Association between onychomycosis and ulcerative complications in patients with diabetes: a longitudinal cohort study in Dutch general practice

INTRODUCTION

Diabetic foot ulcers are feared complications of diabetes mellitus (DM), requiring extensive treatment and hospital admissions, ultimately leading to amputation and increased mortality. Different factors contribute to the development of foot ulcers and related complications. Onychomycosis, being more prevalent in patients with diabetes, could be an important risk factor for developing ulcers and related infections. However, the association between onychomycosis and diabetic complications has not been well studied in primary care.

RESEARCH DESIGN AND METHODS

To determine the impact of onychomycosis on ulcer development and related complications in patients with diabetes in primary care, a longitudinal cohort study was carried out using routine care data from the Extramural Leiden University Medical Center Academic Network. Survival analyses were performed through Cox proportional hazards models with time-dependent covariates.

RESULTS

Data from 48 212 patients with a mean age of 58 at diagnosis of DM, predominantly type 2 (87.8%), were analysed over a median follow-up of 10.3 years. 5.7% of patients developed an ulcer. Onychomycosis significantly increased the risk of ulcer development (HR 1.37, 95% CI 1.13 to 1.66), not affected by antimycotic treatment, nor after adjusting for confounders (HR 1.23, 95% CI 1.01 to 1.49). The same was found for surgical interventions (HR 1.54, 95% CI 1.35 to 1.75) and skin infections (HR 1.48, CI 95% 1.28 to 1.72), again not affected by treatment and significant after adjusting for confounders (HR 1.32, 95% CI 1.16 to 1.51 and HR 1.27, 95% CI 1.10 to 1.48, respectively).

CONCLUSIONS

Onychomycosis significantly increased the risk of ulcer development in patients with DM in primary care, independently of other risk factors. In addition, onychomycosis increased the risk of surgeries and infectious complications. These results underscore the importance of giving sufficient attention to onychomycosis in primary care and corresponding guidelines. Early identification of onychomycosis during screening and routine care provides a good opportunity for timely recognition of increased ulcer risk.

Comparison of dermoscopic characteristics on toenail onychomycosis in psoriatic and non-psoriatic patients: A prospective study

BACKGROUND

Psoriatic patients may experience the coexistence of onychomycosis (OM). However, the evaluation of OM in psoriatics has been hindered by potential clinical differences from OM in non-psoriatics.

OBJECTIVE

To assess and compare dermoscopic features between toenail OM in psoriatic and in non-psoriatic patients.

PATIENTS AND METHODS

Between September 2020 and September 2023, dermoscopy was conducted on 183 affected toenails by OM in psoriatics and 232 affected toenails by OM in non-psoriatics in two centres. The dermoscopic characteristics were compared using the Chi-squared test.

RESULTS

Among toenail OM cases in psoriatic subjects, the most prevalent dermoscopic features included pitting (147/183, 80.33%) and subungual hyperkeratosis (118/183, 64.48%). Conversely, toenail OM in non-psoriatics was characterized by subungual hyperkeratosis (175/232, 75.43%) and nail spikes (139/232, 59.91%). Comparative analysis revealed a significantly higher occurrence of pitting (80.33% vs. 15.96%, p < .001), periungual telangiectasis (22.40% vs. 4.74%, p < .001), oil patches (12.57% vs. 0.43%,p < .001) and transverse grooves (43.72% vs. 28.45%,p < .01) in toenail OM in psoriatics. Furthermore, toenail OM in psoriatics exhibited a significantly lower frequency of yellow structureless area (13.11% vs. 42.67%, p < .001), nail spikes (43.17% vs. 59.91%, p < .01), ruin appearance of sulphur nugget (8.20% vs. 31.03%, p < .001), dotted/blocky haemorrhage (6.01% vs. 20.69%,p < .001) and partial onycholysis (32.79% vs. 46.98%, p < .01).

CONCLUSIONS

Dermoscopic features of toenail OM in psoriatic and non-psoriatic patients exhibit notable differences. OM in psoriatics shows a higher frequency of pitting and periungual telangiectasis, while a lower frequency of yellow structureless areas and nail spikes under dermoscopy.

