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Clinical diagnosis of toenail onychomycosis is possible in some patients: cross-sectional diagnostic study and development of a diagnostic rule

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Summary Background 

Suspected toenail onychomycosis is a frequent problem. Clinical diagnosis has been considered inadequate. Objectives 

To assess the diagnostic accuracy of clinical findings for detecting fungi in toenails, and to develop and validate a clinical diagnostic rule aimed at improving dermatologists’ diagnosis of onychomycosis. Methods 

A cross-sectional diagnostic study was performed including a total of 277 patients seen by 12 dermatologists. The gold standard was the presence of dermatophytes on culture or a positive nail plate biopsy. For each sign we described prevalence, sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results. We developed a diagnostic clinical rule and validated it in a subsample. Results 

Helpful findings to predict the presence of fungi are: previous diagnosis of fungal disease; abnormal plantar desquamation (affecting > 25% of the sole); onychomycosis considered the most probable diagnosis by a dermatologist; and presence of interdigital tinea. When dermatologists considered onychomycosis the most probable diagnosis and plantar desquamation was present (13% of patients), the positive predictive value for presence of fungi was 81%. When both signs were absent (34% of patients), the positive predictive value for absence of fungi was 71%. In other situations, clinical diagnosis might not give enough information to decide on therapy. Conclusions 

In 13% of the patients (a large number in absolute terms), when dermatologists consider onychomycosis the most probable diagnosis and plantar desquamation is present, therapy should be started without any further test, as clinical diagnosis is at least as accurate as laboratory tests. In other situations, an optimal management strategy should be defined.
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Keywords: diagnosis; nail diseases; onychomycosis; sensitivity; specificity; toenail

Document Type: Research Article

Affiliations: 1: Department of Dermatology, Complexo Hospitalario de Ourense (CHOU), SERGAS, Ourense, Spain 2: Department of Dermatology, Hospital Arquitecto Marcide-Novoa Santos, SERGAS, Ferrol, Spain 3: Department of Dermatology, Complexo Hospitalario Universitario de Santiago (CHUS), SERGAS, Santiago de Compostela, Spain 4: Department of Statistics, University of Santiago de Compostela, Santiago de Compostela, Spain 5: Department of Dermatology, Complexo Hospitalario Xeral-Calde de Lugo, SERGAS, Lugo, Spain 6: Department of Dermatology, Complexo Hospitalario Universitario de Vigo (CHUVI), SERGAS, Vigo, Spain 7: Department of Dermatology, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, A Coruña, Spain 8: Department of Dermatology, Hospital Comarcal Valdeorras, SERGAS, O Barco de Valdeorras, Ourense, Spain

Publication date: October 1, 2010

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