TRACHYONYCHIA ASSOCIATED WITH AND SECONDARY

Jose L. Anggowarsito Renate T. Kandou

Department of Dermatovenereology Medical Faculty of Sam Ratulangi University Prof. Dr. R. D. Kandou Hospital Manado Email: [email protected]

Abstract: Trachyonychia is an idiopathic inflammatory disorder that causes nail matrix keratinization abnormality, often found in children, and associated with alopecia areata, , atopic , or nail . Trachyonychia could be a manifestation of associated pleomorphic or idiopathic disorders; therefore, it may occur without skin or other systemic disorders. There is no specific diagnostic criteria for tracyonychia. A is needed to determine the definite pathologic diagnosis for nail matrix disorder; albeit, in a trachyonychia case it is not entirely necessary. Trachyonychia assessment is often unsatisfactory and its management is focused primarily on the underlying disease. We reported an 8-year-old girl with twenty dystrophic nails associated with alopecia areata. Cultures of nail base scrapings were performed two times and the final impression was rubrum. Conclusion: Based on the clinical examination and all the tests performed the diagnosis of this case was trachyonychia with twenty dystrophic nails associated with alopecia areata and secondary onychomycosis.The majority of trachyonychia cases undergo spontaneous improvement; therefore, a specific therapy seems unnecessary. Onychomycosis is often difficult to be treated. Eradication of the fungi is not always followed by nail restructure, especially if there has been dystrophy before the . Keywords: trachyonychia, alopecia areata, onychomycosis.

Abstrak: Trakionikia adalah inflamasi kuku idiopatik yang menyebabkan gangguan keratinisasi matriks kuku, sering terjadi pada anak, dan terkait dengan alopesia areata, psoriasis, dermatitis atopik atau lichen planus kuku. Trakionikia bisa merupakan manifestasi dan asosiasi dari gangguan pleomorfik atau idiopatik, sehingga dapat terjadi tanpa kelainan kulit dan gangguan sistemik lainnya. Tidak terdapat kriteria diagnosis khusus untuk trakionikia. Diagnosis patologik definitif untuk kelainan matriks kuku ialah melalui biopsi, namun hal ini tidak disarankan. Penanganan trakionikia sering tidak memuaskan dan fokus manajemen terutama ditujukan pada penyakit yang mendasarinya. Kami melaporkan seorang anak perempuan berusia 8 tahun dengan dua puluh kuku distrofik disertai alopesia areata. Kultur dari kerokan dasar kuku dilakukan dua kali dengan hasil . Simpulan: Berdasarkan pemeriksaan klinis dan pemeriksaan penunjang, diagnosis kasus ini ialah trakionikia dengan 20 kuku distrofik disertai alopesia areata dan onikomikosis sekunder. Mayoritas kasus trakionikia dilaporkan mengalami perbaikan spontan sehingga terapi khusus untuk trakionikia sering tidak diperlukan. Onikomikosis sering sulit diobati. Eradikasi jamur tidak selalu disertai perbaikan struktur kuku, terutama bila telah terjadi distrofi kuku sebelum infeksi. Kata kunci: trakionikia, alopesia areata, onikomikosis.

