Nailing the diagnosis
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Milie M. Fang
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Lyudmyla Susla
An 81-year-old man was referred to our nail clinic in November 2023 due to two black hard masses on his second digit toenails bilaterally. He was treated for onychomycosis with topical ciclopirox for a year. The masses were found to be sitting atop the nails (Figure 1A). History revealed that the patient developed these lesions over time and applied the lacquer nightly without breaks. Nail polish remover and nail clippers gently removed the masses. Microscopic examination of the sticky contents revealed fibers from the patient’s black socks within the masses (Figure 1B).
Pre- and post-removal of toenail black mass. (A) Black mass on a nail of an 81-year-old man undergoing treatment with ciclopirox lacquer for onychomycosis. (B) Microscopic examination of the black mass after removal.
Onychomycosis is a fungal nail infection primarily caused by the dermatophyte Trichophyton rubrum [1]. Moderate-to-severe cases are commonly treated with oral antifungal medications, including terbinafine, itraconazole, griseofulvin, or off-label fluconazole, with treatment typically lasting at least three months [1], 2]. For mild-to-moderate cases, topical antifungals such as ciclopirox (8 % lacquer), efinaconazole (10 % solution), or tavaborole (5 % solution) are preferred and applied once daily for at least 48 weeks [1], 3]. These topical options are popular with patients because of limited systemic adverse effects and drug-drug interactions. The most common adverse effects reported with all three topical solutions were drug ineffectiveness, discoloration, and erythema [1], 4].
Given the widespread use of topical antifungal lacquers in clinical practice, we recommend counseling patients on appropriate application – emphasizing the importance of allowing the lacquer to dry before wearing socks or stockings – and removing it weekly with alcohol to prevent this unique side effect from continuous application of ciclopirox.
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Research ethics: Not applicable.
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Informed consent: Informed consent was obtained from the individual included in this report.
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Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: None declared.
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Conflict of interest: None declared.
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Research funding: None declared.
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Data availability: Not applicable.
References
1. Falotico, JM, Lipner, SR. Updated perspectives on the diagnosis and management of onychomycosis. Clin Cosmet Investig Dermatol 2022;15:1933–57. https://doi.org/10.2147/ccid.s362635.Search in Google Scholar
2. Maskan, BN, Rodríguez-Tamez, G, Perez, S, Tosti, A. Onychomycosis: old and new. J Fungi Basel Switz 2023;9:559. https://doi.org/10.3390/jof9050559.Search in Google Scholar PubMed PubMed Central
3. Yousefian, F, Smythe, C, Han, H, Elewski, BE, Nestor, M. Treatment options for onychomycosis: efficacy, side effects, adherence, financial considerations, and ethics. J Clin Aesthetic Dermatol 2024;17:24–33.Search in Google Scholar
4. Kawa, N, Lee, KC, Anderson, RR, Garibyan, L. Onychomycosis: a review of new and emerging topical and device-based treatments. J Clin Aesthetic Dermatol 2019;12:29–34.Search in Google Scholar
© 2025 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
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