Rubromycosis of the Nail Plates

The disease is often encountered. In some cases it is an isolated affection of the nails, in others it is combined with affection of the skin on the feet and hands or with generalized rubromycosis. Involvement of many nail plates in the process is a characteristic feature, quite often all the finger and toe nails are affected. In the normotrophic type of rubromycotic onychia, the thickness of the nail plate remains normal; the lesion occurs on the free edge or the sides of the nail as white or yellowish bands; similar bands may show through the thickness of the nail plate. The hypertrophic type of the disease is marked by thickening of the nail plate, which crumbles and breaks easily, and by subunguinal hyperkeratosis; the above-mentioned bands may also be encountered. In the atrophic type of onychia, the nail plate is thinned out, its greater part is destroyed and only the part next to the nail wall remains. Sometimes the nail plate is separated from the nail bed as in onycholysis.

The diagnosis in typical affection of the feet, hands, and nail plates is not difficult, the more so since it is easily verified by microscopy of the pathological material.

Rubromycosis of the skin on the feet and interdigital folds without involvement of the skin on the hands and the nail plates has to be differentiated with intertriginous and squamous forms of tinea pedis the clinical picture of which may be similar in essence. The diseases of the nail plates listed above are, naturally, attended with the corresponding changes on other skin areas and the mucous membranes, which makes the diagnosis of onychia much easier.

The final decision concerning the disease may be made on the basis of cultural diagnosis, i.e. growth of the culture of the fungus, the causative agent of the disease, on nutrient media (usually Sabouraud's medium).

Generalized Rubromycosis

In most patients, generalized rubromycosis develops after a more or less long existence of a localized affection of the skin on the feet (sometimes on the hands too) and of the nail plates. Abnormalities of the internal organs and the endocrine and nervous systems, trophic changes of the skin, and long-term medication with antibiotics, steroid and cytostatic agents predispose to dissemination of the process.

Clinical picture and course. The clinical picture of the disease is diverse and can be conditionally subdivided into several varieties: erythemo-squamous (superficial), follicular-papular (deep), and exudative forms, and affections of the type of erythroderma.

Erythemo-squamous foci of rubromycosis may be found on any skin areas, are attended with severe itching. From the standpoint of clinical diagnosis, the tendency of the foci to gather in groups, to form rings, arches, semi-arches and garlands, the hyperpigmentation and mild scaling in the centre help in suspecting mycosis. Particular importance in the diagnosis is attributed to the scalloped contours of the foci and the interrupted swollen ridge on the periphery. The process takes a chronic course with a tendency to become exacerbated in the warm season.

The follicular-papular (deep) form of rubromycosis usually attacks the legs, buttocks, and forearms. The lesions tend to form figures.

The touching skin in the inguinal and intergluteal areas and under the mammary glands are rather frequent sites of the disease. The surface of the foci is yellowish-red or brown. They are slightly infiltrated and there is scaling. The edges are elevated and have an interrupted scalloped swelling on which small papules and crusts are seen.

In rubromycotic erythroderma, the foci of affection have a deep-red colour with a bluish tinge. They merge and extend over large skin areas. Exudative manifestations of mycosis are relatively rare and may occur in the skin folds and on the limbs.

Treatment. In lesions on the smooth skin of only the palms and soles, treatment is begun with the application of Arievich's keratolytic ointment or varnishes (e.g. Ac. salicylici, Ac. lactici aa 10.0, Collodii elastici 80.0). The keratolytic ointment is applied to the focus under a compress dressing for 48 hours after which 5 per cent salicylic petrolatum is applied under the compress for another 48 hours. As a result of this the horny layer is macerated as a rule and is easily separated (removed with a scalpel or a pair of scissors) in the form of a 'glove' or 'sock'. The keratolytic varnish is applied to the skin on the soles and palms daily for three to five days and no dressing is needed. After that, hot hand or foot baths with potassium permanganate or sodium hydrocarbonate are taken and the remnants of the varnish and the separated horny layer are removed. The procedure is repeated until the hyperkeratotic masses are removed (two or three procedures are sometimes carried out one after the other). Next, the skin is painted with 2 per cent iodine tincture in the morning and with 10-15 per cent sulphur ointment and 2-3 per cent tar or Wilkinson's ointment (for three weeks).

Lesions on the large skin folds and the foci of affection in other forms of generalized rubromycosis are painted with Castellani's paint, 2 per cent iodine tincture, fungicidal ointments. In the generalized forms of rubromycosis and sometimes in cases with localized foci, it is important to reveal the pathogenic mechanisms of the disease and undertake the appropriate treatment. All forms of rubromycosis following a torpid course are managed by non-specific stimulation therapy: injection of imunofan, pyrogenic agents (pyrogenal, prodigiosan), aloe.

The treatment of fungus-infected nails is difficult. Much patience and persistence are required of the patient himself. However, recurrences and reinfections are frequent unfortunately, which is linked with various causes (persistence of the fungus on one nail plate or nail bed leads to the spreading of the process to the 'prepared soil', high prevalence of Epidermophyton and Trichophyton rubrum in nature in high susceptibility to the disease of a person who has recovered from it, etc.).

Oral Lamisil (terbinafin) or Orungal are most effective. Lamisil is prescribed 250 mg daily for 2 months (nails of the hands) and for 3 months (nails of the feet). External therapy is not produced.

Combination of oral griseofulvin with external therapy is prescribed. In some cases, griseofulvin is given at the same time that the nail plates are removed, but usually it is given after all the affected nails and the subunguinal keratotic masses have been removed.

The nail plates are removed by means of keratolytic plasters, (ureaplast, a plaster containing 20 per cent urea; a plaster containing 10 per cent trichloroacetic acid, etc.), keratolytic ointments or surgically with subsequent treatment of the nail bed with fungicidal agents. A thick layer of plaster is applied to the nail plate and covered with adhesive plaster. This dressing is left for 48 hours. The procedure is repeated two to four times until the nail plate becomes soft, after which it is removed with a scalpel or nippers. In removing the nail plate by means of potassium iodide ointment (Araviisky's method), the nail is covered with a thick layer of the ointment over which compress paper and cotton are applied and fastened with a bandage. The dressing is changed several times every four or five days until the nail plate becomes soft and can be removed painlessly with forceps or a scalpel.

With the nail plate removed, treatment of the nail bed with fungicidal agents (nitrofungin, 5 per cent iodine tincture, sulphur-tar ointments, Castellani's paint, etc.) is begun and oral griseofulvin is given at the same time. The adult doses of griseofulvin are as follows: one tablet taken four times a day in body weight less than 60 kg, five times a day in body weight of 60 to 70 kg, six times a day in body weight of 70 to 80 kg, seven times a day in body weight of 80 to 90 kg and eight times a day in body weight over 90 kg. Griseofulvin is taken daily for the first month of treatment and every other day for the next two or three months. It may cause side effects and complications (headache, dizziness, gastro-intestinal disorders, skin eruptions of various character, etc.). Urinalysis and differential blood count must be regularly made during the treatment.

After removal of the nail plates treatment may also be continued by application of 15 per cent resorcin-lactic-salicylic ointment for 48 hours three times running. The ointment is covered with compress paper, cotton and bandage. Next 5 per cent salicylic ointment is applied in the same manner for 48 hours after which the remaining nail plate (the 'root' of the nail) and the keratotic masses are removed. The nail bed is then treated with the fungicidal agents listed above. Whenever necessary, application of keratolytic plasters and dressings with 15 per cent resorcin-lactic-salicylic ointment is repeated.

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