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Cook AC, Cohen NE, Patel R, South S, Ballantyne MC. A Systematic Review and Meta-Analysis of Human Leukocyte Antigen-DR (HLA-DR) in Onychomycosis: HLA-DR8 Confers Susceptibility. Cureus 2024; 16:e69162. [PMID: 39398739 PMCID: PMC11469661 DOI: 10.7759/cureus.69162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Accepted: 09/10/2024] [Indexed: 10/15/2024] Open
Abstract
Onychomycosis (OM) is a nail infection from various fungal species, representing a worldwide dermatologic health concern. The toenails are most often affected. Comorbid chronic health conditions and environmental and genetic factors play a role in the development of OM. It has been observed that certain populations have an increased risk of developing OM, suggesting an inherited component to its etiology. Recent studies have observed the impact of the human leukocyte antigen-DR (HLA-DR) profile on the likelihood of developing OM; however, none have aggregated these studies for a meta-analysis to determine a statistical effect. The literature was systematically reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to determine the effect of the HLA-DR profile on OM susceptibility. Studies that contained HLA-DR allele frequency data on patients with OM were included. Studies that contained too much allele frequency data, did not contain HLA-DR allele frequency data, or were written in a non-English language were excluded. Google Scholar, PubMed, and Scientific Direct databases were searched. The risk of bias was assessed by using the National Institutes of Health (NIH) quality assessment case-control study tool. The results were generated using Review Manager version 5.4 by extracting and inputting HLA-DR allele frequency data into the program. The program created aggregated odds ratios that were visually represented in forest plots. A total of five articles were included in the analysis. One hundred fifty-six patients with OM were used in this analysis. Mexican mestizos and United States Caucasian populations were represented in this study. Overall, the NIH risk of bias tool revealed that most studies included did not justify their sample size, or the assessors were not blinded. Of all the HLA-DR alleles analyzed, only HLA-DR8 revealed a statistically significant result with an odds ratio of 1.70 with a 95% CI (1.05-2.76). This suggests that HLA-DR8 confers a 70% higher risk of susceptibility to OM. This finding can help identify these target populations and serve as the basis for personalized treatment solutions.
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Affiliation(s)
- Andrew C Cook
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine - Bradenton, Bradenton, USA
| | - Nathan E Cohen
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine - Bradenton, Bradenton, USA
| | - Rishi Patel
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine - Bradenton, Bradenton, USA
| | - Shannon South
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine - Bradenton, Bradenton, USA
| | - Marcia C Ballantyne
- Pathology, Lake Erie College of Osteopathic Medicine - Bradenton, Bradenton, USA
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Gupta AK, Wang T, Polla Ravi S, Mann A, Bamimore MA. Global prevalence of onychomycosis in general and special populations: An updated perspective. Mycoses 2024; 67:e13725. [PMID: 38606891 DOI: 10.1111/myc.13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge. OBJECTIVE To provide an updated estimate on the prevalence of toenail onychomycosis. METHODS We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients. RESULTS A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture. CONCLUSION Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | - Tong Wang
- Mediprobe Research Inc., London, Ontario, Canada
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Ouyang J, Yan J, Zhou X, Isnard S, Tang S, Costiniuk CT, Chen Y, Routy JP, Chen Y. The Influence of Oral Terbinafine on Gut Fungal Microbiome Composition and Microbial Translocation in People Living with HIV Treated for Onychomycosis. J Fungi (Basel) 2023; 9:963. [PMID: 37888218 PMCID: PMC10607585 DOI: 10.3390/jof9100963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023] Open
Abstract
People living with HIV (PLWH) display altered gut epithelium that allows for the translocation of microbial products, contributing to systemic immune activation. Although there are numerous studies which examine the gut bacterial microbiome in PLWH, few studies describing the fungal microbiome, or the mycobiome, have been reported. Like the gut bacterial microbiome, the fungal microbiome and its by-products play a role in maintaining the body's homeostasis and modulating immune function. We conducted a prospective study to assess the effects of oral terbinafine, an antifungal agent widely used against onychomycosis, on gut permeability and microbiome composition in ART-treated PLWH (trial registration: ChiCTR2100043617). Twenty participants completed all follow-up visits. During terbinafine treatment, the levels of the intestinal fatty acid binding protein (I-FABP) significantly increased, and the levels of interleukin-6 (IL-6) significantly decreased, from baseline to week 12. Both markers subsequently returned to pre-treatment levels after terbinafine discontinuation. After terbinafine treatment, the abundance of fungi decreased significantly, while the abundance of the bacteria did not change. After terbinafine discontinuation, the abundance of fungi returned to the levels observed pre-treatment. Moreover, terbinafine treatment induced only minor changes in the composition of the gut bacterial and fungal microbiome. In summary, oral terbinafine decreases fungal microbiome abundance while only slightly influencing gut permeability and microbial translocation in ART-treated PLWH. This study's findings should be validated in larger and more diverse studies of ART-treated PLWH; our estimates of effect size can be used to inform optimal sample sizes for future studies.
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Affiliation(s)
- Jing Ouyang
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing 400036, China; (J.O.); (Y.C.)
| | - Jiangyu Yan
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China; (J.Y.); (S.T.)
| | - Xin Zhou
- Department of Pharmacy, Chongqing Public Health Medical Center, Chongqing 400036, China;
| | - Stéphane Isnard
- Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC H4A 3J1, Canada; (S.I.); (C.T.C.)
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Shengquan Tang
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China; (J.Y.); (S.T.)
| | - Cecilia T. Costiniuk
- Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC H4A 3J1, Canada; (S.I.); (C.T.C.)
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Yaling Chen
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing 400036, China; (J.O.); (Y.C.)
| | - Jean-Pierre Routy
- Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC H4A 3J1, Canada; (S.I.); (C.T.C.)
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Division of Hematology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Yaokai Chen
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China; (J.Y.); (S.T.)