50 Anggowarsito, Kandou; Trachyonychia Associated with Allopecia Areata... 51

Trachyonychia is also referred to as Clinic of Prof. Dr. R. D. Kandou Hospital twenty-nail dystrophy (TND)1.2 or sand- with cracked and chipped nails on both papered nails3 which is an idiopathic hands and feet (Fig. 1A). Small pits, the inflammatory nail disorder that causes nail size of the tip of a needle in the 5 finger matrix keratinization abnormality - often in nails of the right hand, each having 4 or 5 children, and associated with alopecia nail pits, had occured 13 months before areata, psoriasis, or nail without any itching or discoloration. The 1,2 lichen planus. The clinical features are number of pits increased, and they partly typically: rough surfaces of the nail, brittle- fused into the nail groove in both hands. ness, and excessive nail destruction. Seve- The curves of the nails appeared thinned ral nails can be involved; however, the but thickened around the sides, especially diagnosis does not require the involvement 1 at the fingertips. Over the next one month, of all twenty nails. Trachyonychia has also this disorder had spread to the toe nails of been reported in autoimmune conditions both feet, followed by a yellow-brownish such as selective IgA deficiency, , 3 discoloration, and there were transverse and chronic graft-versus-host disease. Nail white lines above both thumb and big toe changes can undergo spontaneous improve- nails. The nails turned to a darker color, ment at the age of 20-25 years with no raised, thickened, and were also brittle and tissue; therefore, therapy is often not 1 chipped. necessary. There were no complaints when the Onychomycosis occurs in 15% of the fingers came in contact with cold world’s population, and 40% of them are temperatures. No loss or patchy over 60-years-old.1 Onychomycosis is a baldness was found. There were no fungal infection of superficial forms with a histories of jaundice, , hyper and diagnostic rate of 30%. are hypothyroid, and of other skin diseases mainly (85%) and non- dermatophytes ( sp. 15%). (, porpyria, psoriasis, herpes, Tricophyton rubrum are the most common , contact irritants). Histories of dermatophytes (>90%),4 followed by Trico- long-term consumption of drugs (anti- phyton mentagrophytes var. interdigitale biotics or ), pulmonary infection, and floccosum.5-7 In and were denied. Infant and immunosuppressed individuals, Candida toddler growth appeared normal. There sp. is the only causal and it were histories of in both parents; usually manifests itself as a proximal moreover, the patient’s mother suffered subungual onychomycosis (PSO) with from . There was a history of periungual . Severe onycho- repeated weekly contacts from November may include all 20 nails.1 2011 with river sand as the patient followed The nail, a complex integument struc- her father in his sand mining operation. ture, may be associated with a variety of On physical examination we found that primary and secondary diseases. Nail the patient’s general condition was good abnormalities may have implications for along with her nutritional status and vital the quality of life and have psychosocial signs Dermatological examination of the 20 aspects.1 The therapy of nail disorders is nails showed onycholisis, dystrophic nails, often difficult;6 therefore, knowledge of the Beau's lines, yellowish discoloration, structure and physiology of nails is subungual , red lunulae, important in confirming the diagnosis and onychomadesis, and proximal for managing better therapy.1,6 (Fig. 1A). There was no sign of lateral paronychia, pitting, longitudinal lines, salmon patches, pterygium, or clubbing. CASE REPORT nd The dorsal side of the 2 toe of the right In September 21, 2012 an 8-year-old foot encountered erythematous girl came to the Dermatovenereology which were well demarcated with numular

52 Jurnal Biomedik (JBM), Volume 6, Nomor 1, Maret 2014, hlm. 50-59 sizes, as well as erosion, excoriation, The therapeutical management of this squama, and lichenification (Fig. 1B). patient was oral cetirizine 1 x 10 mg in the Laboratory tests in October 17, 2012 morning, chlorpheniramine maleate 1 x 4 showed results within normal limits. Direct mg in the evening, and 2-time applications microscopy examination using 20% of topical 0.1% diflucortolone valerate potassium hydroxide of samples from the ointment on the skin lesions (dorsal side of nd right thumb nail scrappings revealed spores the 2 toe of the right foot). and long septal hyphae. The first culture of On the second visit (October 10, nail base scrapings (samples dated 2012), the patient complained of . September 21, 2012) macroscopically There were multiple patchy hair loss areas showed colonies of filaments, white like without hair follicles near the hairline at the cotton, with a yellow background; and back of the head and the neck area around microscopically showed long septal hyphae the left ear (Fig. 2). There was no itching, with microconidia in regular orders like , or histories of on those spots. water droplets along the hyphae. The final The surrounding scalp skin looked normal impression was Trichophyton rubrum without inflammation or erosion. (dermatophytes). Based on these findings Complaints about nail abnormalities and the current diagnosis was established as a skin lesions still remained. A direct trachyonychia and a circumscript microscopical examination using 20% neurodermatitis in the dorsal side of the 2nd potassium hydroxide for the scalp and hair toe of the right foot (Fig. 1 B). A biopsy to did not reveal , exothrix, or confirm the diagnosis is required. hyphae. The second culture of the nail base Differential diagnoses for this case were scrapping (samples dated October 18, 2012) confirmed the first culture result as onychomycosis, lichen planus, nail T. rubrum. The results of the scalp and hair psoriasis, and nail atopic dermatitis. cultures from samples dated October 23,

