Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
305
In e na ional Jou nal o Medical
and Pha maceu ical Resea ch
Online ISSN-2958-3683 | P in ISSN-2958-3675
F equency: Bi-Mon hly
A ailable online on: h ps://ijmp .in/
O iginal A icle
A CLINICAL ONYCHOSCOPIC ANALYSIS IN THE DIAGNOSIS OF PRIMARY
ONYCHOMYCOSIS
Zoh a Begum1, Vidhya C2, Ani ha Ch is y3, Monica S4, Vijayabhaska C5, Sandeep R6
1 GOVERNMENT STANLEY MEDICAL COLLEGE, CHENNAI - 600001
2 RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL, CHENNAI - 600003
3-6 GOVERNMENT STANLEY MEDICAL COLLEGE, CHENNAI - 600001
A B S T R A C T
Co esponding Au ho :
Sandeep R
GOVERNMENT STANLEY MEDICAL
COLLEGE, CHENNAI - 600001.
Recei ed: 14-10-2025
Accep ed: 29-10-2025
A ailable online: 12-11-2025
Backg ound: Onychomycosis is one o he commones ungal in ec ions a ec ing
he nails. Labo a o y in es iga ions o onychomycosis a e o en ime-consuming,
so he e is a need o a quick and eliable modali y o es ablish a de ini i e
diagnosis. De moscopy is a non- in asi e, apid and e ec i e me hod o
in es iga ion in de ma ology. In his s udy, we ha e analyzed a ious pa e ns o
onychoscopy among he clinical sub ypes o onychomycosis.
Me hodology: This c oss-sec ional obse a ional s udy included 132 pa ien s
a ending he de ma ology Ou pa ien Depa men (OPD) who we e clinically
diagnosed wi h onychomycosis. O hese, 101 pa ien s wi h KOH-posi i e
inge nail samples, unde wen onychoscopic examina ion using a De mLi e
DL4E4767 wi h X10 magni ica ion. Va ious de moscopic pa e ns o he a ec ed
nails we e eco ded and analysed.
Resul s: Among he 101 pa ien s, Dis al subungual onychomycosis (DLSO) was
he mos common sub ype (75.2%), ollowed by To al dys ophic onychomycosis
(TDO) (31.7%), Pa onychia (27.72%), P oximal subungual onychomycosis (PSO)
(6.9%) and Supe icial Whi e onychomycosis (SWO)5%. No cases o he endonyx
ype we e obse ed. The mos equen de moscopic ea u es included: Ruin pa e n
(68.31%), supe icial ans e se s ia ions (42.57%), ch omonychia (40.59%),
jagged spikes (31.6%), longi udinal idges (22.7%), Subungual hype ke a osis
(15.84%), Au o a bo ealis (10.8%), Splin e haemo hage (3%), and Leukonychia
(3%).
Conclusion: We iden i ied se e al de moscopic ea u es ha we e highly speci ic
o onychomycosis. Onychoscopy, being a simple bedside p ocedu e, should be
conside ed an impo an diagnos ic ool in suspec ed cases o onychomycosis,
pa icula ly when labo a o y con i ma ion is delayed o una ailable.
Copy igh © In e na ional Jou nal o
Medical and Pha maceu ical Resea ch
Keywo ds: Onychomycosis, De moscopy, Onychoscopy, Ruin pa e n.
INTRODUCTION
Onychomycosis is a supe icial ungal in ec ion o he nail. The wo ldwide p e alence o onychomycosis is 4.3% (B
Sigu gei sson e al), while in India, i s incidence anges om 0.5-12% (Shi ani Tyagi e al.). I accoun s o mo e han
hal o nail- ela ed consul a ions in he de ma ology ou pa ien clinics (Kau , Mu ay, Sobbanadh i e al). I is mos
commonly caused by de ma ophy es (T ichophy on ub um, T.men ag ophy es, T.in e digi ale, E. loccosum) and non-
de ma ophy e moulds (Candida albicans, Fusa ium spp, Neoscy alidium spp, Scopula iopsis b e icaulis). I a ec s bo h
sexes equally, hough i is a e in child en. T ea men o onychomycosis is o en p olonged due o slow nail eg ow h,
possible d ug side e ec s and chance o ecu ence despi e adequa e ea men .