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Albucker SJ, Falotico JM, Choo ZN, Matushansky JT, Lipner SR. Risk Factors and Treatment Trends for Onychomycosis: A Case-Control Study of Onychomycosis Patients in the All of Us Research Program. J Fungi (Basel) 2023; 9:712. [PMID: 37504701 PMCID: PMC10381528 DOI: 10.3390/jof9070712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Introda significant: Onychomycosis is the most common nail disorder seen in clinical practice, and it may have significant impact on patient quality of life. Understanding risk factors for onychomycosis may help to devise screening and treatment guidelines for populations that are more susceptible to this infection. Using a national database, we aimed to explore associations between onychomycosis and age, sex, and underlying medical conditions, as well as to examine current onychomycosis treatment trends. Materials and Methods: We performed a nested, matched, case-control study of patients in the All of Us database aged ≥ 18 years (6 May 2018-1 January 2022). Onychomycosis cases were identified using International Classification of Diseases (ICD) and Systematized Nomenclature of Medicine (SNOMED) diagnostic codes (ICD-9 110.1, ICD-10 B35.1, SNOMED 414941008). Demographic information (i.e., age, sex, and race), treatments, and co-diagnoses for onychomycosis patients and case-controls were recorded. Wald's test applied to multivariate logistic regression was used to calculate odds ratios and p-values between onychomycosis and co-diagnoses. Additionally, 95% confidence intervals were calculated with a proportion test. Results: We included 15,760 onychomycosis patients and 47,280 matched controls. The mean age of onychomycosis patients was 64.9 years, with 54.2% female, 52.8% Non-Hispanic White, 23.0% Black, 17.8% Hispanic, and 6.3% other, which was similar to controls. Patients with onychomycosis vs. controls were more likely to have a co-diagnosis of obesity (46.4%, OR 2.59 [2.49-2.69]), tinea pedis (21.5%, OR 10.9 [10.1-11.6]), peripheral vascular disease (PVD) (14.4%, OR 3.04 [2.86-3.24]), venous insufficiency (13.4%, OR 3.38 [3.15-3.59]), venous varices (5.6%, OR 2.71 [2.47-2.97]), diabetes mellitus (5.6%, OR 3.28 [2.98-3.61]), and human immunodeficiency virus (HIV) (3.5%, OR 1.8 [1.61-2.00]) (p < 0.05, all). The most frequently prescribed oral and topical medications were terbinafine (20.9%) and ciclopirox (12.4%), respectively. The most common therapeutic procedure performed was debridement (19.3%). Over the study period, ciclopirox prescriptions (Spearman correlation 0.182, p = 0.0361) and fluconazole prescriptions increased (Spearman correlation 0.665, p = 2.44 × 10-4), and griseofulvin (Spearman correlation -0.557, p = 0.0131) and itraconazole prescriptions decreased (Spearman correlation -0.681, p = 3.32 × 10-6). Conclusions: Our study demonstrated that age, obesity, tinea pedis, PVD, venous insufficiency, diabetes mellitus, and HIV were significant risk factors for onychomycosis. In addition, the most frequent oral and topical onychomycosis medications prescribed were terbinafine and ciclopirox, likely reflective of efficacy and cost considerations. Identifying and managing these risk factors is essential to preventing onychomycosis' primary infections and recurrences and improving treatment efficacy.
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Affiliation(s)
| | - Julianne M Falotico
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, USA
| | - Zi-Ning Choo
- Weill Cornell Medical College, New York, NY 10021, USA
| | | | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY 10021, USA
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Maskan Bermudez N, Rodríguez-Tamez G, Perez S, Tosti A. Onychomycosis: Old and New. J Fungi (Basel) 2023; 9:jof9050559. [PMID: 37233270 DOI: 10.3390/jof9050559] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
Onychomycosis is a common chronic fungal infection of the nail that causes discoloration and/or thickening of the nail plate. Oral agents are generally preferred, except in the case of mild toenail infection limited to the distal nail plate. Terbinafine and itraconazole are the only approved oral therapies, and fluconazole is commonly utilized off-label. Cure rates with these therapies are limited, and resistance to terbinafine is starting to develop worldwide. In this review, we aim to review current oral treatment options for onychomycosis, as well as novel oral drugs that may have promising results in the treatment of onychomycosis.
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Affiliation(s)
- Narges Maskan Bermudez
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33125, USA
| | - Giselle Rodríguez-Tamez
- Dermatology Department, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey 64460, Mexico
| | - Sofia Perez
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33125, USA
| | - Antonella Tosti
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33125, USA
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Antifungal Nail Lacquer for Enhanced Transungual Delivery of Econazole Nitrate. Pharmaceutics 2022; 14:pharmaceutics14102204. [PMID: 36297639 PMCID: PMC9607990 DOI: 10.3390/pharmaceutics14102204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
The fungal disease of the nail, onychomycosis, which is also the most prevalent nail disturbance, demands effective topical treatment options considering the possible adverse effects of systemic antifungal therapy. The current work is focused on development of an adhesive and resistant, drug-delivering and permeation-enhancing polymeric film containing econazole nitrate (ECN) for topical antifungal treatment. The development of the lacquer formulation was guided by the Quality by Design approach to achieve the critical quality attributes needed to obtain the product of desired quality. Eudragit RSPO at 10% w/w was found to be the ideal adhesive polymer for the application and an optimal permeation-enhancing lacquer formulation was achieved by the optimization of other formulation excipients, such as plasticizer and the solvent system. Additionally, novel experimental enhancements introduced to the research included refined D50 drying time and drying rate tests for lacquer characterization as well as a multi-mechanism permeation-enhancing pre-treatment. Moreover, a practical implication was provided by a handwashing simulation designed to test the performance of the lacquer during actual use. In vitro drug release testing and ex vivo nail permeation testing demonstrated that the optimized nail lacquer performed better than control lacquer lacking the permeation enhancer by achieving a faster and sustained delivery of ECN. It can be concluded that this is a promising drug delivery system for topical antifungal treatment of onychomycotic nails, and the novel characterization techniques may be adapted for similar formulations in the future.
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Trovato L, Domina M, Calvo M, De Pasquale R, Scalia G, Oliveri S. Use of Real Time Multiplex PCR for the diagnosis of dermatophytes onychomycosis in patients with empirical antifungal treatments. J Infect Public Health 2022; 15:539-544. [DOI: 10.1016/j.jiph.2022.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/12/2022] [Accepted: 03/31/2022] [Indexed: 12/22/2022] Open
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Castro LÁ, Álvarez MI. Nail dermatophytoma in HIV-infected patients in Cali, Colombia. J Mycol Med 2021; 31:101172. [PMID: 34247063 DOI: 10.1016/j.mycmed.2021.101172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A dermatophytoma is a mass of hyphae that is observed at direct examination, it responds poorly to treatment with antifungal drugs, some authors have proposed that it is actually a biofilm. This pathology is underdiagnosed, and its true incidence is unknown. OBJECTIVES This study presents the clinical findings of dermatophytoma in HIV/AIDS patients from Colombia presenting onychomycosis. MATERIAL AND METHODS A transversal observational descriptive study was carried out in a third level university hospital. One hundred thirty HIV positive patients diagnosed using ELISA and Western Blot that presented nail lesions on their hands and/or feet compatible with onychomycosis were included. Samples taken from affected nails were observed in direct examination with KOH and seeded onto Sabouraud agar, mycosel agar and dextrose-potato agar. Molds were identified based on macroscopic and microscopic characteristics. RESULTS Six (4.6%) individuals presented dermatophytoma. Average age was 43 years (range 33-50); nails more commonly affected (5/6) were on the toes, principally the hallux. Clinical manifestations included a yellow or white, rounded or linear dense area on the nail. Superficial white onychomycosis was present in 83.3% of the patients. Fungal cultures were obtained in only 5 patients; Trichophyton mentagrophytes complex was found in 2 individuals while T. rubrum, T. tonsurans and Epidermophyton floccosum were in the other 3. Average cell count for CD4+T lymphocytes was 86.8 cells/mm3 (range 9-282). CONCLUSIONS This is the first report in Colombia of dermatophytoma in HIV/AIDS patients, most of them had a CD4+ T lymphocytes count less than 200 cells/mm3. Several clinical forms of onychomycosis were observed, the most frequent was the white superficial onychomycosis.
