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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 38  |  Issue : 2  |  Page : 85-88

Effect of onychomycosis on pulse oximeter


1 Department of Dermatology, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey
2 Infectious Diseases and Clinical Microbiology, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey
3 Department of Dermatology, Elazığ Training and Research Hospital, Elazığ, Turkey
4 Department of Dermatology, Fırat University, Elazığ, Turkey

Date of Submission12-Mar-2018
Date of Acceptance24-Jun-2018
Date of Web Publication17-Aug-2018

Correspondence Address:
Hülya Nazik
Department of Dermatology, Kahramanmaraş Sütçü İmam University, Kahramanmaraş 46100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_9_18

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  Abstract 


Objective Onychomycosis causes nail thickness and discoloration of the dorsum of the nail plate. This study was aimed to investigate the effect of discoloration and nail thickness associated with onychomycosis on pulse oximetry measurement.
Materials and methods The involvement degree of onychomycosis was determined using onychomycosis severity index (OSI). Two different measurements were recorded by pulse oximetry. The first one was from the nail with onychomycosis, and the second one was from the normal nail of the same hand.
Results A total of 93 onychomycosis cases were included in the study. When SpO2 values of white nail color were measured, it was statistically significant higher in the onychomycosis group than the control (P<0.001). On the contrary, in the yellow nail, SpO2 values were lower in the onychomycosis group (P<0.001). Similarly in the brown nail, SpO2 values were lower in the onychomycosis group, but there was no statistically significance (P=0.083). It was determined that there was no statistically significant difference between SpO2 values and OSI (P=0.563).
Conclusion As a result, SpO2 values were affected by discoloration owing to onychomycosis. SpO2 values were found lower in patients with moderate and severe OSI, which is related to nail thickness than the control. It was concluded that the discoloration and nail thickness associated with onychomycosis were effective on pulse oximetry measurement.

Keywords: discoloration, nail thickness, onychomycosis, pulse oximetry


How to cite this article:
Nazik H, Nazik S, Gül F&, Demir B, Mülayim MK. Effect of onychomycosis on pulse oximeter. Egypt J Dermatol Venerol 2018;38:85-8

How to cite this URL:
Nazik H, Nazik S, Gül F&, Demir B, Mülayim MK. Effect of onychomycosis on pulse oximeter. Egypt J Dermatol Venerol [serial online] 2018 [cited 2018 Oct 24];38:85-8. Available from: http://www.ejdv.eg.net/text.asp?2018/38/2/85/237845




  Introduction Top


Pulse oximetry, which is used to measure oxygenated hemoglobin saturation (SpO2), is a noninvasive, painless and reliable method. At first it was developed to show pilots’ oxygen saturation during the Second World War. Oxygen saturation is used as a fifth vital sign in surgical procedure, ICU, postanesthesia, operating room, and emergency [1],[2],[3].

Pulse oximetry is based on Lambert–Beer law. Accordingly, two different wavelengths of light are used in the pulse oximetry. One is red, with wavelength of 660 nm, and the other is infrared with a wavelength of 940 nm. Absorption of light at these wavelengths differs significantly between blood loaded with oxygen and blood lacking oxygen. Oxyhemoglobin absorbs more infrared light, whereas deoxyhemoglobin absorbs more red light [4].

Oxygen saturation is measured by pulse oximetry. It shows hypoxia and hyperoxia and helps to separate patients from the ventilator and to reduce frequent blood gas control. However, in some cases, the measurement of oxygen saturation may be misleading. Nail discoloration is the main one [5].

In this study, it was aimed to investigate the effect of discoloration and nail thickness associated with onychomycosis on pulse oximetry measurement.


  Materials and methods Top


Patients with total dystrophic onychomycosis diagnosed on hand nails older than 18 years who were admitted to the Dermatology and Infectious Diseases Clinic between January 2016 and January 2017 were included in the study. Deep anemia, chronic obstructive pulmonary disease, methemoglobinemia, hypoxia, hypotension, and hyperbilirubinemia, which may affect measurement of pulse oximetry, were not included in the study.

The local ethics committee approved the study (No:16/04 Date: 8/9/2015). Information about the illness was given, and patient consent form was filled in.

The specimen was taken from a nail with dystrophic appearance, and it was prepared by adding 20% potassium hydroxide, left in a warm and humid environment for 30–45 min, and then examined with a light microscope NİKON (Eclipse E200; Tokyo, Nikon, Japan) before ×10 and then ×40 magnification. The appearance of hyphae, spore, pseudohyphae, and yeast was accepted as onychomycosis. Age and sociodemographic characteristics of the patients were recorded. Color of the nail plate was recorded as white, yellow, and brown. Degree of involment of cases with total dystrophic type onychomycosis was determined using onychomycosis severity index (OSI). The OSI score is obtained by multiplying the score for the area of involvement (1–10%=1, 11–25%=2, 26–50%=3, 51–75%=4, 76–100%=5) by the score for the proximity of disease to the matrix (involvement from the distal end of the nail, <¼=1, ¼–½=2, ½–¾=3, >¾=4, and matrix involvement=5). Ten points are added for the presence of a longitudinal streak or a patch (dermatophytoma) or for greater than 2 mm of subungual hyperkeratosis. Mild onychomycosis corresponds to a score of 1 through 5; moderate: 6 through 15; and severe: 16 through 35 [6].