The diagnosis is p ima ily clinical, suppo ed by po assium hyd oxide (KOH) examina ion o ungal cul u e. Howe e ,
KOH examina ion esul s a e highly a iable. The sensi i i y is as low as 50% as i is dependen on echnical expe ise o
he examine (Pi accini BM e al.). Despi e nega i e KOH esul s, i clinical suspicion is high, punch biopsy ollowed by
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
306
special s ains like Gomo i-G oco o pe iodic acid-schi (PAS) s ain can be used. These p ocedu es, howe e , a e
expensi e, ime-consuming, and o en yield nega i e cul u e esul s, pa icula ly when sampling he nail pla e.
De moscopy, a simple and non-in asi e o ice p ocedu e, has e olu ionized he ield o de ma ological diagnosis. The
de ice comes wi h ei he pola ized o non-pola ized illumina ion. Pola ized de moscopy helps o isualize deepe
s uc u es si ua ed as deep as 100 mic ome e s while Non-pola ized de moscopy allows o isualize su ace ea u es.
Mode n de ices o en come wi h bo h illumina ion modes as we need bo h illumina ion ypes o assess su ace ea u es
and deepe s uc u es. Recen ly, ideode moscopy de ices ha e been in oduced o be e isualiza ion and eco ding o
he p ocedu e. De moscopy has a wide ange o applica ion which includes onychoscopy, mucoscopy, capilla oscopy,
ichoscopy, in lammoscopy and en omode ma oscopy. Onychoscopy is he de moscopic e alua ion o he nail uni which
helps in diagnosing nail diso de s. Non-pola ized onychoscopy equi es ul asound gel due he con ex shape o he nail
pla e. Nail pla e onychoscopy shows nail pla e pigmen abno mali ies, nail bed essel abno mali ies, o he in lamma o y
de ma osis and he iden i ica ion and p og ession o onychomycosis.
De moscopy o he p oximal nail old capilla oscopy shows capilla y low pa allel o he skin su ace, and any abno mali y
aises he suspicion o connec i e issue diso de s. De moscopy o he dis al edge o he nail pla e is e y use ul in localizing
nail pigmen a ion and umo s such as onychopapilloma and onychoma icoma.
De moscopy o he hyponychium no mally shows capilla y ne wo ks and capilla y loops, which appea as egula ed do s
due o hei pe pendicula a angemen . These indings a e mos o en al e ed in ascula abno mali ies such as nail
pso iasis.
Onychoscopy can play a signi ican ole in de e mining a ious ea u es o onychomycosis, aiding in i s diagnosis. In his
s udy, we analyzed he clinical and onychoscopic indings o onychomycosis and iden i ied he onychoscopic ea u es o
i s a ious sub ypes. (Wal e e al., Pa k e al., 2012).
METHODS AND METHODOLOGY
This was a c oss-sec ional obse a ional s udy conduc ed in he Depa men o De ma ology, Go e nmen S anley Medical
College and Hospi al, Chennai, om Ma ch 2023 o Augus 2023 (6 mon hs). The s udy was ca ied ou a e ob aining
app o al om he E hical Commi ee o S anley Medical College and Hospi al.
[IEC Numbe : ECR/131/Ins /TN/2013/RR-22; DHR Numbe : EC/NEW/2020/46]
The s udy popula ion included pa ien s a ending he De ma ology OPD who we e clinically diagnosed wi h
onychomycosis. The sample size was 132 pa ien s. All pa ien s unde wen KOH examina ion, and only KOH-posi i e
pa ien s we e included in he s udy, a e ob aining in o med consen . A comple e s udy p o ocol was explained, and w i en
in o med consen was ob ained om all pa icipan s.
INCLUSION CRITERIA
• All pa ien s a ending he De ma ology OPD who we e clinically diagnosed wi h onychomycosis and had a posi i e
KOH examina ion.
• Pa ien s who we e able o unde s and he equi emen s o he s udy.
• Pa ien s who we e willing o unde go de moscopic examina ion and clinical pho og aphy.
EXCLUSION CRITERIA
▪ Pa ien s who had ecei ed sys emic o opical an i ungal ea men wi hin he pas h ee mon hs.
▪ Pa ien s wi h o he de ma ological diseases a ec ing he nails.
