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Before treating onychomycosis, it is important to exclude other conditions such as lichen planus and psoriasis. The purpose of this study was to evaluate physician preferences and uses of diagnostic tests for toenail onychomycosis (TO) by surveying dermatologists (D), podiatrists (P) and family practitioners (FP) in the United States. Surveys were mailed to approximately 1000 randomly sampled physicians from each of the three specialities. The questionnaire consisted of 15 items regarding physician and practice characteristics, number of patients with TO seen and treated, tests used to diagnose TO and reasons for using the tests. Results were analysed using several statistical methods. Response rates were low (D33.7%; P16.6%; FP28.4%). Ds and Ps (75.2%) and FPs (43.4%) reported feeling 'very confident' at diagnosing onychomycosis. KOH was the preferred diagnostic test for all three specialities. More Ds (75.4%) felt 'very confident' interpreting potassium hydroxide (KOH) exams than Ps (24.9%) and FPs (18.5%). Use of KOH exams was statistically associated with confidence interpreting exams (P P = 0.04092; D & FP P < 0.0001). Some FPs (46.6%) and Ps (21.6%) did not obtain a confirmatory diagnostic test prior to the treatment of onychomycosis while 63.6% of Ds 'almost always/always' did. While limited by low-response rate, this study provides pilot information on the diagnostic preferences for TO by American D, P and FP.

SummaryA valid and reliable measure that captures onychodystrophy disease severity is important for both clinical and research applications. Three hundred and twenty-two patients at two Veterans Affairs Medical Centers with clinical evidence of onychodystrophy suggesting onychomycosis (at least 25% in a distal subungual pattern) were examined using Naildex parameters. Naildex scores were calculated by a combination of: per cent of each nail infected, area of each nail and number of infected nails. Patients also completed a nail-specific quality of life questionnaire (NailQoL) and nail samples were collected and examined mycologically. Data was analysed for all enrolled patients (n = 322) and patients with mycologically-confirmed onychomycosis (n = 243). Inter-rater reliability was calculated from two examiners who each evaluated 17 patients with mycologically-confirmed onychomycosis. Significant correlations (P < 0.01) between Naildex and NailQoL as well as proxy measures (duration of infection) indicated construct validity of the instrument for all patients as well as mycologically-confirmed cases. Strong correlation (r = 0.754, P < 0.01, n = 17) indicated high inter-rate reliability. This pilot evaluation suggests that Naildex is a valid and reliable measure of onychomycosis severity.

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