After resting for 10 min, the patients were positioned supine. Two separate measurements were carried out with a pulse oximetry from nail with onychomycosis and nail without onychomycosis in the same hand. SpO2 is the percentage of heme groups in the blood that have been filled with oxygen. In pulse oximetry, 660 and 940 nm wavelengths of light are beamed through the nail bed, and the relative absorption is determined. SpO2 measurement was performed by pulse oximetry ChoiceMMed MD300-c26 (Peking, Beijing Choice Electronic, China) in the same room temperature. In this study, noninvasive, simple pulse oximetry was used by clipping a probe onto the fingertip to measure SpO2.

Data analysis

The data of the study were evaluated using the SPSS version 17.0 statistical software (SPSS Inc., Chicago, Illinois, USA). The continuous variables were expressed as mean and SD, and the categorical variables were expressed in numbers and percentage values. The Student’s t-test was used to compare the continuous variables between independent groups. When the distribution of continuous variables was examined by Shapiro–Wilk test, it was determined that the variables did not show normal distribution. The Wilcoxon rank test was used to determine the difference between nonparametric variables in dependent groups. P values less than 0.05 were considered statistically significant.


  Results Top


A total of 93 onychomycosis cases were included in the study. Overall, 56 (60.2%) patients were male and 37 (39.8%) patients were female. The mean age was 45.53±16.0 years (minimum–maximum: 18–82 years). Color distribution of the nail plates was evaluated. Accordingly, white was observed in 37 (39.8%) patients, brown in 29 (31.2%) patients, and yellow in 27 (29.0%) patients.

When the OSI of onychomycosis was examined, it was found that 41.9% (n=39) of the cases were moderate and 58.1% (n=54) were severe. On the contrary, there were no mild cases.

There was no statistically significant relationship between sex and oxygen saturation in patients with onychomycosis (P=0.164).

The measurements of SpO2 values were evaluated according to nail color. In white nail, SpO2 values were statistically significantly higher in the onychomycosis group than the control (P<0.001). On the contrary, SPO2 values of the yellow nail were lower in the onychomycosis group (P<0.001). Similarly SPO2 values of the brown nail were lower in the onychomycosis group, but there was no statistically significance (P=0.083). The comparisons of the SpO2 values according to the nail colors in control and onychomycosis group are presented in [Table 1].
Table 1 The comparison of the SpO2 values according to the nail colors in the control and onychomycotic cases

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It was determined that there was no statistically significant difference between SpO2 values and moderate/severe OSI (P=0.563). The comparison of OSI and SpO2 values in control and onychomycosis groups is presented in [Table 2].
Table 2 The comparison of onychomycosis severity index and SpO2 values in control and onychomycosis groups

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  Discussion Top


Onychomycosis is the most common nail disease and accounts for nearly 50% of all nail disorders. The most common cause of onychomycosis is Trichophyton rubrum. In addition, candida species, yeasts, and nondermatophytic molds may cause onychomycosis less frequently [7]. Onychomycosis causes discoloration in nail depending on different factors. A number of studies investigating the relationship between color changes in the nail and SpO2 have been conducted, and conflicting results have been obtained. In a study by Rubin et al. [8], 31 different nail polishes were tested, and it was determined that SpO2, which is a flame blue, fell from 97 to 87%. On the contrary, it was determined that there was no decrease in SpO2 in the other two blue colors and 28 colors [8]. In a study by Hakverdioğlu et al. [9], 10 different colors of nail polishes were used. There was no statistically significant difference in SpO2 values only in dark red color (P=0.163) before and after the use of nail polishing, whereas SpO2 values in the other nine colors decreased with nail polishing, with statistically significant difference [9]. Brand et al. [1] applied nail polishes, which were blue, green, and lime green, to the of 2–3–4 nails on one hand, and the other hand 2–3–4 nails without polish were accepted as a control. As a consequence, it was determined that these colored nail polishes did not affect the accuracy of pulse oximetry values (P=0.67) [5]. In another study by Miyake et al. [10], four different nail colors (base, red, pink, and bright light pink) were used, and there was only a statistically significant difference in red color (P<0.001) [10]. In a study by Diccini et al. [11], five different nail polishes were used in 80 healthy volunteers, with the uncolored nail on the opposite side accepted as a control. Brown and red nail polishes were found to have significantly lower SpO2 values (P=0.024 and P=0.047, respectively) [11]. SpO2 measurements were performed with nine different nail polishes in the study by Hinkelbein et al. [5] including 50 patients on mechanical ventilation in the ICU. SpO2 values were found to decrease in all colors except light green color. However, it was found that there was a statistically significant decrease especially in black, purple, and dark blue colors (P<0.05) [5]. In another study by Rodden et al. [12], SpO2 values were measured using 10 different nail polishes, and a statistically significant decrease in red (P=0.016), brown (P<0.05), and blue nail polishes (P<0.05) was found [12]. SpO2 values were measured in hand fingers that have henna burns in a study by Torun [13]. As a control, radial arterial blood gas was used in the same cases. As a result, the mean SpO2 measured with blood gas analyzer was 96.8±1.3, and the mean value of SpO2 measured with pulse oximetry was 96.3±1.6 (P=0.157) [13]. In another study about henna by Al-Majed and Harakati [14], it was found that there was no change in the value of SpO2 when red henna was used, whereas the value of SpO2 decreased with the use of black colored henna obtained by adding additives. In the literature, there are many studies about nail polish, but there is no study regarding discoloration in nail owing to onychomycosis. For this reason, data of our study were compared with other reasons (nail polish and henna) that cause discoloration in nail.Hay and Moore [15] have reported that factors such as color changes, nail fragility, and separation of the plaque from the nail bed on onychomycosis may affect the accuracy of pulse oximetry results. But in their study, they did not use an index such as OSI [15]. In a study by Jakpor [16], SpO2 measurements were made with simple pulse oximetry and stationary Nellcor model pulse oximetry using six different colors (blue, white, red, wine red, pink, and transparent) and artificial nail in 23 volunteers. In artificial nails painted with transparent nail polish, SpO2 values were found lower 0.09% ratio with noninvasive pulse oximeter and 0.13% ratio with Nellcor when compared with control [16]. This is the first study to compare SpO2 values with OSI in the literature. In this study, it was determined that the cases were classified as moderate and severe group according to the classification of OSI. When nails with onychomycosis were compared with control group, SpO2 values were lower, but there was no statistically significant difference. Similarly, our results were consistent with study of Jakpor.

