Destructive polyonychomycosis with secondary nails incarnation: analysis of clinical observations, author ’s views of complex treatment

Abstract

The aim of the work: optimization of the complex treatment and surgical intervention for chronic onychopathology associated with onychomycosis and nail incarnation, including complicated, combined and recurrent lesions.

Materials and Methods. A retrospective and prospective analysis of clinical cases and treatment outcomes of 919 patients over a 10-year period: 503 men and 416 women aged 5–92 years were performed. Some biochemical laboratory deviations also simultaneously were studied. Removal of the affected nails in patients with polyonychomycosis was carried out simultaneously with systemic therapy. Systemic 400 mg itraconazole adjuvant pulse therapy used for two days before the primary surgical correction of deformations and incarnations and for the first three days of the postoperative period. Sanation of other affected nails to prevent mycosis reinfection was performed with antifungal 5 % amorolfine or 8 % cyclopyrox nail lacquer. Clinical, paraclinical, microbiological methods, functional diagnostics, radiological, biochemical, morphological methods and statistical analysis were used.

Results and Discussion. Complex treatment of purulent onycheal pathology includes surgical resection or the nail removal, necrectomy and drainage of purulent foci, sanation of soft tissue lesions, conservative treatment of mycosis and comorbide lesions. The complex treatment scheme, which includes pulse therapy with itraconazole, removal of affected nails, treatment of the nail matrix with polyvidone iodine, use of terbinafine liniment and sanation of other nail plates with antifungal lacquer – cyclopirox or amorolfine can be used to treat of difficult polyomycosis cases. It was found that subungual hyperkeratosis and dermatophytoma due to compression of the central part of the nail determine the secondary ingrowth of the nail edges, χ2=20.87, p<0.01. The foci of onycholysis (onychomadesis) and destruction of hyperkeratosis, leading to secondary onycholysis and detachment of the nail plate, χ2=15.23, p<0.0211, determines some methods of minimally invasive onychectomy. Removal of affected nails in patients with destructive onychomycosis complicated by subungual hyperkeratosis or onychogryphosis with nail incarnation is carried out using less traumatic mobilization of the nail plate through the loci of onychomadesis, onycholysis structures with dissection of tissues with sterile PE-10/2 blades and sterile PE-30 instrument (rounded pusher with curved separation blade), simultaneous removal of hyperkeratosis, onychomatricoma (dermatophytoma), necrotical tissues in areas of ingrowth and hypergranulation, which significantly reduces the trauma of the procedure and determines the reduction of postoperative pain (χ2 = 48.32, p <0.01), accelerating wound healing, improving the quality of life.