2012 using Sabouraud dextrose agar

showed no growth of any fungi. The

diagnosis was changed to trachyonychia A associated with alopecia areata and secondary onychomycosis et causa T. rubrum. The were nail atopic dermatitis, nail psoriasis, lichen planus, and circumscript neurodermatitis (which had improved on the dorsal side of the 2nd toe of the right foot). The pasient was given an oral pulse therapy of 1x 150mg/day for 1 B week/month in 3 cycles and the 2-time applications of topical 0.1% diflucortolone valerate ointment on the skin lesion (the dorsal side of 2nd toe of the right foot) was continued. On the last visit (December 11, 2012), the patient still had hair loss on the previous locations with no other new spots emerging; however, the patient complained Figure 1. A, Trachyonychia (arrows). B, about nail abnormalities. The differential Circumscript neurodermatitis (diamond arrow) diagnoses were nail atopic dermatitis, nail at the dorsal side of the 2nd toe of the right foot psoriasis, and lichen planus. A definitive (September 21, 2012). diagnosis could not be confirmed because a

Anggowarsito, Kandou; Trachyonychia Associated with Allopecia Areata... 53 nail biopsy was refused by both parents. DISCUSSION Oral pulse therapy of itraconazole was Trachyonychia was first described by continued for 3 cycles followed by a liver Alkiewicz (1950) and was first called: function test which resulted in normal 1 Twenty-Nail Dystrophy (TND) or limits. Alopecia areata was treated with 2- Sandpapered Nails by Hazelrigg et al. time topical applications of 0.05% 2 (1977). The term TND is preferably used ; however, topical 2,8 if it involves all 20 nails. Trachyonychia 0.1% diflucortolone valerate for the skin is often without symptoms and patients lesion was discontinued. often complain of the nails disfigured appearance.2,6 Trachyonychia has an

insidious onset during the peak ages of 3- A 12 years old8 although it can occur at any age.9 Trachyonychia could be a manifesta- tion of associated pleomorphic or idiopa- thic disorders, or it may occur without skin and other systemic disorders (Table 1).8

Table 1. Abnormalities associated with trachyonychia8

Alopecia areata Atopic dermatitis Autoimmune hemolytic anemia Bart syndrome Congenital cutaneous Dyskeratosis congenita (Zinsser-Engman-Cole syndrome) Graft-versus-host disease Hereditary punctuate palmoplantar keratoderma (Brauer-Buschke-Fischer syndrome) B Hydrotic ectodermal dysplasia (Couston syndrome) vulgaris Idiopathic Immunoglobulin A deficiency Lichen planus Nail-patella syndrome Onychodysplasia of the index fingers Pachyonychia congenital vulgaris Primary biliary cirrhosis Psoriasis Trauma Vitiligo

Figure 2. Alopecia areata: A, At the back of the head (regio occipitalis). B, At the neck area Alopecia areata commonly accom- panies trachyonychia with a prevalence of around the left ear (regio temporalis sinistra) 8 (October 23, 2012). 3.65% with a typical onset in childhood.