Prevalence and Associated Factors of Toenail Onychomycosis Among Patients with Diabetes in Jordan

BACKGROUND

Toenail onychomycosis is common in patients with diabetes and it can increase the risk of secondary infections and foot complications. Despite several studies investigating the prevalence and associated factors of toenail onychomycosis from different parts of the world, there are no data from Jordan.

OBJECTIVE

To determine the prevalence and the associated factors of toenail onychomycosis among patients with diabetes in Jordan.

METHODS

A cross-sectional study was conducted on 375 patients with diabetes at the National Centre for Diabetes, Endocrinology, and Genetics in Amman, Jordan. Several socio-demographic and health-independent variables including foot self-care practices were collected. Toenail onychomycosis was assessed by a specimen culture and microscopic examinations. Descriptive and inferential statistics were used for data analysis.

RESULTS

The prevalence of toenail onychomycosis was 57.6% (n=216). Multiple logistic regression revealed four significant associated factors; the presence of neuropathy (β=1.87, p=0.02), being an ex-smoker (β=2.69, p=0.01), being treated by both insulin and oral hypoglycemics drugs (β=1.32, p=0.03), and using antibiotics in the last year (β=1.78, p=0.02).

CONCLUSION

The prevalence of toenail onychomycosis among patients with diabetes in Jordan is high. Regular foot screening and podiatric care are recommended especially among patients with diabetic neuropathy, current treatment by insulin and oral hypoglycemics drugs, previous history of smoking, and previous use of antibiotics.

Hair and Nail Conditions: Nail Conditions

A thorough understanding of nail anatomy can help physicians identify the causes of nail conditions. Observation of changes to the nail can help establish a diagnosis. Patient evaluation should include a physical examination, dermoscopy, and, in some cases, nail biopsy. Onychomycosis is the most common nail condition worldwide, and should be distinguished from other nail conditions with similar manifestations. Empiric onychomycosis treatment without confirmatory tests has been proposed, but studies have shown the cost-effectiveness of testing to prevent inappropriate therapy. Systemic drugs for management include terbinafine and itraconazole. Longitudinal melanonychia is a brown band through the length of the nail. Nail melanoma should be suspected if the band is dark brown-black, is located on a single digit, and occupies 40% or more of the nail plate width. Biopsy with local anesthesia should be performed in patients with suspected nail melanoma or other neoplastic nail conditions. Identification of warning signs of nail melanoma can result in earlier diagnosis and limit potential morbidity and mortality. Nail psoriasis often is overlooked but can affect up to 50% of patients with psoriasis. Nail lichen planus can cause permanent scarring with loss of normal nail anatomy. Other common nail conditions include acute and chronic paronychia, onychocryptosis, onycholysis, Pseudomonas infection (ie, green nails), onychogryphosis, subungual hematoma, and onychomadesis.

[Persistently crumbling nails in a patient with limited Dutch proficiency]

BACKGROUND

Nail psoriasis, also called psoriasis unguium, is a variant of psoriasis in which nail changes appear due to inflammation of nail bed or nail matrix. 15% to 50% of patients with cutaneous psoriasis have nail psoriasis, the condition also occurs without or before the appearance of skin lesions.

CASE DESCRIPTION

A 54-year-old male visits his general practitioner because of crumbling of his fingernails. Upon clinical examination, this was interpreted as onychomycosis and treated with oral antimycotics. Due to the lack of improvement and a negative PCR-test on dermatophytes, the condition was later diagnosed as nail psoriasis.

CONCLUSION

Nail psoriasis is often diagnosed as fungal infection of the nails. To make the right diagnosis, a complete medical history should be obtained, and physical examination of skin and joints need to be conducted. Furthermore, we advise to rule out onychomycosis in patients with known skin psoriasis to prevent overtreatment with antimycotics.

PECULIARITIES OF TREATMENT OF PATIENTS WITH ONYCHOMYCOSIS WITH CONTRAINDICATIONS TO SYSTEMIC ANTIMYCOTICS

OBJECTIVE

The aim: To increase the effectiveness of treatment of patients with onychomycosis with contraindications to administration of systemic antifungal therapy.

PATIENTS AND METHODS

Materials and methods: The study involved 63 patients with onychomycosis of the toes aged 18 to 72 years under supervision at the clinic of the Institute of Dermatology and Venereology of the National Academy of Medical Sciences of Ukraine, who were divided into groups: Group I (30 patients) received naftifine hydrochloride solution and cream; Group II (33 patients) additionally used nail kit mycosan and cytoflavin 2 tablets 2 times a day for 1-1.5 months. The study implied microscopic and molecular genetic examination of nail plates before treatment and starting from the 4th week every 2 weeks. The study included patients with onychomycosis with positive results of both microscopic and PCR studies. Mycological recovery was noted in case of coincidence of results of these studies.