As a result, SpO2 values were effected by discoloration owing to onychomycosis. SpO2 values were found lower in patients with moderate and severe OSI, which is related to nail thickness, than control. It was concluded that the discoloration and nail thickness associated with onychomycosis were effective on pulse oximetry measurement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brand TM, Brand ME, Jay GD. Enamel nail polish does not interfere with pulse oximetry among normoxic volunteers. J Clin Monit Comput 2002; 17:93–96.  Back to cited text no. 1
    
2.
Simon SB, Clark RA. Using pulse oximetry: a review of pulse oximetry use in acute care medical wards. Clin Effect Nurs 2002; 6:106–110.  Back to cited text no. 2
    
3.
Popovich DM, Richiuso N, Danek G. Pediatric health care providers’ knowledge of pulse oximetry. Pediatr Nurs 2004; 30:14–20.  Back to cited text no. 3
    
4.
Cook LB. Extracting arterial flow waveforms from pulse oximeter waveforms apparatus. Anaesthesia 2001; 56:551–555.  Back to cited text no. 4
    
5.
Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation 2007; 72:82–91.  Back to cited text no. 5
    
6.
Carney C, Tosti A, Daniel R, Scher R, Rich P, DeCoster J et al. A new classification system for grading the severity of onychomycosis severity index. Arch Dermatol 2011; 147:1277–1282.  Back to cited text no. 6
    
7.
Effendy I, Lecha M, Feuilhade de Chauvin M, Di Chiacchio N, Baran R. Epidemiology andclinical classification of onychomycosis. J Eur Acad Dermatol Venerol 2005; 19:8–12.  Back to cited text no. 7
    
8.
Rubin AS. Nail polish color can affect pulse oximeter saturation. Anesthesiology 1988; 68:825.  Back to cited text no. 8
    
9.
Hakverdioğlu YG, Akin KE, Dizer B. The effect of nail polish on pulse oximetry readings. Intensive Crit Care Nurs 2014; 30:111–115.  Back to cited text no. 9
    
10.
Miyake MH, Diccini S, Bettencourt ARC. Interference of nail polish colors and time on pulse oximetry in healthy volunteers. J Bras Pneumol 2003; 29:386–390.  Back to cited text no. 10
    
11.
Diccini S, Pereira EM, Im SY, Shida LY, Bettencourt ARC. Evaluation of pulse oximetry measurements in healthy subjects with nail polish. Acta Paul Enferm 2011; 24:784–788.  Back to cited text no. 11
    
12.
Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs 2007; 23:51–55.  Back to cited text no. 12
    
13.
Torun E. The effect of henna paste on oxygen saturation reading obtained by pulse oximetry. İzmir Göğüs Hastanesi Dergisi 2009; 23:77–80.  Back to cited text no. 13
    
14.
Al-Majed SA, Harakati MS. The effect of henna paste on oxygen saturation reading obtained by pulse oximetry. Trop Geogr Med 1994; 46:38–39.  Back to cited text no. 14
    
15.
Hay RJ, Moore MK. Clinical features of superficial fungal infections caused by Hendersonula toruloidea and Scytalidium hyalinum. Br J Dermatol 1984; 110:677–683.  Back to cited text no. 15
    
16.
Jakpor O. Do artificial nails and nail polish interfere with the accurate measurement of oxygen saturation by pulse oximetry? Young Scientists J 2011; 9:33–37.  Back to cited text no. 16
    



 
 
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