54 Jurnal Biomedik (JBM), Volume 6, Nomor 1, Maret 2014, hlm. 50-59

TND with alopecia areata occurs more was the only child; moreover, no other frequently in children (12%) than in adults family members suffered from such a (3.3%),6 whereas idiopathic TND only disorder although her family had a strong occurs in children.2 Trachyonychia accom- history of atopy. panied by alopecia areata is more common Clinical forms of nail trachyonychia in males.10 The most common form is are thin, opaque, dull, and often totalized alopecia (alopecia univer- hyperkeratotic cuticles which also look like salis),2,6,8,11 but it can also manifest itself sand paper with excessive longitudinal with mild hair loss.8 Hair loss and nail patterns.1-3,5,8 The nail discoloration was changes may occur simultaneously or opaque and dull. Based on the degrees of separately.8,11 severity, trachyonychia is divided into mild Among children with alopecia areata, and severe types. The severe type is frosted 50% have abnormal nails, while among and has sandpaper dull nails, meanwhile adults 20%.1,2 In alopecia areata, nail the mild type still has shiny nail surfaces abnormalities are typically in the geometric with diffuse lines and pittings. Koilonychia pitting form and trachyonychia.1,2,6,8 The can be found in both types.8 Early lesions geometric pitting is formed by small form of patient’s are irregular pittings; curves, superficially, and distributed in a some are partially joined to form tranverse regular pattern (grid-like) in longitudinal grooves accompanied by thinning of the and/or transverse rows. Other nail ab- nail curves. Thickening and discoloration normalities of alopecia areata are: punctate (dull yellow-brownish), especially on the , lunula (mottled), distal edge of the nail, are accompanied by , and onychomadesis.1,2 The removal of the nail plate and roughness of cosmetic concern of 20 nails is the primary the nail surface. Tissues under the nail reason to seek treatment. appear thickened, especially on the thumbs Alopecia areata was discovered on the and toes. During the clinical assesment on 2nd visit, which may have occurred the first visit, neither longitudinal lines nor previously and was not noticed by the pterygium formations were found. patient nor her parents. The early form of Trachyonychia caused by lichen nail disorders of such patients are minor planus is considered rare (<10%).8,16 Oral curves without itching or color changes - lesions are common forms of lichen planus then they multiply. Some of them fuse and accompanying nail lichen planus.17 In are marked with a pitting nail in alopecia general, nail lichen planus in the form of areata. This patient’s brittle and easily trachyonychia has been proposed as chipped nails were in the proximal parts, another form of lichen planus due to the suggesting onychomadesis which were thinning, splitting, and atrophy of the nails, marked by Beau's lines. There was a and is rarely associated with pterygium scar history of repeated contacts with the river tissue formation,18 and often have sand, and in the course of the disease this spontaneous healing.8,17 In children, nail patient had nail discoloration, which may lichen planus in the form of trachyonychia have occured due to a secondary infection is often without skin or mucosal lesions.17 of onychomycosis (The culture resulted in In this patient, there were thinning nails, T. rubrum). discoloration, and subungual dystrophic Trachyonychia has been reported in hyperkeratosis, without longitudinal autosomal dominant transmission12-14 and ridging, pterygium formation, and lichen its occurance in monozygotic twins.15 This planus lesions on the skin or mucosal layer. transmission form is associated with Nail abnormalities of patients with alopecia areata that occurs in twins and psoriasis as many as 10-55%.19 Psoriasis is several other family members. Idiopathic found in 25-50% of children.20 A total of trachyonychia is more common and more 5% of nail psoriasis lesions are not widely reported in literature.8 This patient accompanied with skin lesions.19,20 Pitting

