Treatment of onychomycosis and tinea pedis with intermittent itraconazole therapy

A 40-year-old woman had a 10-year history of dermatophyte-related toenail onychomycosis (tinea unguium) and dry-type tinea pedis, which had failed to respond to previous therapy with topical antifungal agents or oral griseofulvin. The patient was successfully treated with four cycles of intermittent itraconazole therapy (that is, 400 mg/d for 1 week per month for 4 months). At the end of this time, the tinea pedis had resolved and the onychomycosis improved significantly after four cycles were completed. Twelve months after the onset of therapy, both conditions had resolved completely according to both clinical and mycologic criteria. Itraconazole was well tolerated, with no side effects reported. These observations suggest that itraconazole intermittent dosing is a highly effective therapy for the treatment of onychomycosis caused by dermatophyte organisms, because it provides a high cure rate after only a short course of therapy.

Newer systemic antifungal drugs for the treatment of onychomycosis

Onychomycosis, the infection of the nail unit by any fungus, far from being just a cosmetic problem, has significant psychological, physical, social, and financial implications. Further, it has experienced a dramatic rise in incidence in recent years. The introduction of newer systemic antifungal drugs (itraconazole, fluconazole, and terbinafine) offer an increased cure rate, a broader spectrum of activity, shortening of the treatment period, and increased safety, compared with the traditional systemic antifungal drugs griseofulvin and ketoconazole. Because the fungi involved are difficult to eradicate from the floors of communal bathing facilities, where the infection is often contracted, an effective treatment is likely to have a significant impact on disease prevalence.

Incidence of osteoperiostitis of the great toe in psoriatic arthritis

OBJECTIVE

To assess the incidence of osteoperiostitis of the distal phalanx of the great toe in psoriatic arthritis (PsA).

METHODS

One thousand great toes (202 of PsA, 44 of cutaneous psoriasis, 274 of low back pain patients, 296 of rheumatoid arthritis, 136 of spondyloarthropathy, and 48 of connective tissue diseases) were studied for osteoperiostitis of the distal phalanx of the great toe (slight, moderate, or severe), destructive joint lesions of the feet, nail dystrophy, fungal infection, and HLA-B type (patients with PsA).

RESULTS

Osteoperiostitis was observed in 92 great toes. Moderate and severe osteoperiostitis were observed only in PsA. Osteoperiostitis was statistically more frequent in PsA (53/202, 26.2%, especially in those with onychosis: 20/41, 48.8%) than in other groups (39/798, 4.9%) (p < 0.01). In PsA, osteoperiostitis was more frequent in patients with nail dystrophy (20/41, 48.8%) than in patients without (33/161, 20.5%) (p < 0.05). Fungal infection of the nail and HLA haplotype were not associated with osteoperiostitis. In patients with PsA, osteoperiostitis was associated with destructive joint lesions of the feet.

CONCLUSION

Osteoperiostitis of the distal phalanx of the great toe is an enthesopathy evocative of PsA.

Special patient populations: onychomycosis in the diabetic patient

There are approximately 14 million persons with diabetes in the United States. These patients must cope with the serious complications of this disease, including neuropathy and impaired circulation (leading to the "diabetic foot" and possible amputation), renal disease, cardiovascular disease, and retinopathy (possibly leading to blindness). Although onychomycosis is no more common in diabetics than in the general population, it poses a greater risk because of the possible sequelae. Most notably, impaired sensation can make many diabetics less aware of minor abrasions and ulcerations on their feet that may be caused by trauma from poor nail grooming or by the nail changes characteristic of onychomycosis. These lesions, in turn, may develop into serious bacterial infections and contribute to the severity of the diabetic foot. Thus there is an important clinical rationale for treating diabetic patients with fungal nail infections. A secondary benefit is the improved self-esteem and enhanced quality of life.

Onychomycosis: a significant medical disorder

A number of factors have contributed to the growing incidence of fungal nail infections, including an aging population, an expanding number of immunocompromised patients, and increasing participation in fitness-related activities. Although onychomycosis and other nail diseases can adversely affect the appearance of the nail unit, the impact of such nail disfigurement extends well beyond the aesthetic realm. In fact, many patients with fungal nail infections experience serious physical, psychosocial, and occupational effects as a result of this disease. In addition, onychomycosis is a serious health burden, particularly in older persons, and has a major economic impact on the healthcare system.