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Affiliation(s)
- Luz Ángela Castro
- School of Bacteriology and Clinical Laboratory, Faculty of Health, Universidad del Valle, Cali, Colombia.
| | - María Inés Álvarez
- School of Basic Sciences, Department of Microbiology, Faculty of Health, Universidad del Valle, Cali, Colombia.
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Khosravi AR, Shokri H, Saffarian Z. Anti-fungal activity of some native essential oils against emerging multi-drug resistant human nondermatophytic moulds. J Herb Med 2020. [DOI: 10.1016/j.hermed.2020.100370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gupta A, Stec N, Summerbell R, Shear N, Piguet V, Tosti A, Piraccini B. Onychomycosis: a review. J Eur Acad Dermatol Venereol 2020; 34:1972-1990. [DOI: 10.1111/jdv.16394] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 01/25/2023]
Affiliation(s)
- A.K. Gupta
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Mediprobe Research Inc. London ON Canada
| | - N. Stec
- Mediprobe Research Inc. London ON Canada
| | - R.C. Summerbell
- Sporometrics Toronto ON Canada
- Dalla Lana School of Public Health University of Toronto Toronto ON Canada
| | - N.H. Shear
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Division of Dermatology Sunnybrook Health Sciences Centre Toronto ON Canada
| | - V. Piguet
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Division of Dermatology Women's College Hospital Toronto ON Canada
| | - A. Tosti
- Department of Dermatology and Cutaneous Surgery Leonard Miller School of Medicine University of Miami Miami FL USA
| | - B.M. Piraccini
- Dermatology Unit Department of Experimental, Diagnostic and Specialty Medicine University of Bologna Bologna Italy
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Validated 60-Second General Foot Screen: A Pilot Trial and Guide to Diagnoses and Treatment. Adv Skin Wound Care 2020; 32:490-501. [PMID: 31625965 DOI: 10.1097/01.asw.0000582624.75772.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
GENERAL PURPOSE To provide information on a 60-second General Foot Screen to assist in the prevention and/or identification and management of common foot problems. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant should be better able to:1. Use the 60-second General Foot Screen to assist healthcare professionals in the recognition of common foot problems.2. Identify risk factors, causes, and treatment of selected foot problems. ABSTRACT Foot health is important to overall patient health. Early diagnosis and treatment of diabetes, neuropathy, fungal foot infections, foot deformity, and vascular disease/lower leg edema can improve patient quality of life. One way to achieve this is effective screening. To this end, researchers piloted a validated 10-item screening tool to assess foot health on 120 patients; 74.17% had at least one positive abnormality, demonstrating the critical importance of these early findings. Only 25.83% of individuals had completely low-risk feet. This easy-to-use tool can assist healthcare professionals in the recognition and treatment of common foot problems. The article also outlines the early signs of disease by screening item and provides a guide to treatment to enable effective prevention and quality care.
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Foley K, Gupta AK, Versteeg S, Mays R, Villanueva E, John D. Topical and device-based treatments for fungal infections of the toenails. Cochrane Database Syst Rev 2020; 1:CD012093. [PMID: 31978269 PMCID: PMC6984586 DOI: 10.1002/14651858.cd012093.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails. OBJECTIVES To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis. SEARCH METHODS We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials. SELECTION CRITERIA Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events. MAIN RESULTS We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment. AUTHORS' CONCLUSIONS Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.
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Affiliation(s)
- Kelly Foley
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Aditya K Gupta
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Sarah Versteeg
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Rachel Mays
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Elmer Villanueva
- Xi'an Jiaotong‐Liverpool UniversityDepartment of Public Health111 Ren'ai Road, Dushu Lake Higher Education TownSuzhou Industrial ParkSuzhouJiangsuChina
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14
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Gupta AK, Stec N, Bamimore MA, Foley KA, Shear NH, Piguet V. The efficacy and safety of pulse vs. continuous therapy for dermatophyte toenail onychomycosis. J Eur Acad Dermatol Venereol 2019; 34:580-588. [PMID: 31746067 DOI: 10.1111/jdv.16101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Onychomycosis is a chronic, fungal infection of the nails. Complete cure remains challenging, but oral antifungal medications have been successful in managing the fungus for a significant proportion of patients. Treatment with these drugs can be continuous or intermittent, albeit the evidence on their relative efficacies remains unclear. OBJECTIVE To determine the relative effectiveness and safety of pulse versus continuous administration, of three common oral therapies for dermatophyte onychomycosis, by conducting multiple-treatment meta-analysis. METHODS This systematic review and network meta-analysis compared the efficacy (as per mycological cure) and adverse event rates of three oral antifungal medications in the treatment of dermatophyte toenail onychomycosis, namely terbinafine, itraconazole and fluconazole. A total of 30 studies were included in the systematic review, while 22 were included in the network meta-analysis. RESULTS The likelihood of mycological cure was not significantly different between continuous and pulse regimens for each of terbinafine and itraconazole. Use of continuous terbinafine for 24 weeks - but not 12 weeks - was significantly more likely to result in mycological cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9-12 months. Rank probabilities demonstrated that 24-week continuous treatment of terbinafine was the most effective. There were no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole and fluconazole. Drug treatments were similar to placebo in terms of their likelihood of producing adverse events. CONCLUSION More knowledge about the fungal life cycle and drugs' pharmacokinetics in nail and plasma could further explain the relative efficacy and safety of the pulse and continuous treatment regimens. Our results indicate that in the treatment of dermatophyte toenail onychomycosis, the continuous and pulse regimens for terbinafine and itraconazole have similar efficacies and rates of adverse events.
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Affiliation(s)
- A K Gupta
- Mediprobe Research Inc., London, ON, Canada
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
| | - N Stec
- Mediprobe Research Inc., London, ON, Canada
| | | | - K A Foley
- Mediprobe Research Inc., London, ON, Canada
| | - N H Shear
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - V Piguet
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
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15
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Borgohain P, Barua P, Dutta PJ, Shaw D, Rudramurthy SM. Onychomycosis Associated with Superficial Skin Infection Due to Aspergillus sydowii in an Immunocompromised Patient. Mycopathologia 2019; 184:683-689. [PMID: 31502093 DOI: 10.1007/s11046-019-00383-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
Abstract
Opportunistic fungal infections of the skin and nail are frequently encountered in human. Recent years have shown increased incidence of fungal infections especially in immunocompromised patients. Onychomycosis in HIV-infected patients is reported to occur in 15-40%, four times more than in the general population. Here, we report a case of fingernail proximal subungual onychomycosis with associated skin infection caused by an opportunistic mold, Aspergillus sydowii, in a HIV positive individual. Isolation of A. sydowii from nail and skin of an immunocompromised person needs accurate identification for successful treatment.
