At the end of his dermatology visit for an entirely different problem, this 48-year-old man mentions that his toenails have become discolored and misshapen in recent years. Consulting a long line of providers about the problem has not produced a successful solution. Among the treatments tried were oral formulations of fluconazole, ketoconazole, and terbinafine, as well as various OTC topical products, including window-cleaning fluid, tea tree oil, and petroleum jelly.
Ten years ago, he was persuaded to have his right big toenail surgically removed, in hopes of a cure. However, when the nail grew back, it gradually reverted to its previous appearance.
He claims to be in good health otherwise and takes no prescription medications (aside from the attempts to treat his toenail problem). For many years, he has worked in construction, wearing heavy 9 in boots. For the past seven years, he has worked 12-hour days.
He denies any pain in his toes and admits that his main motivation for seeking help with this problem is that his wife is convinced she will “catch” it and end up with toenails like his.
EXAMINATION
Eight out of 10 toenails, including the first and second toes of both feet, are decidedly yellowed and thickened, displaying multiple focal areas of breakage on the ends of the nail plates. No such changes are noted on his fingernails. The surrounding skin on his feet and hands is entirely within normal limits, except for a rim of faint scaling around the periphery of both feet. The latter is KOH positive for fungal elements.
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