Anggowarsito, Kandou; Trachyonychia Associated with Allopecia Areata... 55 of the nail psoriasis describes intermittent which can be found in alopecia areata, psoriasis lesions of the nail matrix. lichen planus, psoriasis, and onycho- Irregular pitting in nail psoriasis can be mycosis.1,2 Onychomycosis is a fungal distinguished with pitting in alopecia areata infection (dermatophytes, non-dermato- or in atopic dermatitis, especially if it is phytes, and , especially Candida accompanied by discoloration (oily spots), sp).1,2,4,5,7 Onychomycosis is clinically onycholysis, or subungual hyperkeratosis.20 classified as distal-lateral subungual Changes in the nail structure might increase onychomycosis (DLSO), white superficial the risk of secondary infection due to onychomycosis (WSO), proximal sub- bacteria, candida, or dermatophytes.19,20 ungual onychomycosis (PSO), candidal Trachyonychia in psoriasis causes thicker onychomycosis, and total dystrophic nail plates, meanwhile trachyonychia onychomycosis.1-5 All clinical forms of associated with nail lichen planus onychomycosis may develop TND.1,2,4 experiences thinner nails. Chronic skin Distal-lateral subungual onycho- lesions of psoriasis involving the nail fold mycosis (DSLO) are common clinical can evolve into trachyonychia.19 This forms in children.10 was patient’s history of irregular pitting as early also complained by this patient, especially lesions, paronychia, onycholysis, and concerning fragile and chipped nails. onychomadesis were the underlying Thickening and discoloration of the nails, concern of nail psoriasis, although there especially the big toe in the distal and were no psoriasis skin lesions. lateral sides were also found in patient. Trachyonychia also occurs in atopic Most of onychomycosis affects the toe dermatitis especially hand eczema that nails (80%) and the most common cause is often leads to changes of the nails such as: T. rubrum (90%).1,2,4,7,10 Although the papules, vesicles, and erythema of the majority are caused by secondary infection, proximal nail fold or hyponychium. T. rubrum has been considered as a main Damage of the nail matrix creates irregular pathogen.7 Dermatophytes nail pittings and Beau's lines; moreover, are often in the form of DLSO with onychomadesis can occur in severe cases.20 onycholysis and subungual hyperkeratosis Trachyonychia resulting from atopic which can also be found in nail psoriasis.21 dermatitis in children can occur for many C. albicans and T. mentagrophytes which months without abnormalities on muco- are variations of interdigital infections, are cutaneus layers.8,20 The course of the more rarely to be seen.5,7 Onychomycosis disease varies, but it can improve spon- in children caused by Candida sp. is less taneously in later months or years. A common than by dermatophytes infection. majority of 50% occurred in the first 6 Sometimes combined infections occur, and years of life.20 Nail discoloration, it is not uncommon that T. rubrum is found especially in the lunulae can also be caused from the isolate.10,21 Infections of C. by alopecia areata, psoriasis,1-3,6,20 albicans or Candida sp. are often marked erythematosus, dermatomyositis, conges- with paronychia, onychodistrophic, and tive heart failure, reticulosarcoma, carbon- onycholysis, while others rarely cause monoxide poisoning, or lymphogranuloma onychomycosis paronychia.21 Common venereum.20 This patient had a history of clinical forms of onychomycosis caused by severe atopy along with her parents and DLSO type of dermatophytes infection are other family members. In this case, 93%,7 onychodystrophy 56%, and underlying suspicion of atopic dermatitis paronychia due to candida infection 50%.10 was a cause of trachyonychia. Erythema of If onychomycosis in children with her proximal nail fold suggested an inflam- trachyonychia is suspected, microbiological matory process of a secondary infection. diagnosis should be done immediately, so Nail fragility (brittle nails/onychorr- that appropriate therapy can be given hexis) can be dermatological disorders, immediately to prevent more widespread