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Affiliation(s)
- Parismita Borgohain
- Department of Microbiology, Jorhat Medical College, Jorhat, Assam, 785001, India
| | - Purnima Barua
- Department of Microbiology, Jorhat Medical College, Jorhat, Assam, 785001, India.
| | - Pranjal Jyoti Dutta
- Department of Dermatology, Jorhat Medical College, Jorhat, Assam, 785001, India
| | - Dipika Shaw
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Onychomycosis is the most common affliction of the nail. It may be caused by dermatophytes, yeasts, and non-dermatophyte molds. Traditionally, oral antifungal treatments have been used to treat the fungus, although they can be accompanied by side effects and drug interactions. Topical treatments provide an alternative modality, bypassing the systemic effects of oral drugs; recent research has centered on topical drug improvement and development. Physical and laser treatments are being used in conjunction with topicals, which may help penetrate the thick nail plate. In this review, techniques from all categories are outlined: both novel experimental approaches and progress and effectiveness of recently developed treatments. More long-term studies are required to determine the efficacy of various treatments, but cure rates are improved when patients adhere to treatments and follow preventative measures to avoid disease recurrence.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Canada.,Mediprobe Research Inc., London, Ontario, Canada
| | - Nadia Stec
- Mediprobe Research Inc., London, Ontario, Canada
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17
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Brown SJ. Pharmacy Technicians and Improving Onychomycosis Treatment Outcomes. J Pharm Technol 2019; 35:82-87. [PMID: 34860989 DOI: 10.1177/8755122518815057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To provide an overview of onychomycosis and current treatments and to identify opportunities for pharmacy technicians to improve treatment outcomes. Data Sources: A MEDLINE/PubMed search (1966 to October 2018) was performed using search terms designed to identify English-language articles on onychomycosis diagnosis, treatment, and prevention, as well as articles on the impact of pharmacy technicians on onychomycosis outcomes and the use of pharmacy technicians to improve treatment adherence. Study Selection and Data Extraction: Review articles and clinical studies describing onychomycosis, risk factors, treatment efficacy, and prevention of recurrent infections were included. Data Synthesis: Although no articles on the impact of pharmacy technicians in the treatment of onychomycosis were found, the importance of treatment adherence on positive outcomes highlights a potential role of pharmacy technicians. Pharmacy technicians can identify patients with potential onychomycosis based on questions about over-the-counter products and refer patients to the pharmacist for counseling on treatment. Pharmacy technicians can also reinforce treatment adherence at refill visits. Conclusions: Pharmacy technicians can have a positive impact on onychomycosis treatment outcomes by addressing barriers to successful treatment and promoting treatment adherence.
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18
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Lipner SR, Scher RK. Onychomycosis. J Am Acad Dermatol 2019; 80:835-851. [DOI: 10.1016/j.jaad.2018.03.062] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 02/03/2023]
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19
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Heinen MP, Cambier L, Antoine N, Gabriel A, Gillet L, Bureau F, Mignon B. Th1 and Th17 Immune Responses Act Complementarily to Optimally Control Superficial Dermatophytosis. J Invest Dermatol 2019; 139:626-637. [DOI: 10.1016/j.jid.2018.07.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/09/2018] [Accepted: 07/27/2018] [Indexed: 01/14/2023]
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20
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A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level. Am J Clin Dermatol 2019; 20:123-133. [PMID: 30456537 DOI: 10.1007/s40257-018-0403-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Onychomycosis is a fungal nail infection caused by dermatophytes, non-dermatophyte molds, and yeasts. Treatment of this infection can be difficult, with relapse likely to occur within 2.5 years of cure. The objective of this article is to review factors that can impact cure and to suggest practical techniques that physicians can use to maximize cure rates. Co-morbidities, as well as disease severity and duration, are among the many patient factors that could influence the efficacy of antifungal therapies. Furthermore, organism, treatment, and environmental factors that may hinder cure include point mutations, biofilms, affinity for non-target enzymes, and exposure to fungal reservoirs. To address patient-related factors, physicians are encouraged to conduct confirmatory testing and treat co-morbidities such as tinea pedis early and completely. To combat organism-focused factors, it is recommended that disruption of biofilms is considered, and drugs with multiple routes of delivery and unique mechanisms of action are prescribed when traditional agents are not effective. Extending follow-up periods, using combination treatments, and considering pulse regimens may also be of benefit. Through these practical techniques, physicians can maximize cure and limit the risk of relapse and re-infection.
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21
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Gupta AK, Mays RR, Versteeg SG, Piraccini BM, Takwale A, Shemer A, Babaev M, Grover C, Di Chiacchio NG, Taborda PRO, Taborda VBA, Shear NH, Piguet V, Tosti A. Global perspectives for the management of onychomycosis. Int J Dermatol 2018; 58:1118-1129. [PMID: 30585300 DOI: 10.1111/ijd.14346] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/24/2018] [Accepted: 11/24/2018] [Indexed: 12/18/2022]
Abstract
Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophyte molds, and yeasts. This difficult-to-treat chronic infection has a tendency to relapse despite treatment. This paper aims to offer a global perspective on onychomycosis management from expert physicians from around the world. Overall, the majority of experts surveyed used systemic, topical, and combination treatments approved in their countries and monitored patients based on the product insert or government recommendations. Although the basics of treating onychomycosis were similar between countries, slight differences in onychomycosis management between countries were found. These differences were mainly due to different approaches to adjunctive therapy, rating the severity of disease and use of prophylaxis treatment. A global perspective on the treatment of onychomycosis provides a framework of success for the committed clinician with appreciation of how onychomycosis is managed worldwide.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Incorporated, London, Canada.,Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
| | | | | | - Bianca Maria Piraccini
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Anita Takwale
- Gloucestershire Royal Hospital, Gloucester, United Kingdom
| | - Avner Shemer
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Meir Babaev
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Chander Grover
- Division of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Nilton G Di Chiacchio
- Dermatology Clinic, Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil
| | - Paulo R O Taborda
- Division of Dermatology, Faculdade de Medicina do ABC, Santo André, Brazil
| | | | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Dermatology, Women's College Hospital, Toronto, Canada.,Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Antonella Tosti
- Fredric Brandt Endowed Professor of Dermatology, University of Miami, Miami, FL, USA
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22
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Antimycotic activity of zinc oxide decorated with silver nanoparticles against Trichophyton mentagrophytes. POWDER TECHNOL 2018. [DOI: 10.1016/j.powtec.2018.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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23
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Ali SY, Gajjala SR, Raj A. Study of prevalence of dermatophytes among human immunodeficiency virus/AIDS patients in Shadan Institute of Medical Sciences and Teaching Hospital and Research Centre, Hyderabad, Telangana, India. Indian J Sex Transm Dis AIDS 2018; 39:98-101. [PMID: 30623179 PMCID: PMC6298157 DOI: 10.4103/ijstd.ijstd_103_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: The objective of the study was to evaluate the prevalence of dermatophytoses in human immunodeficiency virus (HIV) patients as well as to analyze the influence of CD4+ T-cell level in the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state). The patients were tested for dermatophytic infections, as well as for the CD4+ T-cell counts. A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. A majority of patients were in the 21–30 years’ age group. Tinea cruris was seen in majority of the cases, with Trichophyton rubrum being the most common culprit. Background: Cutaneous fungal infections have been reported worldwide as being one of the most common human infectious diseases in clinical practice. Dermatophytoses in individuals with HIV infection seem to manifest with atypical, multiple, or extensive lesions more frequently. Aims: The aim of this study was to determine the prevalence of dermatophytic infections among HIV-seropositive patients and their relation with CD4 count. Materials and Methods: This single-center prospective study was conducted in all HIV-seropositive patients (by double ELISA methods) who attended the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state), from March 2015 to September 2016. They were screened for cutaneous fungal infections and those who tested positive were recruited for this study. Results: A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. Most patients were in the 21–30 years’ age group. Tinea cruris was the most common variant, and T. rubrum was the most common offending pathogen. It was also found that the CD4+ T-cell count does not influence the occurrence of dermatophytoses. Conclusion: Superficial fungal infections are a common yet significant problem in HIV infection. They are characterized by the diversity of clinical aspects; the lesions are mostly caused by T. rubrum. It is essential that optimum treatment should be administered.