A o al o 132 pa ien s we e included in he s udy. An elabo a e his o y and physical examina ion we e pe o med, ollowed
by a de ailed clinical examina ion o all inge nails and oenails. The ea u es o onychomycosis in each a ec ed nail we e
documen ed, and clinical pho og aphs o he diseased nails we e aken. All pa ien s unde wen onychoscopic examina ion
o he a ec ed inge nails and oenails using a handheld de moscope (De mLi e DL4E4767, ×10 magni ica ion). Bo h
pola ized and non-pola ized modes we e used o isualiza ion o he a ec ed nails
RESULTS
Ou o 132 pa ien s, 101 pa ien s who we e KOH-posi i e unde wen onychoscopic examina ion. The age o he pa ien s
anged om 17 o 75 yea s. Females we e mo e commonly a ec ed (58.4%) compa ed o males (41.6%). When
occupa ions we e analysed, housewi es accoun ed o he highes p opo ion (39.6%), ollowed by indi iduals wo king as
manual labou e s (coolies).
Among he 101 pa ien s s udied, inge nails we e mo e commonly a ec ed (71.2%) compa ed o oenails (28.7%). The
igh humb was he mos equen ly a ec ed inge nail, while he g ea oe was he mos commonly a ec ed oenail.
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
307
In e ms o clinical sub ypes, dis al la e al subungual onychomycosis (DLSO) was he mos common (75.2%), ollowed by
o al dys ophic onychomycosis (TDO) (31.7%), pa onychia (27.7%), p oximal subungual onychomycosis (PSO) (6.9%),
and supe icial whi e onychomycosis (SWO) (5%). No cases o endonyx onychomycosis we e obse ed.
The mos common de moscopic pa e ns obse ed we e he uin pa e n (68.3%), supe icial ans e se s ia ions (42.6%),
ch omonychia (40.6%), jagged spikes (31.6%), longi udinal idges (22.7%), subungual hype ke a osis, au o a bo ealis
pa e n (10.8%), splin e haemo hages (3%), and leukonychia (3%).
Among he de moscopic ea u es o DLSO (N = 75), he mos common pa e n was he uin pa e n (62.7%), ollowed by
supe icial ans e se s ia ions (32%), ch omonychia (30.6%), jagged spikes (22.7%), longi udinal idges (17.3%),
subungual hype ke a osis (12%), au o a bo ealis pa e n (8%), and splin e haemo hage (2.7%). The leas obse ed inding
was leukonychia (2.6%).
In pa ien s wi h TDO (N = 32), he mos equen pa e n was he uin pa e n (37.5%), ollowed by supe icial ans e se
s ia ions (28.1%), jagged spikes (28.1%), ch omonychia (28.1%), au o a bo ealis (15.6%), and subungual hype ke a osis
(12.5%). Leukonychia and longi udinal idges we e no obse ed in his g oup.
When analysing he de moscopic ea u es o SWO (N = 5), supe icial ans e se s ia ions we e seen in 40%, while
leukonychia, appea ing as whi e lu y shadows, was no ed in 60%. In pa ien s wi h PSO (N = 7), supe icial ans e se
s ia ions we e obse ed in 67%, longi udinal idges in 33%, and jagged spikes in 17%. Fungal pa onychia, analysed
sepa a ely in 28 pa ien s, showed de moscopic ea u es including he uin pa e n in 32.1%, supe icial ans e se s ia ions
in 14.2%, jagged spikes in 10.7%, subungual hype ke a osis in 10.7%, and ch omonychia in 7%.
Table 1: Desc ip i e o Socio-economic cha ac e is ics o he s udy popula ion
Va iable
Desc ip i e
Age (Mean±SD)
48.71±11.93
Sex (n, %)
Male
42, 41.6%
Female
59, 58.4%
Occupa ion (n, %)
Coolie
23, 22.8%
Desk job
6, 5.9%
D i e
3, 3%
Fa me / Flowe handle
3, 3%
Housemaid/ Housekeepe
15, 14.9%
Housewi e
40, 39.6%
Mechanic
5, 5%
Secu i y s a / S uden / Tailo / Teache
4, 4%
Tea s all
2, 2%
Table 2: Clinical ea u es o Onychomycosis among he s udy popula ion N = 101
Clinical ea u e
P esen (n, %)
DLSO
76, 75.2%
TDO
32, 31.7%
Endonyx
0,0%
Pa onychia
28, 27.72%
PSO
7, 6.9%
SWO
5, 5%
Table 3: De moscopic ea u es o Onychomycosis among he s udy popula ion N = 101
De moscopic ea u e
P esen (n, %)
Supe icial T ans e se S ia ions
43,42.57%
leukonychia
3,3%
Subungual hype ke a osis
16,15.84%
Longi udinal idges
23,22.7%
Jagged spike
32,31.6%
Splin e hemo hage
3, 3%
Au o a bo ealis
11,10.8%
Ch omonychia
41,40.59%
Ruin pa e n
69,68.31%
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
308
Table 5: Co ela ion be ween clinical and de moscopic ea u es o Onychomycosis
De moscopic
Fea u es
CLINICAL FEATURES
DLSO
TDO
Endonyx
Pa onychia
PSO
SWO
P- alue
Supe icial
T ans e se
S ia ions
24
9
0
4
4
2
0.000*
leukonychia
0
0
0
0
0
3
0.700
Subungual
hype ke a osis
9
4
0
3
0
0
0.000*
Longi udinal idges
13
5
0
2
2
1
0.000*
Jagged spike
17
9
0
3
2
1
0.000*
Splin e hemo hage
2
0
0
0
1
0
0.315
Au o a bo ealis
6
5
0
0
0
0
0.012
Ch omonychia
23
9
0
9
0
0
0.000*
Ruin pa e n
47
12
0
10
0
0
0.000*
Figu e 1: (A) Dis al la e al subungual onychomycosis (DLSO) o he humb. (B) De moscopic image showing he uin
pa e n. (C) Magni ied de moscopic image o he uin pa e n.