Use of terbinafine in HIV-positive subjects: pilot studies in onychomycosis and oral candidiasis

Study 1. Eighteen HIV-positive Caucasian homosexual men with initial positive fungal microscopy were recruited into this prospective, dual-centre, open-label study. They received a once-daily oral dose of 250 mg terbinafine for 12 weeks. Eight were subsequently excluded after screening cultures proved negative. The mean CD4 count of the 10 evaluable subjects was 302/mm3. All 10 positive fungal cultures were confirmed as Trichophyton rubrum. Using an intention-to-treat analysis, healthy unaffected nail growth increased from a mean of 1.6 mm at baseline to 5.2 mm after 12 weeks' treatment. Clinical response after treatment was 6.4 mm at 36 weeks and 8.0 mm at 48 weeks. Three of the 10 toenail infections were cured mycologically. This 30% cure rate was maintained over 48 weeks' follow-up, despite three patients discontinuing the study. One withdrew following a terbinafine-induced drug rash. Two others stopped treatment during HIV-related illnesses, but without terbinafine side-effects. Study 2. Ten HIV-positive subjects, nine culture-positive for Candida albicans and one for Candida albicans and Candida glabrata, were recruited into this pilot study. They received 250 mg oral terbinafine daily for 14 days. Their average CD4 count was 131/mm3. All patients remained culture-positive throughout the study. Slight improvements in signs and symptoms were seen in one or two patients but this might well have been attributable to improved oral hygiene. Oral terbinafine at this dosage was therefore not thought an effective treatment for this indication in HIV-positive patients. The drug was well tolerated and no serious treatment-related adverse events were reported.

Yellow nail syndrome and onychomycosis. Experience with itraconazole pulse therapy combined with vitamin E

We describe the case of a female patient suffering from yellow nail syndrome (YNS) accompanied by bronchial hyperactivity and sinusitis. A dermatophyte onychomycosis was evident on some of her nails. Following treatment of the respiratory pathology and oral administration of vitamin E, there was an improvement in the nails. The improvement of the yellow nails was however more discernible subsequent to the introduction of itraconazole pulse therapy for secondary onychomycosis suggesting an effect of this treatment on ungual growth.

Prevalence of Candida ciferrii in elderly patients with trophic disorders of the legs

In order to define the prevalence of Candida ciferrii in onychomycosis, the fungal biota associated with toe nail onyxis was examined in 50 elderly patients with trophic disorders of the legs and in 220 patients without clinical evidence of trophic disorders. Candida ciferrii was more frequent in the first group of patients since it was recovered from 24% of these patients, whereas its prevalence was only 1.4% in the control group. Moreover, the positivity of the direct examination of toe nail scrapings, the absence of any other associated pathogens, and the repeated isolation of this yeast species for some of the patients confirmed its pathogenicity.

Atopy and reaction to nail dust inhalation

Inhalation of nail dust is a chronic problem facing podiatric physicians. This problem is compounded in physicians who develop allergic reactions to nail dust. This article defines atopy, reviews the characteristics of nail dust, and suggests methods to reduce the potential hazard that nail dust presents to the podiatric physicians and their employees.

[Effects of fluconazole on onychomycosis in the patients with collagen diseases]

Thirty-four patients with collagen diseases suffering from onychomycosis were treated with fluconazole and showed remarkable improvement. Thirty-one patients showed improvement while only four patients showed adverse reactions. More than half of the cases with onychomycosis in their fingers showed improvement within four weeks and complete recovery within 20 weeks after the administration of fluconazole. Patients with collagen diseases are liable to have onychomycosis as an opportunistic infection which is recalcitrant and resistant disease from the previous therapy. In this trial it became obvious that fluconazole was not only effective on onychomycosis but also a safe drug for the patients with collagen diseases.

Management of common superficial fungal infections in patients with AIDS

Cutaneous fungal infections are a major source of morbidity in HIV-infected patients, and their management poses special challenges. Superficial mycoses, such as tinea pedis, tinea cruris, tinea corporis, and onychomycosis, are no more common in HIV-infected patients than in the HIV-negative population but are of greater severity. Although they respond to topical and systemic antifungal agents, HIV-positive patients are predisposed to frequent recurrences. Unusual types of fungal infections such as Majocchi's granuloma are more likely to develop in HIV-infected patients and respond best to systemic antifungal therapy with imidazoles or triazoles. Infections with Candida albicans develop in virtually all HIV-positive patients. Although mucosal involvement is the most common, patients may also develop superficial cutaneous infections. Topical agents are frequently all that is necessary, but in some, oral medications are required. Although fluconazole is effective, an appreciable number of isolates are resistant. Patients with pityriasis versicolor and seborrheic dermatitis, in which Pityrosporum species are thought to be involved, respond well to short courses of oral ketoconazole. Milder forms of seborrheic dermatitis can also be treated with low-potency topical steroids or topical ketoconazole. The oral triazole fluconazole is not particularly effective in the management of seborrheic dermatitis. Although the cause of eosinophilic pustular folliculitis, a common disorder in immunosuppressed HIV-positive patients, is unknown, some can be cured with high doses of itraconazole, suggesting that fungi are important in the pathogenesis of the disease in some patients.

Common superficial fungal infections in immunosuppressed patients

HIV-positive patients and those persons immunosuppressed as a result of other diseases or chemotherapy are especially susceptible to mycotic infections. The superficial fungal infections seen most often in patients with HIV infection include seborrheic dermatitis, various dermatophyte infections, candidiasis, and onychomycosis. Uncommonly, systemic fungal infections, such as candidiasis, histoplasmosis, cryptococcosis, and coccidioidomycosis, may disseminate to the skin, producing a wide variety of cutaneous lesions. All cutaneous lesions in these patients should be biopsied and cultured if any question exists regarding the diagnosis. The diagnosis of superficial and deep mycotic infections in HIV-positive patients can be particularly difficult because the clinical presentation varies greatly and is often atypical.

