The Best of the Best
May 2010

Top-Accessed Article: White Superficial Onychomycosis

Author Affiliations

Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Dermatol. 2010;146(5):554. doi:10.1001/archdermatol.2010.57

Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol.2004;140(6):696-701.

In their article, Piraccini and Tosti better define the deep variant of white superficial onychomycosis (WSO). The authors observe deep WSO in 3 situations: (1) mold infections (particularly Fusarium species and Aspergillus species infections), (2) children with Candida or Trichophyton rubrum infection, and (3) immunocompromised patients with T rubrum infection. Deep WSO is characterized by diffuse involvement of the nail plate and presence of fungi in both the superficial and intermediate layers. Traditionally, the toenails are affected; however, in children and immunocompromised patients, deep WSO can also affect fingernails. Certain host factors may affect the severity of WSO including immune function, genetics, and local factors such as nail thickness.

Piraccini and Tosti recognize WSO as a progressive disease that may infect the entire nail plate. Onychomycosis is amenable to current therapies; however, WSO and deep WSO may pose a therapeutic challenge. Deep WSO infections require systemic therapy and may be less likely to respond to itraconazole, fluconazole, or terbinafine.

From June 2004 through August 2009, this article was viewed 4434 times on the Archives of Dermatology Web site.

Drs Carney and Elewski are with the Department of Dermatology, University of Alabama at Birmingham; contact Dr Elewski at