56 Jurnal Biomedik (JBM), Volume 6, Nomor 1, Maret 2014, hlm. 50-59 lesions.5,7 nail pathological change is hypergranulosis Positive cultures of nail scrapings and which may occur in idiopathic nail bed tissues on the Sabouraud dextrose trachyonychia, nail lichen planus, and nail agar, with or without cycloheximid, psoriasis. Inflammation in the nail matrix confirmed the clinical diagnosis of can interfere with keratinization process, onychomycosis. The result of the first causing abnormal expression and culture of nail scraping and distal side of accumulation of keratohyalin granules in nail-bed tissue obtained T. rubrum which the nail plate. These changes can be also confirmed by the second culture, permanent although the inflammatory although the yellowish discoloration and process has subsided.25 Histopathological paronychia of the proximal nail fold was changes in trachyonychia are more often more common in patients with common in the proximal nail matrix and candida infections. proximal nail fold ventral side associated There was no specific clinical criteria with clinical changes occuring on the for the diagnosis of the disease causing dorsal nail plate. This situation confirms tracyonychia. The incidence of abnormalities the occurrence of variations in the shape of on onychodermal lines indicates a problem the nail plate which is not uniform due to with the nail matrix and the separation of the inflammatory activity in the nail matrix. the nail plate at the distal tip of the finger.22 Sandpaper nail shape indicates a consistant Abnormalities in trachyonychia are the inflammatory activity, and shiny nails disorders of nail matrix; so to establish a trachyonychia shape indicate there was a definite pathologic diagnosis matrix biopsy latent period of the normal nail matrix.8 is required. On the contrary, some experts The variability of this inflammatory suggested that the pathological diagnosis of process explained why there was no trachyonychia was not entirely necessary as scarring lesions in trachyonychia which it was a benign nature of the disorder and it differed with other nail matrix disorders.6,8 did not cause scars.2,8 Moreover, even Consideration of the advantages and though it was caused by lichen planus in disadvantages of the nail biopsy for the children, it might recover spon- diagnosis of pathological causes of taneously.2,6,8,9 Another reason not to trachyonychia concluded that a biopsy encourage a biopsy in children is the should not be a standard part of the consideration of the objection of the management procedures.8 parents.8,17 Gordon et al.8 did not Assessment of trachyonychia is often recommend biopsy of the nail disorders unsatisfactory as it focuses primarily on the such as lichen planus, trachyonychia, and management of the underlying disease. In idiopathic nail atrophy.8 children, most trachyonychia cases If the biopsy of the proximal nail fold experience spontaneous resolutions.2,6,8,9 is carried out, the nail matrix will present a Our patient’s situation is reflected in the view of spongiosis, and exocytosis lympho- lack of the decision by the parents to cytic infiltrates in epithelial nails.23,24 This procede with invasive measures such as is also found in trachyonychia with biopsy and injection therapy. Therapy of alopecia areata3,6,8,11,24 and most cases of trachyonychia with alopecia areata idiopathic trachyonychia;11,23,24 besides especially the universal/totalized type is that, it has also been reported to have more difficult, but can undergo histopathological similarities to nail lichen spontaneous resolution in several years.24 planus16-18,24 and nail psoriasis.3,6,19,24 After Tosti et al. observed the nail lichen planus removing the psoriasis and lichen planus in children up to 10 years that improved in histopathologically, parakeratosis on the first 6 years of therapy with or without trachyonychia can be distinguished to systemic therapy.17,20 Some determine the cause, either alopecia areata, of the success of topical therapy and atopic dermatitis, or idiopathic.23,24 Another systemic injections for trachyonychia have

