الفهرس 
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Abstract
Onychomycosis is a common persistent infection of the nail unit by fungi either dermatophytes, yeasts or non dermatophyte moulds (NDMs). It is classified clinically to distal and lateral subungual onychomycosis (DLSO), superficial white onychomycosis (SWO), proximal subungual onychomycosis (PSO), candidal onychomycosis, endonyx onychomycosis and total dystrophic onychomycosis (TDO).
Onychomycosis is not just a simple cosmetic problem but a handicap as it hinders the patient from practicing normal life and prevents the patient from doing certain jobs like typists or tailors.
It is commonly confirmed by clinical examination side by side with regular diagnostic techniques such as direct microscopy and fungal culture, which are considered the golden are considered the golden standards of diagnosis.
It is used when direct microscopy and the culture test are negative masy help in establishing the correct diagnosis demonstrating the presence of fungi inside the nail plate
Newer methods for diagnosis of onychomycosis have been known molecular biological methods as diagnostic tool including diagnostic Polymerase chain reaction. Some of the important types of PCR include repetitive Extragenic Palindromic sequence polymerase chain reaction (REP-PCR) real-time quantitative PCR, light cycler PCR, reverse Transcriptase-PCR, nested PCR and polymerase chain reaction-restriction fragment length polymorphism assay (PCR-RFLP). Polymerase chain reaction-enzyme-linked immunosorbent assay (PCR-ELISA) for direct detection of dermatophyte DNA. Matrix-assisted laser desorption ionization (MALDI-TOF MS). Optical coherence tomography; immunohistochemistry, flow cytometry, confocal laser scan microscopy, phase contrast hard X-ray microscopy and fluorescence microscopy.
Onychomycosis is a challenging problem to both the patient and the physician. The patient suffers from a disease that reduces his quality of life while the physician struggle with long time, expensive treatments with many side effects and drug interactions that can harm the patient.
Regarding the management of onychomycosis it is difficulty, for this reason several treatment regimens were designed to cure this disease such as palliative care
The primary aim of treatment is to eradicate the organism as demonstrated by microscopy and culture. This is defined as the primary end-point. Clinical improvement and clinical cure are secondary end-points based on a strict scoring system of clinical abnormalities in the nail apparatus Also, important goals are to reduce morbidity and to prevent complications.
Antifungal drugs include Topical antifungal treatment including creams, gels, ointments, and solutions are usually not effective against onychomycosis (except for a very mild case of onychomycosis). This is due to their inability to penetrate through the nail plate commen drugs used Whitfield’s Ointment, Nail lacquers and solutions for onychomycosis, Tioconazole nail solution.
Systemic treatments include oral antifungal agents are one of the most effective agents available to treat onychomycosis even more successful than topical treatment.
Griseofulvin was used as a classic first line treatment option but it was widely replaced by newer Triazole and allylamine antifungal drugs such as itraconazole, and terbinafine, as these agents offer shorter treatment courses, higher cure rates and fewer relapses and adverse effects fluconazole and ketoconazole are also prescribed for onychomycosis.
Mechanical procedures include surgical or chemical nail avulsion that may be useful in patients with severe onycholysis, extensive nail thickening or longitudinal streaks or spikes in the nail.
Device-Based Therapies for Onychomycosis Treatment. There are four categories of device-based treatments: laser devices, photodynamic therapy, iontophoresis and ultrasound.
Laser treatment of onychomycosis infections uses the principle of selective photothermolysis
Laser therapy is intended to exploit the differences in laser energy absorption and thermal conductivity between the fungal infection and the surrounding tissue. The absorption of light energy by the fungi results in the conversion of the energy into heat or mechanical energy.
Photodynamic therapy is based on the usage of photosensitizing agents and light with exact wavelength. Singlet oxygen is generated, leading to cell death. It has been examined whether PDT is appropriate for treatment of superficial nail infections.
PDT, combined with methyl-aminolevulinic acid, is administrated in three sessions, with 15 days interval between each procedure
PDT is suitable for treatment of distal and lateral subungual onychomycosis caused by T. rubrum
Iontophoresis is a technique that uses a low level electrical current to increase the transport of drugs across semi-permeable barriers. The limitation of many topical treatments for onychomycosis is their inability to fully penetrate the nail plate.
Ultrasound treatment increased the nail uptake of a blue dye. Findings showed that the 120 second period was the most effective.
Individual modification of therapy is possible, sometimes even compulsory—in polymedicated patients with significant comorbidities, including liver, kidney, or heart failure, as well as immunosuppressed patients. Antifungal therapy should be administrated carefully.