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Affiliation(s)
- Syed Yousuf Ali
- Department of Dermatology and STD, Shadan Institute of Medical Sciences, Teaching Hospital and Research Centre, Post Graduate Institute, Hyderabad, Telangana, India
| | - Sukumar Reddy Gajjala
- Department of Dermatology and STD, Shadan Institute of Medical Sciences, Teaching Hospital and Research Centre, Post Graduate Institute, Hyderabad, Telangana, India
| | - Akhilesh Raj
- Department of Dermatology and STD, Shadan Institute of Medical Sciences, Teaching Hospital and Research Centre, Post Graduate Institute, Hyderabad, Telangana, India
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25
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Gupta AK, Carviel J, Shear NH. Antibiofilm Treatment for Onychomycosis and Chronic Fungal Infections. Skin Appendage Disord 2017; 4:136-140. [PMID: 30197888 DOI: 10.1159/000480023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/03/2017] [Indexed: 01/05/2023] Open
Abstract
Onychomycosis is a difficult-to-treat chronic fungal infection of the nail. The chronic nature of onychomycosis, with relevance to current treatment practices, could be attributed to host anergy, development of increased virulence in causal agents (multidrug resistance efflux pump), and biofilms. Biofilms must be disrupted prior to antifungal treatment suggesting the necessity of combination treatment. Once the biofilm has been disrupted, further techniques in addition to antifungal usage are suggested to ensure a positive prognosis including use of antimicrobial photodynamic therapy or low-frequency surface acoustic waves. Overall, with continued success in developing antibiofilm treatment for bacterial and yeast pathogens, therapy can be more quickly expanded to dermatophytes. With a rise in predisposing factors, it is important to preemptively address treatment for this disease with continued investigation into antibiofilm therapy including optimal treatment combinations and dosages targeted specifically at dermatophytes.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | - Neil H Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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26
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Exfoliative erythroderma and palmoplantar hyperkeratosis associated with Majocchi's granuloma by Trichophyton tonsurans in a patient with AIDS. Rev Iberoam Micol 2017; 34:185-188. [PMID: 28462859 DOI: 10.1016/j.riam.2016.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 10/05/2016] [Accepted: 11/04/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Dermatophytoses are skin superficial mycoses in which clinical manifestations are directly related to the virulence of the infecting microorganism or the host immunity. CASE REPORT We describe a severe case of dermatophytosis associated with exfoliative erythroderma, substantial palmoplantar keratoderma, onychodystrophy affecting all nails, diffuse non-scarring alopecia and tissue fungal invasion by Trichophyton tonsurans, which led us to the diagnosis of AIDS. Direct examination and culture for fungi from skin scraping from two different sites were performed. Biopsy and histopathological exam were also performed on three different sites. Direct examination of the lesions' scraping revealed septate hyaline hyphae and arthroconidia, identified as Trichophyton tonsurans by culture in glucose Sabouraud agar and Mycosel agar. A scalp biopsy revealed follicular fungal invasion and Majocchi's granuloma. Due to the severity of the presentation we requested an anti-HIV serology, which was positive. The patient was treated with itraconazole, 200mg/day, for 120 days, which promoted a complete regression of the lesions. CONCLUSIONS Severe and atypical forms of dermatophytosis could lead to a diagnosis of AIDS.
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27
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Heinen MP, Cambier L, Fievez L, Mignon B. Are Th17 Cells Playing a Role in Immunity to Dermatophytosis? Mycopathologia 2016; 182:251-261. [PMID: 27878642 DOI: 10.1007/s11046-016-0093-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/13/2016] [Indexed: 12/24/2022]
Abstract
Despite their superficial localization in the skin, pathogenic dermatophytes can induce a complex but still misunderstood immune response in their hosts. The cell-mediated immunity (CMI) is correlated with both clinical recovery and protection against reinfection, and CD4+ T lymphocytes have been recognized as a crucial component of the immune defense against dermatophytes. Before the discovery of the Th17 pathway, CMI was considered to be only dependent of Th1 cells, and thus most studies on the immunology of dermatophytosis have focused on the Th1 pathway. Nevertheless, the fine comparative analysis of available scientific data on immunology of dermatophytosis in one hand and on the Th17 pathway mechanisms involved in opportunistic mucosal fungal infections in the other hand reveals that some key elements of the Th17 pathway can be activated by dermatophytes. Stimulation of the Th17 pathway could occur through the activation of some C-type lectin-like receptors and inflammasome in antigen-presenting cells. The Th17 cells could go back to the affected skin and by the production of signature cytokines could induce the effector mechanisms like the recruitment of polymorphonuclear neutrophils and the synthesis of antimicrobial peptides. In conclusion, besides the Th1 pathway, which is important to the immune response against dermatophytes, there are also growing evidences for the involvement of the Th17 pathway.
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Affiliation(s)
- Marie-Pierre Heinen
- Veterinary Mycology, Fundamental and Applied Research for Animals & Health (FARAH), Faculty of Veterinary Medicine, University of Liège, Quartier Vallée 2, Avenue de Cureghem 6, B-43a, 4000, Liège, Belgium
| | - Ludivine Cambier
- Veterinary Mycology, Fundamental and Applied Research for Animals & Health (FARAH), Faculty of Veterinary Medicine, University of Liège, Quartier Vallée 2, Avenue de Cureghem 6, B-43a, 4000, Liège, Belgium
| | - Laurence Fievez
- Laboratory of Cellular and Molecular Immunology, GIGA Research, Quartier Hôpital, University of Liège, Avenue de l'Hôpital 11, B-34, 4000, Liège, Belgium
| | - Bernard Mignon
- Veterinary Mycology, Fundamental and Applied Research for Animals & Health (FARAH), Faculty of Veterinary Medicine, University of Liège, Quartier Vallée 2, Avenue de Cureghem 6, B-43a, 4000, Liège, Belgium.