Anggowarsito, Kandou; Trachyonychia Associated with Allopecia Areata... 57 been reported. These successes are therapy for onychomycosis in children in derivatives of vitamin A as a selective doses of 5 mg/kg/day in capsule dosage receptor (tazarotene 0.1% gel) for 100 mg should be given as follows: 10-15 psoriasis trachyonychia,26 psoralen plus kg bodyweight with 1 x 100 mg/alternant 1 ultraviolet A (PUVA),27 intralesional day; 16-20 kg with 100 mg/day; 21-40 kg injection at the proximal nail with 2x100 mg/day; and bodyweight >40 fold,17,28 oral prednisolone,17 acitretin and kg with 2x200 mg/day.31 This patient was etretinate for severe psoriasis,19 even given oral daily dosages of 150 mg supplementation, anti-malaria, and more itraconazole in pulse therapy for 3 cycles. aggressive treatments such as cyclosporin.8 Monitoring of liver function was performed It is important to remember that the vast before treatment and at the end of third majority of cases of trachyonychia are self- cycle. The selection of itraconazole was limiting and treatment is not really based on the drug cost and its availability necessarily.2,6,8,9,20 in our health facilities. Onychomycosis therapy is difficult Alopecia areata in patients treated with because the infection occurs in the nail and clobetasol propionate 0.05% cream, being the degree of nail growth is long enough applied 1-2 times on the area of alopecia, is (fingernails 3 mm/month and toenails 1 the first line therapy according to the mm/month),2 so that new clinical will British association of dermatologists appear after several years or more.8 The guidelines for the management of alopecia success of the eradication of the fungi is areata in 2012, although it is stated that not always followed by normal shapes of without treatment alopecia areata may the nails, especially if there have been experience spontaneous remission (80%) dystrophic nails before infection. This within 1 year.32 Alopecia areata in children dystrophic circumstance might facilitate is often difficult to overcome when it is secondary pathogens and saprophyte followed by changes in the nature and infections on nails,5 as found in this case. behavior of the children as noticed by their In immune-competent children, topical parents, and should be referred to therapy should be considered psychologists for further assessment. first, such as the application of imidazole Literature stated that even without with occlusion, to increase penetration.7 treatment alopecia areata may experience The use of nail lacquer ( 15% spontaneous remission (80%) within 1 and olamine 1.5%) is not so year. In general, psychological aspect of advisable, because of the risk of being alopecia areata in children are often inhaled by children.4,7 , impaired, because of the changes in the itraconazole, and are safe and nature and behavior of children as noticed efficient for children.7 Terbinafine is the by their parents.32 This patient was referred most effective fungicidal as anti- to psychologists for further assessment. dermatophytes are currently avail- Promising alternative therapies for able.4,5,7,329 Onychomycosis therapy with onychomycosis are laser therapy, photo- terbinafine was given 250mg/day for 3-6 dynamic therapy, iontophoresis, and months.29 Itraconazole is an anti-fungal, ultrasound.33 These four non-invasive including yeast, dermatophytes, , and alternative therapies may shorten the non-dermatophytes, but is not as effective duration of treatment and improve patient as terbinafine against dermatophytes.4,7,30 adherence to long-term therapy. The Both drugs accumulate in the skin, nails, photodynamic therapy, iontophoresis, and hair, and sebum for a long time, although ultrasound might be used in combination they have been eliminated in the with the systemic therapy to avoid adverse plasma.5,30,31 Itraconazole can be used as an drug reactions.33,34 The efficacy of alter- intermittent/pulse therapy for native therapies still needs more onychomycosis.4,30,31 Itraconazole pulse randomized controlled trials to evaluate the

58 Jurnal Biomedik (JBM), Volume 6, Nomor 1, Maret 2014, hlm. 50-59 long-term mycological therapy and REFERENCES observations. 1. Tosti A, Piraccini BM. Biology of nails and Education and information that the nail disorders. In: Goldsmith LA, Katz eradication of fungal infection is not SI, Gilchrest BA, Paller AS, Leffell DJ, always followed with nail repair, especially Wolff K, editors. Fitzpatrick’s when there has been dystrophy before in General Medicine infection, although there will be no scar (Eighth Edition). New York: Mc. Graw tissue as informed to the worrisome Hill Inc., 2012; p.1009-30. parents. It is suggested that to prevent 2. Tosti A, Piraccini BM. Hair, nails and onychomycosis one should always attempt mucous membranes. Nail disorders. In: to dry the nails after being wet. Children Jean L. Jorizzo, Joseph L. editors. Bolognia Dermatology. St. Louis: are advised to dry the skin around the nails Mosby, 2008; p.1019-36. after a bath or in contact with water or after 3. Baran R, Barnett JM, Bodmann MA, sweating and change socks if they have 8 Cohen PR, Rich P, Scher R, et al. become wet through sweating. Disease of the skin appendages. Disease

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