RESULTS

Results: Mycological recovery in patients of Group II began in the sixth week in 6.3% and occurred in 100% of cases at the 24th week of treatment, depending on the severity and clinical form. The overall effectiveness of therapy at the 48th week reached 56.7% in Group I and 72.7% in Group II.

CONCLUSION

Conclusions: The developed method of treatment, which includes the use of naftifine hydrochloride solution and cream, nail kit micozan and cytoflavin, allows to achieve clinical and mycological recovery in 72.7% of patients and is a priority in the treatment of patients with onychomycosis with comorbid conditions.

Toenail onychomycosis by Trichophyton rubrum and concurrent infestation with Tyrophagus putrescentiae

A remarkable case of onychomycosis by Trichophyton (T.) rubrum combined with nail infestation by Tyrophagus (T.) putrescentiae in an elderly diabetic farmer is described and discussed. Large numbers of eggs and mites in all development stages were present in nail debris, reflecting active reproduction on site. Treatment with ivermectin 0.1% cream and environmental decontamination cleared the mite infestation, while onychomycosis responded well to oral terbinafine and ciclopirox 8% nail lacquer. Such a combination of onychomycosis and mite infestation of the same nail is an exceptional finding reported only twice in the literature.

Pediatric Onychomycosis: The Emerging Role of Topical Therapy

Fungal infection of the nails is an increasingly recognized disease in infants and children. However, it can be difficult to distinguish clinically from other nail dystrophies. In addition, many mistakenly believe that onychomycosis does not occur in childhood. Under-recognition of this infectious disorder therefore occurs. Although many consider "nail fungus" a trivial cosmetic concern, it can lead to discomfort, risk of secondary infection, and a more significant health threat in immunocompromised or diabetic individuals. It should always be considered in the differential diagnosis of nail plate disorders in children as it is one of the more common causes.</p> <p>Here we review the latest data on prevalence of the disease, reasons for its relatively low incidence compared with adults, and important predisposing factors. It is important to confirm the clinical diagnosis of onychomycosis in children, and affected individuals should be examined for concomitant tinea pedis. As familial disease often occurs, it is important to check parents and siblings as well for onychomycosis and tinea pedis.</p> <p>Treatment of onychomycosis is challenging, and recurrence appears to be more common in children than in adults. Prolonged systemic antifungal therapy is commonly required. However, pediatric practitioners and parents alike hesitate when asked to treat young children with a systemic drug that requires laboratory monitoring and can have systemic toxicities. Due to their thinner, faster-growing nails, children are theoretically more likely to respond to topical monotherapy than adults, and therefore good candidates for topical antifungal therapy.</p> <p>The clinical data on the use of topical antifungals in pediatric onychomycosis is scarce. We review data that exist from case reports and small clinical trials. New topical antifungals are now available that afford better nail penetration and additional delivery routes to the site of infection. Pediatric trials are now on-going, and should clarify the usefulness of these agents in children.

[Clinical problems in medical mycology: Problem number 50]

We present the case of a 34 year-old man, HIV-positive, who had suffered a disseminated histoplasmosis treated with amphotericin B one year before his admission. He was admitted at the Infectious Diseases Muñiz Hospital with a non-lithiasic chlolecystitis. During the clinical examination perigenital skin lesions compatible with tinea cruris, as well as proximal subungual onychomycoses of toenails, were observed. Microsporum gypseum was isolated from both types of lesions. Oral terbinafine led to a good clinical response. Treatment prescription was a big challenge in this patient because he was receiving HAART and itraconazole, and there was scarce experience in the treatment of nail infections due to M. gypseum.

Prevalence, Risk Factors, and Type of Organism in Fungal Foot Infection and Toenail Onychomycosis in Thai Diabetic Patients

BACKGROUND

Diabetes mellitus (DM) is a known and important predisposing factor for toenail onychomycosis and fungal foot infection. DM also increases the risk of patient developing secondary bacterial infection if fungal infection goes unrecognized and untreated.