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28
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Gupta AK, Studholme C. Novel investigational therapies for onychomycosis: an update. Expert Opin Investig Drugs 2016; 25:297-305. [PMID: 26765142 DOI: 10.1517/13543784.2016.1142529] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Onychomycosis is an infection of the nail plate that is prevalent among the ageing population. Onychomycosis is difficult to treat with low initial cure rates, high rates of relapse, and reinfection. Present treatment options include oral and topical therapies, with oral therapies yielding better results. However, there has been a greater emphasis on the development of topical antifungal therapies as they have fewer side effects and drug interactions. AREAS COVERED This review summarizes new and reformulated drugs. Results from in vitro studies to Phase III clinical trials are discussed. Novel drugs include: the oral azole VT-1161, the topical azole efinaconazole, the benzoxaborole tavaborole, reformulations of terbinafine P-3058 and LI-P, novel inhibitor of succinate dehydrogenase ME1111, and off-label use of tazarotene. Enhanced permeation of the morpholine amorolfine through the nail plate is also discussed using ultraviolet (UV) curable gels, and a fractional CO2 laser. EXPERT OPINION Novel topical antifungals and the reformulation of current antifungals have demonstrated marked improvement in nail penetration. Current research has an emphasis on topical therapies due to their minimized risk for adverse effects and higher patient demand. Nevertheless, few topical agents have surfaced in the past few years and the investigation of efficacious combination therapies may become more important.
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Affiliation(s)
- Aditya K Gupta
- a Department of Medicine , University of Toronto , Toronto , Canada.,b Mediprobe Research Inc ., London , Canada
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29
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Gupta AK, Ryder JE, Skinner AR. Treatment of Onychomycosis: Pros and Cons of Antifungal Agents. J Cutan Med Surg 2016. [DOI: 10.1177/120347540400800107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Antifungal agents are beneficial in the treatment of onychomycosis in the general population, as well as in children, the elderly, and immunocompromised individuals. Special patient populations can be more difficult to treat due to such factors as drug interactions with concomitant medications, adverse events, and poor compliance. In addition, there is limited information about the use of antifungal agents in special populations, e.g., children. Objective: The pros and cons of oral and topical antifungal agents are discussed, with focus on special patient populations. Methods: We searched MedLine (1966 to April 2003) for clinical studies evaluating the efficacy of oral and topical antifungal agents to treat onychomycosis. The key words used in conjunction with “onychomycosis” include: “terbinafine,” “itraconazole,” “fluconazole,” “amorolfine nail lacquer,” “ciclopirox nail lacquer,” “HIV,” “transplant patients,” “diabetes,” “children,” and “elderly.” Studies were excluded if published in a language other than English. Results: Studies have shown that antifungal agents can be of benefit in treating the elderly, children, and immunocompromised individuals (e.g., transplant patients, Down's patients, HIV patients, and diabetics) with onychomycosis. Conclusion: The treatment modality of onychomycosis in special patient populations should take into account the clinical presentation of the onychomycosis, the causative organism, patient and physician preference, the concomitant medications that the patient is on, and the potential for adverse events for that patient if antifungal therapy is undertaken.
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Affiliation(s)
- Aditya K. Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook site) and the University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research, London, Ontario, Canada
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Maraki S, Mavromanolaki VE. Epidemiology of onychomycosis in Crete, Greece: a 12-year study. Mycoses 2016; 59:798-802. [DOI: 10.1111/myc.12533] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/25/2016] [Accepted: 06/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Sofia Maraki
- Department of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine; University Hospital of Heraklion; Heraklion Greece
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31
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Abstract
Background: Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management. Objective: To identify ways to improve cure rates for onychomycosis. Method: The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates. Results and Conclusion: To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.
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Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Mediprobe Research, Inc, London, ON, Canada
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Abstract
The prevalence of onychomycosis has been estimated at approximately 6.48% (95% confidence interval 6.09–6.88%) within the Canadian population. Dermatophytes are the most commonly cultured organisms, appearing in approximately 75 to 91% of nails with fungal involvement, with Trichophyton rubrum and Tricophyton mentagrophytes most commonly isolated. However, Candida spp and nondermatophyte molds are also sometimes cultured. The most common presentation is distal and lateral subungual onychomycosis (DLSO), which can involve 75% of patients with pedal onychomycosis. The distribution of DLSO, superficial white onychomycosis, and proximal subungual onychomycosis (PSO) has been reported to be 360:59:1 in patients with mycologic confirmation of onychomycosis; however, some reported that the incidence of PSO is slightly higher in immunocompromised individuals. Age, gender, family history, and the presence of tinea pedis are all elements associated with a nail fungal infection. In addition, many conditions, including diabetes mellitus, immune disorders, and vascular disease, have been associated with the presence of onychomycosis. When choosing the best treatment regimen for individuals with onychomycosis, it is very important to consider all of the factors involved, including the infecting species, the presentation of the disease, the level of disease progression, and its predisposing factors.
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Affiliation(s)
- Ronald B. Vender
- From Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; and Laval University, Quebec City, PQ
| | - Charles W. Lynde
- From Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; and Laval University, Quebec City, PQ
| | - Yves Poulin
- From Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; and Laval University, Quebec City, PQ
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33
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Barber K, Claveau J, Thomas R. Review of Treatment for Onychomycosis: Consideration for Special Populations. J Cutan Med Surg 2016. [DOI: 10.2310/7750.2006.00054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article provides a brief discussion of onychomycosis treatment in special populations such as children, the elderly, and patients with diabetes, human immunodeficiency virus (HIV), or Down syndrome. These subjects are generally not included in clinical trials, and few data on antifungal therapy are available in the literature. Issues with onychomycosis infection and treatment affecting each group are discussed, and where treatment reports exist, efficacy and safety data are presented. The discussion is restricted to agents approved for use in onychomycosis in Canada: oral terbinafine, oral itraconazole, and ciclopirox 8% nail lacquer. Although sparse, the literature demonstrates that onychomycosis therapies can be used safely and effectively in these special populations, although it is likely that the appropriateness of such treatment would have to be assessed on a case-by-case basis. Typically, oral medications are used reluctantly in these groups as the potential for adverse liver or kidney effects and medication interactions may be significant. Ciclopirox nail lacquer has recently become available for use and may offer an alternative to oral therapy in the future for mild to moderate cases of onychomycosis; however, the efficacy in these patients has not typically been reported. It remains to be seen what impact this medication will have for special populations. More knowledge of treatment in special populations must be accumulated in the literature before more formal treatment guidelines may be formulated.
