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Journal of the American Academy of Dermatology
Volume 71, n° 1
pages 56-61 (juillet 2014)
Doi : 10.1016/j.jaad.2014.02.020
accepted : 19 February 2014
Original Articles

Diagnosis and treatment monitoring of toenail onychomycosis by reflectance confocal microscopy: Prospective cohort study in 58 patients

Momen Pharaon, MD a, Martine Gari-Toussaint, MD b, Abdallah Khemis, MD a, Kevin Zorzi, MSc c, Laurent Petit d, Philippe Martel, MD d, Robert Baran, MD, PhD e, Jean Paul Ortonne, MD, PhD e, Thierry Passeron, MD, PhD a, f, Jean Philippe Lacour, MD, PhD a, Philippe Bahadoran, MD, PhD a, c, g, h,
a Dermatology Department, Centre Hospitalier Universitaire de Nice, Nice, France 
b Parasitology Mycology Laboratory, Centre Hospitalier Universitaire de Nice, Nice, France 
c Clinical Research Center (CRC), Centre Hospitalier Universitaire de Nice, Nice, France 
d Galderma Research and Development, Sophia Antipolis, France 
e Nail Disease Center, Cannes, France 
f L'Institut National de la Santé et de la Recherche Médicale U 1065, Team 12, Nice, France 
g INSERM U 1065, Team 1, Nice, France 
h Groupe Imagerie Cutanée Non Invasive de la Société Française de Dermatologie 

Correspondence to: Philippe Bahadoran, MD, PhD.

The clinical presentation of onychomycosis is often nonspecific and can lead to inappropriate antifungal therapy. Available mycologic tests share many drawbacks.


We sought to evaluate the accuracy of reflectance confocal microscopy (RCM) for the diagnosis of onychomycosis compared with standard mycologic tests.


In all, 58 patients with suspected onychomycosis were enrolled prospectively. RCM, potassium hydroxide preparation, and fungal culture were performed at baseline and after treatment in patients with confirmed onychomycosis. RCM diagnosis of onychomycosis was based on the presence of filamentous and/or roundish structures in the nail plate, corresponding respectively to septate hyphae and/or arthroconidia.


Of patients, 46 of 58 were correctly classified by RCM, with a diagnosis yield of 79.3%, sensitivity of 52.9%, specificity of 90.2%, positive predictive value of 69.2%, and negative predictive value of 82.2%. The use of a handheld RCM imager permitted a faster examination with the same accuracy. RCM performed after treatment in 9 patients showed a normal nail plate, and healing was confirmed by mycologic tests or by follow-up.


Existing RCM scanner heads are not intended for nail examination.


RCM has excellent specificity and can be used as a rapid, office-based test to strengthen the prescription of antifungal therapy and for follow-up. Technical improvement could aid sensitivity.

The full text of this article is available in PDF format.

Key words : confocal, onychomycosis, reflectance confocal microscopy

 Supported in part by Galderma.
 Conflicts of interest: None declared.
 Reprints not available from the authors.

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