OBJECTIVE

To assess the prevalence and risk factors of toenail onychomycosis and fungal foot infection in Thai diabetic patients.

MATERIAL AND METHOD

This single center cross-sectional observational study recruited type 1 and type 2 diabetic patients older than 18 years who attended Siriraj Hospital between October 1, 2012 and November 30, 2013. Patient demographic data, clinical data, and medical history were collected by questionnaire and assessed. Diagnosis of fungal infection was confirmed by potassium hydroxide investigation and fungal culture was performed to identify the type of organism.

RESULTS

One hundred forty four diabetes outpatients were enrolled and 38.9% were men. The mean (±SD) age was 59.6±12.7 years. Fungal infection was diagnosed 46 cases (31.9%). There were 28 cases (61%) with only toenail onychomycosis, two cases (4%) with only fungal foot infection, and 16 cases (35%) with co-infection (fungal foot infection and toenail onychomychosis). The organisms identified as causing fungal foot infection and toenail onychomycosis were dermatophytes (44.4% and 34.1%, respectively), non-dermatophytes (44.5% and 47.7%, respectively), and Candida species (5.6% and 4.5%, respectively). Risk factors found to be significantly correlated with toenail onychomycosis and fungal foot infection were male gender (p = 0.001), age older than 60 years (p = 0.006), agriculture-related activities (p = 0.006), family history of dermatophytosis (p = 0.034), and co-morbidity coronary heart disease (p = 0.044). No significant association was found for BMI, duration of DM, HbA1c, and diabetes related complications.

CONCLUSION

Prevalence of fungal foot and toenail infection in Thai diabetes patient was 31.9%. We found higher prevalence of non-dermatophyte organisms as the cause of dermatomycosis and toenail onychomycosis. Accordingly, clinical diagnosis without proper culture identification may result in treatment failure.

IS NON-TRAUMATIC NAIL DYSTRPOPHY ONLY DUE TO CHRONIC ONYCHOMYCOSIS? THE ONYCHOMATRICOMA. CASE REPORT

Onychomatricoma is a rare benign fibroepithelial tumour that originates from the nail matrix and can affect the nail bed of fingers and toes. Onychomatricoma may represent a premalignant lesion and although the etiology is still not fully understood, a previous finger trauma is considered the main predisposing factor. Unlike previous scientific articles we report a case of a "non traumatic" onychomatricoma in a 60 years old woman underlining the clinical and histological features to distinguish this uncommon lesion from other lesions originating from the nail apparatus.

Implementation of a Pan-Genomic Approach to Investigate Holobiont-Infecting Microbe Interaction: A Case Report of a Leukemic Patient with Invasive Mucormycosis

Disease can be conceptualized as the result of interactions between infecting microbe and holobiont, the combination of a host and its microbial communities. It is likely that genomic variation in the host, infecting microbe, and commensal microbiota are key determinants of infectious disease clinical outcomes. However, until recently, simultaneous, multiomic investigation of infecting microbe and holobiont components has rarely been explored. Herein, we characterized the infecting microbe, host, micro- and mycobiomes leading up to infection onset in a leukemia patient that developed invasive mucormycosis. We discovered that the patient was infected with a strain of the recently described Mucor velutinosus species which we determined was hypervirulent in a Drosophila challenge model and has a predisposition for skin dissemination. After completing the infecting M. velutinosus genome and genomes from four other Mucor species, comparative pathogenomics was performed and assisted in identifying 66 M. velutinosus-specific putatively secreted proteins, including multiple novel secreted aspartyl proteinases which may contribute to the unique clinical presentation of skin dissemination. Whole exome sequencing of the patient revealed multiple non-synonymous polymorphisms in genes critical to control of fungal proliferation, such as TLR6 and PTX3. Moreover, the patient had a non-synonymous polymorphism in the NOD2 gene and a missense mutation in FUT2, which have been linked to microbial dysbiosis and microbiome diversity maintenance during physiologic stress, respectively. In concert with host genetic polymorphism data, the micro- and mycobiome analyses revealed that the infection developed amid a dysbiotic microbiome with low α-diversity, dominated by staphylococci. Additionally, longitudinal mycobiome data showed that M. velutinosus DNA was detectable in oral samples preceding disease onset. Our genome-level study of the host-infecting microbe-commensal triad extends the concept of personalized genomic medicine to the holobiont-infecting microbe interface thereby offering novel opportunities for using synergistic genetic methods to increase understanding of infectious diseases pathogenesis and clinical outcomes.