Oral candidiasis and multiple myeloma. An unusual association

A case of oral candidiasis possibly associated with multiple myeloma is presented. A review of the literature and a pertinent discussion relevant to this unusual association are offered.

Penicillium species causing onychomycosis

Onychomycosis caused by mould infection is rare. A 40 year old male patient presented with dystrophic finger nails and multiple, erythematous lesions with slightly raised borders and scaling all over the body. The patient was a known diabetic. He did not respond to griseofulvin. Samples from nails and skin scales were cultured. From the nails, Penicillium species and from the skin scales. Trichophyton rubrum were isolated. Ketoconazole therapy (200 mg twice daily x 4 mths) led to complete cure with negative cultures and normalization of nails.

Onychomycosis is more than a cosmetic problem

The nails serve several important functions and, when they are infected by fungal organisms, these functions are severely impaired. In addition, the quality of life, in terms of self-esteem and social interaction, is adversely affected when fungal nail infections are present. Finally, when finger and/or toenails are abnormal this may interfere with patients' occupations.

The spectrum of HIV related skin diseases in an Irish population

A prospective study was carried out between January 1988 and January 1990 in St. James's hospital, Dublin, which is the chief referral centre for the HIV population in Ireland. Patients were routinely referred from the genitourinary medicine department to the dermatology clinic for a full dermatological assessment which was carried out by one physician (LB). The patients were not preselected on the basis of a skin complaint. The study aimed to detect the prevalence of skin disease amongst this HIV group of patients and to compare them with an age and sex matched group of normal controls. There were 92 patients in each group, with 62 intravenous drug users (IVDU), 21 homosexuals, eight haemophiliacs and one heterosexual in the HIV positive group. A wide spectrum of skin disorders were seen, with a significantly higher prevalence of seborrhoeic dermatitis, xerosis, Kaposi's sarcoma, oral candidiasis, folliculitis, molluscum contagiosum, onychomycosis, gingivitis, perianal herpes simplex and genital/perianal warts in the HIV positive group compared to controls.

Relapsing severe Trichophyton rubrum infections in an immunocompromised host: evidence of onychomycosis as a source of reinfection based on lectin typing

A 64-year-old patient developed recurrent (about 3-6 times a year) generalized skin lesions due to Trichophyton rubrum during long-term steroid treatment of lung fibrosis. Additionally, he suffered for years from onychomycosis of all toes. In the past, short-term internal treatment with griseofulvin and ketoconazole resulted in fast clearing of skin symptoms. Since 1991 relapses have been treated with itraconazole orally. In 1992 material was collected from diseased nails and toe and other skin lesions during three severe attacks of fungal infections and in addition once from toenails during a period without skin manifestations. Trichophyton rubrum was isolated from each sample. Lectin typing of the isolates using five lectins of plant origin resulted in identical lectin patterns for all isolates, thus localizing the toenails as the source of reinfection. The results indicate that lectin typing may play an important role in clinical and epidemiological analysis of dermatophytes.

Atopic dermatitis associated with dermatophyte infection and Trichophyton hypersensitivity

An atopic patient with tinea unguium, immediate hypersensitivity to Trichophyton, and elevated specific IgE antibody to Trichophyton had recalcitrant hand and foot eczema that resolved following the administration of systemic antifungal therapy for her tinea unguium. The patient fulfills criteria for the atopic-chronic-dermatophytosis syndrome described by Jones. The authors suggest that the patient's atopic dermatitis may have been exacerbated by her chronic dermatophyte infection and Trichophyton hypersensitivity.

Scytalidium hyalinum isolated from the toe nail of an Australian patient

The isolation of Scytalidium hyalinum from the toe nail of a patient from Melbourne is reported. This is the first record of the isolation of this fungus from a clinical site in Australia. A brief history is given of the occurrence of Scytalidium hyalinum and the related fungus, Hendersonula toruloidea, in tinea pedis and tinea unguium in immigrants to the United Kingdom from tropical countries. Attention is drawn to the possible presence of these dermatophyte-like infections in patients in Australia.

Onychomycosis and AIDS. Clinical and laboratory findings in 62 patients

The results of a study on onychomycosis in AIDS related complex and AIDS patients presenting for dermatology consultation at an infectious diseases department are reported. The clinical results showed that most patients presented a proximal white superficial onychomycosis. The association with a clinical interdigital involvement was rare, but the association with a mycotic plantar keratoderma was more frequent. The laboratory results showed that dermatophytes were the most frequent etiologic agents, especially Trichophyton rubrum (58%). Although most of these patients presented an oral candidiasis, Candida albicans was isolated only in seven patients' nails. Surprisingly, Pityrosporum ovale was the only etiologic organism that was found in two patients. This result was confirmed with a histologic examination.