Many different species of Aspergillus have caused onychomycosis including A. niger, A. fumigatus, A. versicolor, A. terreus and some rare species (Rosenthal, 1968). Among non-dermatophyte mould onychomycosis, proportional rates of Aspergillus onychomycosis vary from 5% to as high as 30% (Hilmioglu-Polat, 2005; Romano, 2005; Gupta, 2007; Bonifaz, 2007) and overall about 0.5-3% (Gianni, 2004; Bonifaz, 2007) There are 2 common patterns of disease, destructive and superficial white onychomycosis (Onsberg P, 1978; McAleer R, 1981; Piraccini, 2004), but lateral and distal onychomycosis may also be seen (Bonifaz, 2007). Particular features suggestive of Aspergillus infection are a chalky, deep white nail with early involvement of the lamina and painful perionyxis without pus (Gianni, 2004).The affected nail may have been previously subjected to trauma and is most often a toenail; peripheral vascular disease is occasionally implicated. Microscopy of nail clippings was positive in 84% of cases (Gianni, 2004)
Several reports have described the efficacy of itraconazole (200mg daily) for Aspergillusonychomycosis (Scher, 1990) and pulsed terbinafine (Gianni & Romano, 2004). The duration of therapy depends on which nails are affected and the extent of infection. Affected fingernails typically require 3 months therapy and toenails at least 6 months. Topical amorolfine hydrochloride 0.25% is not always active against Aspergillus species (Li, 2004) and is not recommended, although one patient is described with A. candidus onychomycosis whose affected big toenail did respond to 6 months therapy (Piraccini, 2002). (If only one nail is affected alternative options include avulsion of the nail or dissolution of the nail with urea paste (BSMM, 1995)).
David W. Denning FRCP FRCPath FIDSA FMedSci
Professor of Medicine and Medical Mycology
Director, National Aspergillosis Centre
Education and Research Centre
University Hospital of South Manchester (Wythenshawe Hospital)
Manchester M23 9LT UK