Onychomycosis in KwaZulu-Natal: Clinical spectrum, risk factors and fungal susceptibility.

BACKGROUND: Although onychomycosis is common worldwide and often significantly impairs the quality of life of patients, local epidemiological and mycological data are lacking. We therefore investigated the risk factors, clinical features and mycological aspects of onychomycosis in KwaZulu-Natal. METHODS: This study had two components. In the retrospective arm, positive fungal nail cultures from 2018 to 2024 were analysed. Prospectively in 2025, clinical and mycological data were collated. Descriptive statistical methods were used to summarise the dataset. RESULTS: Out of a total of 301 patients, 229 patients with positive cultures were analysed. The retrospective analysis (n = 177) showed Candida species were the most common (66.7%), followed by moulds (13.6%) and Trichophyton species (11.9%). Prospectively, 124 patients were included; 51.6% females and 48.4% males with a median age of 58.0 years. Candida species (40.4%), moulds and Trichophyton species (25.0% each) were most frequent in 52 patients with positive cultures. All Candida species were susceptible to fluconazole. Most patients had subungual hyperkeratinisation. Immunosuppression (other than human immunodeficiency virus [HIV] infection and diabetes mellitus) was the most common risk factor. CONCLUSION: Candida species were the commonest cause of onychomycosis; therefore fluconazole is an appropriate treatment modality. However, revision of the existing essential drug list is recommended to include itraconazole or terbinafine for patients with confirmed infection with moulds or dermatophytes. CONTRIBUTION: This is the first detailed analysis of onychomycosis in KwaZulu-Natal and contributes to the limited body of data in South Africa. Our results may be used to inform therapeutic recommendations.