PseudomonasSurgical-Site Infections Linked to a Healthcare Worker With Onychomycosis

Objective:

To determine the etiology ofPseudomonas aeruginosasurgical-site infections following cardiac surgery.

Setting:

University teaching hospital.

Patients:

Those with wound cultures that grewP. aeruginosaafter cardiac surgery performed from 1999 to 2001.

Methods:

Medical records and operating room (OR) records of patients withP. aeruginosacardiac surgical-site infections from 1999 to 2001 were reviewed. Healthcare workers involved with two or more cases were interviewed and examined. Specimens for environmental cultures were obtained from the ORs and cardiac surgical equipment. Cardiac surgery cases were observed and postoperative care and the cleaning of surgical instruments were investigated. OR air handling system records during the epidemic period were reviewed. Molecular fingerprinting of availableP. aeruginosaisolates from infected patients and a healthcare worker was done.

Results:

There were fiveP. aeruginosacardiac surgical-site infections from January to August 2001, compared with no such infections from 1999 to 2000. All were adult patients. One cardiac surgeon with onychomycosis operated on all five cases. He did not routinely double glove. The involved fingernail grewP. aeruginosa.ThreeP. aeruginosapatient isolates were available for pulsed-field gel electrophoresis; two were identical to the isolate from the involved surgeon's onychomycotic nail. No environmental OR cultures grewP. aeruginosa.The surgeon's culture-positive nail was completely removed. There have been noP. aeruginosasurgical-site infections among cardiac surgery patients since this intervention.

Conclusion:

At least two cases of a cluster ofP. aeruginosasurgical-site infections resulted from colonization of a cardiac surgeon's onychomycotic nail.

[Report of a case of strongyloidiasis with a coinfection by HTLV-1 and onychomycosis]

The infection caused by the human T-cell lymphotropic virus type 1 (HTLV-1) (HTLV-I) has a worldwide distribution. This condition has a worldwide distribution and now it is spreading towards non-endemic areas and it is becoming a public health problem. It is not unusual to see patients with HTLV-1 coinfected with Strongyloides stercoralis and presenting with digestive manifestations, but it is less frequent to find the additional occurrence of other pathogens leading to bacterial infections and multiple onychomycosis. We present the case of a 34-year old man with all those coinfections with peripheral vascular involvement. Some aspects of HTLV-1 pathogenesis are discussed, emphasizing the presence of this virus and the other associated pathogens, and we suggest that tests for determining the presence of HTLV-1 infection may be requested in such cases.

Role of omalizumab in a patient with hyper-IgE syndrome and review dermatologic manifestations

Hyper-IgE syndrome (HIES) is a rare idiopathic primary immunodeficiency. It is characterized by a triad of findings, including high levels of serum IgE, recurrent skin abscesses and pneumonia and leads to pneumatocele formation. The diagnosis of HIES is complicated by a diversity of clinical and immunological spectrums and a heterogeneous set of genetic defects. The National Institute of Health (NIH) developed a scoring system for HIES in which a score greater than 14 indicates a probable diagnosis. Our patient presented with recurrent multiple abscesses on her scalp, recalcitrant eczema, candida onychomycosis, alopecia universalis, and highly elevated levels of serum IgE. Using the NIH scoring system, a 30 total-point score in this patient indicated the likelihood of carrying the HIES genotype. To our knowledge, there are no specific treatments of HIES. The humanized recombinant monoclonal antibody against IgE, subcutaneous omalizumab, was successfully used in this patient.

[Treatment of fungus infection with diabetic foot--importance of the foot care]

Fungus infection is high frequently complicated of the diabetic foot. Especially onychomycosis make a injury neighbor toe skin or paronychia. This tiny lesion make a bacterial infection, and progress to foot gangrene unfortunately if patient delayed treatment. So it is important to do daily check of the foot and regularly foot care included nail care. Toenail onychomycosis need medicational treatment just after microscopically diagnosis. It is important to check the interaction between the antifungal medicine and other medicine, and side effect after started treatment.