Figu e 2: (A) Shows supe icial whi e onychomycosis o igh index inge (B)Shows onychoscopic image o Leukonychia
showing Whi e lu y shadows
Figu e 3:(A) Shows Onychoscopy image o Au o a bo ea (B)Shows onychoscopic image o De ma ophy oma(Red ci cle)
A
B
C
A
B
A
B
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
309
Figu e 4: (A) Shows onychoscopic image o Supe icial ans e se s ia ions (B) Shows nec oscopic image o jagged
spikes.
Figu e 5:(A) Clinical image o Tinea manuum (B)Shows same pa ien ha ing onychomycosis o almos all inge s
Figu e 6: (A)Shows clinical image o pa onychia a ec ing le ing,middle and index inge s. (B)Shows clinical image o
o al dys ophic onychomycosis
Figu e 7: KOH examina ion o nail clipping showing ungal hyphae
DISCUSSION
Onychomycosis is he mos common nail condi ion encoun e ed in de ma ology, accoun ing o mo e han 50% o all nail
consul a ions. Onychoscopy is a non-in asi e, quick, and eliable diagnos ic ool o onychomycosis. Onychomycosis is
A
B
A
B
A
B
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
310
an umb ella e m ha e e s o ungal in ec ion o he nail pla e, caused by bo h de ma ophy es and non-de ma ophy e
molds. The mos common de ma ophy ic species include T ichophy on ub um, T. men ag ophy es, T. soudanense, and T.
iolaceum. Non-de ma ophy es include Candida albicans, Fusa ium spp., Neoscy alidium spp., Scopula iopsis
b e icaulis, Ac emonium spp., and Onychocola canadensis.
Fungal pa onychia is commonly associa ed wi h DLSO o PSO and is equen ly caused by Candida spp., Fusa ium spp.,
and Neoscy alidium spp. The hyponychium is he weakes pa o he nail appa a us and may se e as a ese oi o
pa hogens.
Rou ine in es iga ions include KOH examina ion, ungal cul u e, luo escen mic oscopy, and nail biopsy wi h special
s ains (PAS, Gomo i, and G oco ). Mode n molecula echniques a e also a ailable, wi h ungal cul u e emaining he gold
s anda d.
KOH examina ion: Nail clippings ea ed wi h 40% KOH and examined unde ligh mic oscopy e eal b anched,
anslucen , sep a e, long hyphae and a h oconidia. Howe e , his es has a high alse-nega i e a e (>15%). Fungal cul u e
equi es 10–14 days, and incuba ion mus be con inued o 21 days be o e decla ing a nega i e esul . The alse-nega i e
a e o cul u e is e en highe , anging om 15–50%.
In ou s udy, emales we e mo e commonly a ec ed (58.4%) compa ed o males (41.6%), consis en wi h he indings o
Pi accini e al. (2013), Jesus-Sil a e al. (2015), and Kan h e al. (2016). The mos common occupa ion associa ed wi h
onychomycosis was housewi es (39.6%), ollowed by manual labo e s (coolies). This is likely due o equen hand
we ing, c ea ing a a o able en i onmen o ungal g ow h.
Finge nails (71.2%) we e mo e commonly a ec ed han oenails (28.7%), possibly due o equen imme sion o hands in
wa e . The hicke nail pla es in males may also explain his obse a ion, which is consis en wi h Ra hod e al. (2017).