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Affiliation(s)
- Kirk Barber
- From The Dermatology Centre, Calgary, AB; Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ; and Department of Dermatology, University of British Columbia, Vancouver, BC
| | - Joël Claveau
- From The Dermatology Centre, Calgary, AB; Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ; and Department of Dermatology, University of British Columbia, Vancouver, BC
| | - Richard Thomas
- From The Dermatology Centre, Calgary, AB; Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ; and Department of Dermatology, University of British Columbia, Vancouver, BC
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Vlahovic TC, Joseph WS, Scher RK, Tosti A, Plasencia J, Pariser DM, Markinson BC. Diagnosis and Management of Onychomycosis Perspectives from a Joint Podiatric Medicine-Dermatology Roundtable. J Am Podiatr Med Assoc 2016; 106:155-62. [PMID: 27031556 DOI: 10.7547/14-170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Onychomycosis is a fungal infection, and, as such, one of the goals of treatment should be eradication of the infective agent. Despite this, in contrast to dermatologists, many podiatric physicians do not include antifungals in their onychomycosis treatment plans. Before initiating treatment, confirmation of mycologic status via laboratory testing (eg, microscopy with potassium hydroxide preparation, histopathology with periodic acid-Schiff staining, fungal culture, and polymerase chain reaction) is important; however, more podiatric physicians rely solely on clinical signs than do dermatologists. These dissimilarities may be due, in part, to differences between specialties in training, reimbursement patterns, or practice orientation, and to explore these differences further, a joint podiatric medicine-dermatology roundtable was convened. In addition, treatment options have been limited owing to safety concerns with available oral antifungals and relatively low efficacy with previously available topical treatments. Recently approved topical treatments-efinaconzole and tavaborole-offer additional options for patients with mild-to-moderate disease. Debridement alone has no effect on mycologic status, and it is recommended that it be used in combination with an oral or topical antifungal. There is little to no clinical evidence to support the use of lasers or over-the-counter treatments for onychomycosis. After a patient has achieved cure (absence of clinical signs or absence of fungus with minimal clinical signs), lifestyle and hygiene measures, prophylactic/maintenance treatment, and proactive treatment for tinea pedis, including in family members, may help maintain this status.
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Affiliation(s)
- Tracey C. Vlahovic
- Department of Podiatric Medicine and Orthopedics, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Warren S. Joseph
- Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Huntingdon Valley, PA
| | - Richard K. Scher
- General Dermatology, Weill Cornell Medical College, New York, NY
| | - Antonella Tosti
- Dermatology and Cutaneous Surgery, Leonard Miller School of Medicine, University of Miami, Miami, FL
| | | | - David M. Pariser
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, VA
| | - Bryan C. Markinson
- The Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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35
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Topical and device-based treatments for fungal infections of the toenails. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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36
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Machado Vila TV, Sousa Quintanilha N, Rozental S. Miltefosine is effective against Candida albicans and Fusarium oxysporum nail biofilms in vitro. J Med Microbiol 2015; 64:1436-1449. [DOI: 10.1099/jmm.0.000175] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Taissa Vieira Machado Vila
- Laboratório de Biologia Celular de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Natália Sousa Quintanilha
- Laboratório de Biologia Celular de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Sonia Rozental
- Laboratório de Biologia Celular de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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37
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Snell M, Klebert M, Önen NF, Hubert S. A Novel Treatment for Onychomycosis in People Living With HIV Infection: Vicks VapoRub™ is Effective and Safe. J Assoc Nurses AIDS Care 2015; 27:109-13. [PMID: 26585031 DOI: 10.1016/j.jana.2015.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
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38
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Auvinen T, Tiihonen R, Soini M, Wangel M, Sipponen A, Jokinen J. Efficacy of topical resin lacquer, amorolfine and oral terbinafine for treating toenail onychomycosis: a prospective, randomized, controlled, investigator-blinded, parallel-group clinical trial. Br J Dermatol 2015; 173:940-8. [DOI: 10.1111/bjd.13934] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 11/28/2022]
Affiliation(s)
- T. Auvinen
- Department of Vascular Surgery, Heart Centre; Kuopio University Hospital; FI-70029 Kuopio Finland
| | - R. Tiihonen
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - M. Soini
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - M. Wangel
- Vääksy Medical Centre; FI-17200 Vääksy Finland
| | - A. Sipponen
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - J.J. Jokinen
- Department of Cardiac Surgery, Heart and Lung Centre; Helsinki University Hospital; FI-00029 Helsinki Finland
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Kawai M, Suzuki T, Hiruma M, Ikeda S. A retrospective cohort study of tinea pedis and tinea unguium in inpatients in a psychiatric hospital. Med Mycol J 2015; 55:E35-41. [PMID: 24943206 DOI: 10.3314/mmj.55.e35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We conducted a retrospective cohort study on clinical and mycological features of tinea pedis and tinea unguium in psychiatric inpatients in Japan. Of the 317 inpatients (152 with schizophrenia and 165 with depression), 46.1% had tinea pedis and 23.7% had tinea unguium. Of those with tinea pedis, 48.6% also had tinea unguium. The most common clinical type of tinea pedis was the combination of interdigital type and hyperkeratotic type. The mean clinical score of tinea pedis was 5.9, and that of tinea unguium based on the Scoring Clinical Index for Onychomycosis (SCIO) was 15.8. The main causative species of tinea pedis were Trichophyton rubrum (68.4%) and T. mentagrophytes (26.3%). No statistically significant differences were observed in incidence rates of tinea pedis or tinea unguium between men and women or between patients with schizophrenia and those with depression. As for incidence rates by age, patients with depression showed a single peak for tinea pedis and / or tinea unguium in their 50's, while patients with schizophrenia exhibited twin peaks for tinea pedis and / or tinea unguium in their 50's and 70's. Both tinea pedis and tinea unguium tended to become more severe in patients with chronic schizophrenia. Our study suggests that schizophrenia and depression, like diabetes mellitus and HIV infections, should be regarded as risk factors for tinea pedis and tinea unguium.
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Affiliation(s)
- Masaaki Kawai
- Department of Dermatology, Juntendo University Koshigaya Hospital
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40
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Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol 2015; 171:937-58. [PMID: 25409999 DOI: 10.1111/bjd.13358] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/12/2022]
Affiliation(s)
- M Ameen
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, U.K
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41
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Ruíz-López P, Moreno-Coutiño G, Fernández-Martínez R, Espinoza-Hernández J, Rodríguez-Zulueta P, Reyes-Terán G. Evaluation of improvement of onychomycosis in HIV-infected patients after initiation of combined antiretroviral therapy without antifungal treatment. Mycoses 2015; 58:516-21. [PMID: 26155930 DOI: 10.1111/myc.12350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/20/2015] [Accepted: 05/30/2015] [Indexed: 11/28/2022]
Abstract
Onychomycosis in HIV-infected patients has a prevalence of 20-44% and is more frequently seen with CD4(+) T cell counts ≤450 cel μl(-1). There are case reports of improvement in onychomycosis after initiation of combined antiretroviral therapy (cART), but there are no prospective studies that prove the existence and frequency of this phenomenon. The aim of this study was to evaluate if HIV-infected patients with onychomycosis who begin cART improve and/or cure without antifungal treatment. We included HIV-infected patients with onychomycosis who had not started cART and nor received antifungal therapy during 6 months prior to the study. We evaluated affected the nails with the Onychomycosis Severity Index (OSI); nail scrapings were collected and direct microscopy with potassium hydroxide (KOH) as well as mycological culture were performed. We repeated these procedures at 3 and 6 months to assess changes. CD4 T cell counts and HIV viral load were obtained. A total of 16 patients were included, with male gender predominance (68.7%); distal and lateral subungual onychomycosis (DLSO) was the most common form (31.3%). Trichophyton rubrum was the most frequently isolated microorganism. OSI decreased 21.5% at 3 months and 40% at 6 months after initiation of antiretrovirals (P = 0.05). We found a non-significant tendency towards improvement with higher CD4(+) T cell counts and with viral loads <100 000 copies ml(-1). This could be due to the increase in CD4(+) T cells, decreased percentage of Treg (CD4(+)CD25(+)) among CD4(+) Tcells and/or a decreased viral load; further studies are necessary to prove these hypothesis.
