Superficial white onychomycosis caused by Trichophyton verrucosum

A 79-year-old woman presented with a complaint of nail problems and generalized skin lesions. She denied any other diseases apart from gout. White discoloration of both the fingernail and toenail plates was noted (Fig. 1a,b). There were broken hairs, patchy alopecia, scaling, and erythematous papules on her scalp (Fig. 1c). Erythematous patches with active scaly borders were scattered on her chest, abdomen, and limbs (Fig. 1d). Scraping of the nail plates with a scalpel easily removed the white material. Microscopic examination of this material treated with 20% potassium hydroxide solution showed chains of spores and hyaline hyphae (Fig. 2). Culture of the material yielded a slow-growing, white, glabrous colony. Microscopically, there were many chains of chlamydoconidia and a few teardrop-shaped microconidia and club-shaped macroconidia, characteristic of Trichophyton verrucosum (Fig. 3b). Growth of the organism was enhanced on Trichophyton Agar No. 4 (Fig. 3a). Cultures from the patient’s hair grew the same microorganism. The final diagnosis was widespread T. verrucosum infection with superficial white onychomycosis. The patient was instructed to trim the diseased part of the nails, followed by topical application of sulconazole (Exelderm®). Oral terbinafine 250 mg/day was prescribed for the scalp and body lesions. After 4 weeks of terbinafine treatment, however, the patient developed mildly impaired liver function. From then on, she was treated with topical antifungal agents alone. A blood test was positive for anti-hepatitis C virus (anti-HCV) antibody, but abdominal ultrasound was normal and, on subsequent testing, her liver function had returned to baseline. Nine months after the start of treatment, new healthy hair and nails were growing, and the skin lesions had disappeared. Discussion