Ciclopirox 8% nail lacquer topical solution for the treatment of onychomycosis in patients with diabetes: a multicenter, open-label study

BACKGROUND

An open-label, noncomparative study was conducted to assess the safety and efficacy of ciclopirox 8% nail lacquer topical solution in patients with type 2 diabetes mellitus.

METHODS

Forty-nine diabetic patients with distal subungual onychomycosis were treated once daily for 48 weeks with ciclopirox 8% nail lacquer, a topical nail solution approved for the treatment of patients with mild-to-moderate onychomycosis.

RESULTS

Treatment resulted in clinical improvement in 63.4% of patients. Most patients (85.7%) had a mycologic outcome of improvement or cure, with 54.3% attaining mycologic cure. Consideration of mycologic and clinical outcomes generated a treatment outcome of improvement, success, or cure in 84.4% of patients. Moreover, patients experienced improvement in the diseased area of the nail (63.4%), nail surface (56.1%), nail color (48.8%), and nail thickness (65.9%). Ciclopirox 8% nail lacquer was safe, with treatment-related adverse events limited to infection in one patient, which resolved in 15 days; the patient completed the study. No treatment-related serious adverse events were observed.

CONCLUSION

Ciclopirox 8% nail lacquer is a safe and effective treatment for distal subungual onychomycosis in patients with type 2 diabetes mellitus receiving insulin or oral hypoglycemic therapy.

The prevalance, epidemiology and risk factors for onychomycosis in hemodialysis patients

BACKGROUND

Onychomycosis has a high prevalance among immunocompromised patients such as diabetics and hemodialysis patients. In the present study, we aimed to investigate the prevalence of onychomycosis among hemodialysis patients with and without diabetes mellitus, and to find out the factors likely to be associated with the development of onychomycosis among hemodialysis patients.

METHODS

One hundred and nine hemodialysis patients were enrolled. Fifty-seven of hemodialysis patients had the diagnosis of diabetes mellitus. Nail scrapings were obtained from 76 patients who had dystrophic nail changes. Samples were examined with 20% potassium hydroxide solution and all of the samples were inoculated on Saboraud's dextrose agar, potateus dextrose agar and mycobiotic agar. Diagnosis of onychomycosis was based on the presence of both positive clinical signs and positive potassium hydroxide test.

RESULTS

Onychomycosis was diagnosed in 26.6% of hemodialysis patients. Diabetes mellitus was present in 68.9% of patients with onychomycosis. Toenail scraping cultures were reported to be positive in 19.7% of patients with dystrophic nail changes. Logistic regression analysis revealed that the presence of diabetes mellitus and the mean duration of hemodialysis were the significant predictors associated with the development of onychomycosis.

CONCLUSION

The prevalence of dystrophic nail changes and onychomycosis is increased among hemodialysis patients. The dialysis duration and the presence of diabetes mellitus are the independent risk factors associated with the development of onychomycosis in uraemic patients.

Evaluation of quality of life in patients with toenail onychomycosis by Polish version of an international onychomycosis-specific questionnaire

BACKGROUND

Onychomycosis is the most frequent nail disease, which could impair the patient's quality of life.

OBJECTIVE

The present study was undertaken to evaluate the impact of toenail onychomycosis on quality of life among Polish population.

PATIENTS AND METHODS

Three thousand nine-hundred and four (3904: 2269 females and 1635 males) individuals fulfilled an international onychomycosis-specific quality-of-life questionnaire consisting of statements regarding social, emotional and symptoms problems. All patients had toenail onychomycosis confirmed by the positive direct microscopic examination and/or by the positive mycologic culture. Seven hundred and sixty-seven patients simultaneously had fingernail onychomycosis. All patients were divided into subgroups according to sex, age, education level, place of living, type of onychomycosis, number of involved toenails, fingernails involvement, duration of illness and previously used antimycotic therapy.

RESULTS

Most of the patients demonstrated significantly reduced quality of life. The degree of life impairment varied between analysed subgroups. Patients with more advanced toenail onychomycosis and with fingernail involvement were more seriously affected. Both social and emotional impairments were more pronounced in female than in male patients, although there were no differences according to symptoms. Moreover, patients with better educational level and people living in towns or cities were more emotionally and socially affected by onychomycosis, although people living in the country or with poorer education level presented with significantly more severe symptoms.

CONCLUSIONS

Toenail onychomycosis is still a serious medical problem, which can significantly reduce the patient's quality of life.