to a pathogen with certain specific epidemiological and clinical determinants. It may be primarily a skin pathogen with less or no affinity toward the hair and nail.

Google search trends in onychomycosis: Influences of flip flops and advertising.

BACKGROUND: Onychomycosis is a fungal infection of the nail, affecting 5.5% of the population. Individuals affected by this disease experience increased anxiety about this disorder and a decreased quality of life. There are multiple available treatments across the globe, leading people to search online for information on the various therapies. AIMS: To analyze Google search trends of fungal infection and treatment keywords and the influence of different geographical locations, season, regulatory decisions, and advertisements on these trends. METHODS: In May, 2020 we used Google Trends to determine the relative interest of various fungal infection and treatment keywords worldwide and in the US, the UK, Canada, and Australia. Notable peaks were investigated for contemporaneous news events. RESULTS: In general, searches for toenail fungus and associated treatment terms peak during the summer months. Interest in individual treatments peaks when a product is launched, is the subject of an advertising campaign, or becomes more available to the public through approval or reclassification. Yeast infection, thrush, and ringworm terms are consistently searched more often than toenail fungus, jock itch, or foot fungus; all terms are most popular in the summer months, with toenail fungus reaching annual popularity one month prior to jock itch. DISCUSSION: In general, interest in toenail fungus and treatments is the highest when social anxiety about toenail appearance and the occurrence of fungal infection is the greatest. Curiosity about treatment products increases with their availability and visibility to the public. Combining the power of seasonal interest and advertising generates the greatest search profile for onychomycosis treatments.

Emerging drugs for the treatment of onychomycosis.

Introduction: Onychomycosis is a widespread nail disease, often occurring on the feet. It is a chronic and often recurring disease, which makes it difficult to eradicate. The infection may be caused by dermatophytes, non-dermatophyte molds, and yeasts. Traditionally, systemic antifungal medications have been used to treat this infection, but in recent years topical formulations have been the focus of research.Areas covered: This review outlines the current antifungal market and novel treatments currently in development or in experimental phases. It highlights a shift from systemic treatments to topical options as well as penetration enhancers. There are also several novel systemic options in development.Expert opinion: Although there have been significant developments in treatment options for onychomycosis, it remains a challenging chronic condition with less than desirable cure rates. This may be attributed to the formation of fungal biofilms and limited understanding of the fungal lifecycle. However, when patients adhere to treatment protocols and employ preventative measures, outcomes are generally favorable.

Clinicomycological and Histopathological Profile of Onychomycosis: A Cross-sectional Study from South India.

BACKGROUND: Onychomycosis (OM) is a fungal infection of the finger or toenails caused by dermatophytes, yeasts, or nondermatophyte molds (NDMs) and can involve any component of the nail unit. OM, apart from being asymptomatic, is a chronic disease and warrants long-term treatment. AIMS: The aim was to study the clinicoepidemiological features of OM and to evaluate the mycological and histopathological features among patients attending the dermatology outpatient department. SUBJECTS AND METHODS: A cross-sectional hospital-based study was performed in 500 patients with symptoms related to the nails and nail folds. OM was confirmed in 284 patients by potassium hydroxide (KOH) mount, fungal culture, or biopsy. Descriptive analysis of the data was undertaken. RESULTS: The study included 284 confirmed cases of OM of which 117 (41.1%) were positive for fungal elements by KOH mount, 168 (59.1%) samples showed positivity in fungal culture, and 62 (21.8%) samples had positive nail biopsy results. Distolateral subungual OM was the most common clinical type (47.6%). Among the fungal isolates, a predominance of dermatophytes was observed followed by yeasts and NDMs. The most common dermatophytic fungal isolate in the culture was Trichophyton rubrum (45%). CONCLUSION: Our study implies the importance of laboratory diagnosis of OM as it can mimic diverse nail disorders. As the role of NDMs and yeasts is on the rise for etiology of OM, investigations such as KOH examination, culture, or nail biopsy becomes essential for correct diagnosis and management.