The mos common clinical sub ypes we e dis al la e al subungual onychomycosis (DLSO, 75.2%), ollowed by o al
dys ophic onychomycosis (TDO, 31.7%), p oximal subungual onychomycosis (PSO, 6.9%), and supe icial whi e
onychomycosis (SWO, 5%). These indings we e consis en wi h De C ignis e al. (2014), Yada and Khopka (2016), and
Ra hod e al. (2017). No ably, pa onychia accoun ed o 27.7%, which is signi ican bu o en unde epo ed as a dis inc
en i y in o he s udies. No cases o endonyx onychomycosis we e obse ed.
De moscopic Fea u es: The mos common de moscopic ea u e was he uin pa e n (68.3%), ollowed by supe icial
ans e se s ia ions (42.6%), ch omonychia (40.6%), jagged spikes (31.6%), longi udinal idges (22.7%), subungual
hype ke a osis and au o a bo ealis (10.8%), splin e hemo hages (3%), and leukonychia (3%).
• Ruin pa e n: The mos common inding in DLSO (62.7%), TDO (37.5%), and pa onychia (32.1%), bu no obse ed
in PSO o SWO. This pa e n esul s om en al inden a ions o he nail pla e caused by de mal deb is. Ou indings
a e consis en wi h De C ignis e al. (2014).
• Supe icial ans e se s ia ions: Second mos common ea u e, obse ed in DLSO (32%), TDO (28.1%), SWO
(40%), PSO (67%), and pa onychia (14.2%).
• Jagged spikes: Non-linea bo de s a he p oximal ma gin o onycholy ic a eas wi h sha p whi e longi udinal
p ojec ions poin ing o he p oximal nail old. Obse ed in DLSO (22.7%) and TDO (28.1%).
• Longi udinal idges: Obse ed in DLSO (17.3%) and PSO (33%), consis en wi h Yada and Khopka (2016).
• Ch omonychia: Pigmen a ions o a ious colou s (black, b own, whi e, yellow) we e obse ed in DLSO (30.6%),
TDO (28.1%), and pa onychia (25%).
• Subungual hype ke a osis: Obse ed in DLSO (12%), TDO (12.5%), and pa onychia (33%) (Yada and Khopka ,
2016).
• Au o a bo ealis pa e n: Mul i-colou ed a eas wi h g een, bluish-g ey, black, whi e, and yellow, associa ed wi h
onycholysis, s iae, and s eaks. Seen in DLSO (6.7%) and mo e commonly in TDO (15.6%).
• Splin e hemo hages: Linea b own, black, o pu ple haemo hages, obse ed in 2.7% o DLSO cases only.
• Leukonychia: Seen mainly in SWO, cha ac e ized by homogeneous whi e opaci ies (40%) and lu y shadows
sugges i e o de ma ophy oma (60%), consis en wi h Manasa Na ayan e al. (2020).
S a is ical Co ela ion: Co ela ion analysis be ween de moscopic ea u es and clinical sub ypes showed s a is ically
signi ican associa ions o uin pa e n (p = 0.000), supe icial ans e se s ia ions (p = 0.000), ch omonychia (p = 0.000),
jagged spikes (p = 0.000), and au o a bo ealis (p = 0.012) (Pi accini, Jesus, and Na gis e al.).
CONCLUSION
Onychomycosis is a ch onic disease equi ing p olonged ea men . Con en ional diagnos ic me hods such as KOH
examina ion, ungal cul u e, and biopsy ha e hei own limi a ions, being ime-consuming and ha ing a iable posi i e
Zoh a Begum e al. A Clinical Onychoscopic Analysis in he Diagnosis o P ima y Onychomycosis. In . J Med. Pha m.
Res., 6 (6): 305‐311, 2025
311
p edic i e alues. Onychoscopy, as a simple bedside p ocedu e, o e comes he need o edious labo a o y in es iga ions
and may se e as a aluable adjunc in he diagnosis o onychomycosis. In his s udy, we obse ed ha ce ain de moscopic
ea u es we e speci ic o onychomycosis; he e o e, onychoscopy should be conside ed in all suspec ed cases whe e ungal
cul u e o biopsy canno be pe o med.
Limi a ions o he S udy:
Fungal cul u e was no pe o med o con i ma ion o he diagnosis, as cul u e equi es a minimum o ou weeks o
esul s.
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