Onychomycosis
Fingernail Fungus
Jacksonville, FL
Thickened, discolored, crumbling fingernails — onychomycosis is a fungal infection of the nail plate and nail bed. Dr. R. David Graham at JOI identifies and diagnoses onychomycosis, then refers to dermatology or podiatry for antifungal management. Dr. Graham addresses nail bed pathology when it coexists with a hand surgery problem that requires surgical intervention.
- Identifies onychomycosis on clinical examination
- Confirms diagnosis: nail clipping culture or KOH prep
- Refers to dermatology or podiatry for oral antifungal management
- Oral antifungals (terbinafine, itraconazole): 3–4 month course
- Addresses nail bed pathology when it coexists with a surgical hand problem
- Does not prescribe long-course antifungals in the hand surgery context
Antifungal management of onychomycosis is in the domain of dermatology and podiatry. Dr. Graham recognizes and diagnoses it, directs patients appropriately, and addresses nail bed pathology that requires surgical management when it is part of a larger hand problem.
Understanding Onychomycosis
Fungal Nail Infection —
Diagnosis, Referral, and Nail Bed Care
Onychomycosis is a fungal infection of the nail unit — typically caused by dermatophytes (Trichophyton rubrum most commonly), though Candida and non-dermatophyte molds can also be responsible. It produces characteristic nail changes: thickening, yellow-brown discoloration, onycholysis (separation of the nail plate from the nail bed), brittleness, and crumbling of the nail edge. Fingernails are less commonly affected than toenails, but hand surgeons encounter onychomycosis regularly because nail changes are visible and patients often raise them during visits for other hand problems.
The diagnosis is confirmed with nail clipping for fungal culture or KOH preparation (which demonstrates hyphae under microscopy). Psoriasis, trauma, and other nail conditions can mimic onychomycosis and are excluded clinically and with fungal testing before antifungal treatment is started.
Treatment of onychomycosis is with oral antifungal medications — terbinafine or itraconazole — for a course of 3–4 months. This is managed by dermatology or podiatry, where the appropriate drug choice, monitoring for hepatotoxicity, and follow-up are coordinated. Dr. Graham diagnoses, confirms, and refers — he does not manage long-course antifungal therapy in the hand surgery context.
Where Dr. Graham does address the nail directly: when onychomycosis or nail bed pathology (subungual mass, nail bed laceration, nail bed inclusion cyst) coexists with a hand surgery problem requiring operative intervention. In those cases, nail bed surgery is performed at the same setting as the primary hand procedure.
- ✓ Onychomycosis: yellow-brown thickening, crumbling, onycholysis, subungual debris
- ✓ Psoriasis: pitting, oil spots, salmon patches, joint involvement elsewhere
- ✓ Trauma: history of injury, may have subungual hematoma
- ✓ Lichen planus: pterygium (nail scarring), multiple nails
- ✓ Fungal culture or KOH prep confirms diagnosis before antifungal treatment
- ✓ Subungual melanoma (rare but serious): dark linear streak warrants biopsy
Management
Diagnose Here — Antifungal Treatment with Dermatology
Clinical Identification
Onychomycosis is recognized on examination of the nail unit. The characteristic appearance — thickening, discoloration, onycholysis, subungual debris — is usually clinically recognizable. Other nail conditions that mimic it are considered.
Confirmation
Nail clipping for fungal culture or KOH preparation confirms the diagnosis. Culture identifies the specific organism and guides antifungal selection. Results take 4–6 weeks for definitive culture.
Referral to Dermatology or Podiatry
Oral antifungal management is referred to dermatology or podiatry. Terbinafine (fingernails: 6 weeks; toenails: 12 weeks) or itraconazole (pulse dosing) are the standard options. Liver function monitoring is required. Follow-up for treatment response is managed by the referring provider.
Nail Bed Surgery (When Coexisting Hand Problem)
When nail bed pathology requires surgical treatment as part of a hand surgery procedure — subungual mass excision, nail bed laceration repair, nail bed reconstruction — Dr. Graham addresses it at the same operative setting as the primary hand procedure.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Nail changes noticed during
a hand surgery visit?
Dr. Graham will identify and document nail abnormalities and direct you to the right specialist for antifungal management. Nail bed pathology requiring surgical treatment is addressed at the same setting as any other hand procedure.
Jacksonville Beach, FL 32250
No imaging required.