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Affiliation(s)
- Patricia Ruíz-López
- Dermatology Division, Hospital General Dr. Manuel Gea González, México, México
| | | | | | | | | | - Gustavo Reyes-Terán
- Center for Research in Infectious Diseases, National Institute of Respiratory Diseases, México, México
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42
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Soltani M, Khosravi A, Shokri H, Sharifzadeh A, Balal A. A study of onychomycosis in patients attending a dermatology center in Tehran, Iran. J Mycol Med 2015; 25:e81-7. [DOI: 10.1016/j.mycmed.2015.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/04/2015] [Accepted: 03/11/2015] [Indexed: 11/25/2022]
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Yadav P, Singal A, Pandhi D, Das S. Clinico-mycological study of dermatophyte toenail onychomycosis in new delhi, India. Indian J Dermatol 2015; 60:153-8. [PMID: 25814703 PMCID: PMC4372907 DOI: 10.4103/0019-5154.152511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction: There is a constant need to define the epidemiological and mycological characteristics of onychomycosis (OM) for optimal management strategies. Objectives: To define the epidemiological and mycological characteristics of patients with dermatophyte toenail OM in a tertiary care hospital. Materials and Methods: Hundred consecutive patients of KOH and culture-positive dermatophyte toenail OM were subjected to detailed history, clinical examination and investigations. Results: Maximum number of patients (40%) belonged to 31-45 years age group and there was a male preponderance (M:F = 6.7:1). The mean duration of disease was 54 months. Thirty-three patients had fingernail involvement in addition to the toenail OM and 37% had co-existent cutaneous dermatophyte infection. Discoloration was the most common symptom (98%). Ninety-four (94%) patients had distal lateral subungual onychomycosis (DSLO) while two had superficial onychomycosis (SO) and only one had proximal superficial onychomycosis (PSO). Trichophyton interdigitale was the most common etiological agent (61%) followed by Trichophyton rubrum and Trichophyton verrucosum. Conclusions: Toenail OM is more common in males. DSLO was the most common clinical variant and T. interdigitale the most common etiological fungus responsible for toenail OM in our region. The importance of early diagnosis and treatment is highlighted as long-standing toenail OM predisposes to fingernail onychomycosis and recurrent tinea pedis.
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Affiliation(s)
- Pravesh Yadav
- Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
| | - Archana Singal
- Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
| | - Shukla Das
- Department of Microbiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
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Abstract
Background Onychomycosis has several clinical presentations and is caused by various infectious organisms. Objective To provide guidance for selection of appropriate treatment. Methods The literature on onychomycosis management was reviewed to generate an evidence-based decision tree. Results and Conclusion Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.
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Affiliation(s)
- Aditya K. Gupta
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
| | - Maryse Paquet
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
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45
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Abstract
Background Dermatophyte infections are a common cause of superficial fungal infection in different geographical locations of the world. Usually, it involves superficial invasion of keratinized tissue, eg, skin, nails, and hair, but in immunosuppressed individuals, it may cause atypical, extensive and deep lesions, which may pose serious diagnostic and therapeutic challenges. Aim To find out the causative dermatophyte species responsible for the various clinical types of dermatophyte infection. Results Trichophyton violaceum was found to be the predominant species, being the causative organism responsible for all the clinical types. Conclusion T. violaceum was found to be the most common species responsible for most of the clinical forms of dermatophytosis (96; 80%). Tinea unguium was found to be the most frequent clinical type of dermatophytosis (33; 27.50%).
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Affiliation(s)
- Rameshwari Thakur
- Department of Microbiology, Muzzaffarnagar Medical College, Uttar Pradesh, India
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46
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Gupta AK, Simpson FC. New pharmacotherapy for the treatment of onychomycosis: an update. Expert Opin Pharmacother 2014; 16:227-36. [DOI: 10.1517/14656566.2015.993380] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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47
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Gupta AK, Daigle D, Foley KA. The prevalence of culture-confirmed toenail onychomycosis in at-risk patient populations. J Eur Acad Dermatol Venereol 2014; 29:1039-44. [PMID: 25413984 DOI: 10.1111/jdv.12873] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/22/2014] [Indexed: 11/30/2022]
Abstract
Onychomycosis is a fungal infection of the nail and is the most common nail affliction in the general population. Certain patient populations are at greater risk of infection and the prevalence of onychomycosis reported in the literature has yet to be summarized across these at-risk groups. We performed a systematic review of the literature and calculated pooled prevalence estimates of onychomycosis in at-risk patient populations. The prevalence of dermatophyte toenail onychomycosis was as follows: general population 3.22% (3.07, 3.38), children 0.14% (0.11, 0.18), the elderly 10.28% (8.63, 12.18), diabetic patients 8.75% (7.48, 10.21), psoriatic patients 10.22% (8.61, 12.09), HIV positive patients 10.40% (8.02, 13.38), dialysis patients 11.93% (7.11, 19.35) and renal transplant patients 5.17% (1.77, 14.14). Dialysis patients had the highest prevalence of onychomycosis caused by dermatophytes, elderly individuals had the highest prevalence of onychomycosis caused by yeasts (6.07%; 95% CI = 3.58, 10.11) and psoriatic patients had the highest prevalence of onychomycosis caused by non-dermatophyte moulds (2.49%; 95% CI = 1.74, 3.55). An increased prevalence of onychomycosis in certain patient populations may be attributed to impaired immunity, reduced peripheral circulation and alterations to the nail plate which render these patients more susceptible to infection.
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Affiliation(s)
- A K Gupta
- University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | - D Daigle
- Mediprobe Research Inc., London, ON, Canada
| | - K A Foley
- Mediprobe Research Inc., London, ON, Canada
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48
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Gupta AK, Simpson FC. Efinaconazole (Jublia) for the treatment of onychomycosis. Expert Rev Anti Infect Ther 2014; 12:743-52. [DOI: 10.1586/14787210.2014.919852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc.,
645 Windermere Rd., London, ON, Canada
- Department of Medicine, University of Toronto,
Toronto, ON, Canada
| | - Fiona C Simpson
- Mediprobe Research Inc.,
645 Windermere Rd., London, ON, Canada
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49
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Affiliation(s)
- Tiffany T Mayo
- Tiffany T. Mayo is a dermatology clinical research fellow and Wendy Cantrell is an assistant professor at The University of Alabama-Birmingham Department of Dermatology, Birmingham, Ala
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50
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Gupta AK, Simpson FC, Brintnell WC. Do Genetic Mutations and Genotypes Contribute to Onychomycosis? Dermatology 2014; 228:207-10. [DOI: 10.1159/000358586] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 01/14/2014] [Indexed: 11/19/2022] Open
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