Epidemiology and prevalence of onychomycosis in HIV-positive individuals

Non-dermatophyte mould onychomycosis: a clinical and epidemiological study at a dermatology referral centre in Bogota, Colombia

Worldwide prevalence of non-dermatophyte mould onychomycosis has increased in recent years; however, available information on the topic is confusing and oftentimes contradictory, probably due to the small number of reported cases. The aim of this study was to determine and describe the aetiological agents, as well as the epidemiological and clinical characteristics of non-dermatophyte mould onychomycosis in a dermatology referral centre in Bogota, Colombia. A cross-sectional descriptive study was conducted between January 2001 and December 2011 among patients who attend the National Institute of Dermatology with a confirmed diagnosis of onychomycosis by non-dermatophytes moulds. There were 317 confirmed cases of non-dermatophyte mould onychomycosis in 196 women and 121 men whose average age was 43 years. Twenty-seven per cent of them had a history of systemic disease. The habit of walking and showering barefoot was the major infection-related factor. Distal and lateral subungual presentation was the most common pattern of clinical presentation. The most frequent non-dermatophyte mould was Neoscytalidium dimidiatum followed by Fusarium spp. No relationship was observed with predisposing factors previously reported in the literature. Clinical features found in this population are indistinguishable from onychomycosis caused by dermatophytes. High prevalence of N. dimidiatum found here was in contrast to a large number of studies where other types of moulds predominate.

A preformulation strategy for the selection of penetration enhancers for a transungual formulation

Onychomycosis is associated with the cutaneous fungal infection of the nail and the nail folds (skin surrounding the nail). It is therefore important to target drug delivery into the nail folds along with nail plate and the nail bed. Systematic and strategic selection of the penetration enhancers specific for the skin and the nail is discussed. Twelve penetration enhancers were screened for their ability to improve solubility, in vitro nail penetration, in vitro skin permeation, and in vitro skin penetration of the antifungal drug ciclopirox olamine. In contrast to transdermal drug delivery, the main selection criteria for skin penetration enhancer in topical drug delivery were increased drug accumulation in the epidermis and minimal permeation across the skin. Thiourea improved the solubility and nail penetration of ciclopirox olamine. It also showed enhancement in the transungual diffusion of the drug. Propylene glycol showed a 12-fold increase in solubility and 3-fold increase in epidermal accumulation of ciclopirox olamine, while minimizing the transdermal movement of the drug. Thiourea was the selected nail permeation enhancer and propylene glycol was the selected skin penetration enhancer of ciclopirox olamine. A combination of the selected enhancers was also explored for its effect on drug delivery to the nail and nail folds. The enhancer combination reduced the penetration of ciclopirox in the skin and also the permeation through the nail. The proposed preformulation strategy helps to select appropriate enhancers for optimum topical delivery and paves way towards an efficient topical formulation for passive transungual drug delivery.

Medical devices for the treatment of onychomycosis

Device-based therapies are the most rapidly expanding area of onychomycosis treatment. Traditional pharmacotherapy of onychomycosis has a low to moderate efficacy and is associated with adverse reactions and drug interactions that limit its use in many patients. These new therapies include laser systems, photodynamic therapy, iontophoresis, and ultrasound. Device-based therapies are procedures conducted in the clinic by a trained professional, which mitigates the requirement for long-term patient compliance. In addition, the drug component of these therapies is topical, preventing the adverse events associated with systemic antifungal administration, and potentially allowing for the treatment of individuals who were previously excluded due to drug interactions. Device-based therapy is a nascent field, so clinical data is still in an emergent stage; however, preliminary clinical trials of laser, photodynamic therapy, and iontophoresis suggest that some devices may have a degree of efficacy. More studies are required to better determine their ability to treat onychomycosis.

Association between onychodystrophy and human T-lymphotropic virus type 1 infection

OBJECTIVE

To assess the association between human T-lymphotropic virus type 1 (HTLV-1) infection and onychodystrophy.

METHODS

This was a cross-sectional study. At our institute, we provide HTLV-1 testing to relatives of HTLV-1-infected people and patients with suspected HTLV-1-associated diseases. The diagnosis of onychodystrophy was made clinically before testing for HTLV-1; the number and distribution of affected nails was registered. We assessed the association between onychodystrophy and HTLV-1 through bi- and multivariable analyses. Logistic regression was used to adjust for age, sex, and indication for HTLV-1 testing, using six affected nails (90(th) percentile) as the cut-off point.

RESULTS

Between April 2006 and March 2008, we included 893 subjects; their mean age was 38 years (standard deviation 19 years), and 527 (59%) were women. Onychodystrophy of one or more nails was observed in 323 participants (36%), and 236 subjects (26%) were HTLV-1-positive. The median number of affected nails was higher in HTLV-1-positive than in HTLV-1-negative subjects (Mann-Whitney test, p < 0.001). Thirty-eight of 97 subjects with six or more affected nails (39%) were HTLV-1-infected, compared to 198 of 796 subjects with fewer than six affected nails (25%) (crude OR 1.9, 95% confidence interval (CI) 1.2-3.1; p = 0.003). This association remained significant in the multiple logistic regression model (adjusted OR 2.0, 95% CI 1.2-3.3; p = 0.005).

CONCLUSIONS

There is an independent association between HTLV-1 infection and onychodystrophy. Patients with an HTLV-1 infection might have a higher risk for onychomycosis given the abnormal nail plate and a decreased T-cell-mediated immunologic response.

Prevalence of xerosis, eczema, and hair and nail abnormalities in PLWHA in Cotonou, Benin

BACKGROUND

The objective of this investigation was to study the prevalence of xerosis, eczema, and hair and nail abnormalities in PLWHA in Cotonou.

PATIENTS AND METHODS

A retrospective study was performed on the records of PLWHA in Cotonou. All PLWHA with xerosis, eczema, or abnormal appendages were included.

RESULTS

Forty-seven patients had xerosis or eczema. Their mean age was 38 years; the sex ratio 0.51 and the mean CD4 count 89 cells/mm(3). Twenty-three patients had xerosis, which affected the whole body (n = 20), lower limb (n = 2), limbs and trunk (n = 1), without gender difference. Twenty-four patients had eczema of which eight had both eczema and xerosis. Forty-two patients had abnormalities of the hair or nails. Their sex ratio was 0.80 and the mean CD4 count 110 cells/mm(3) . Nineteen patients had abnormalities of the hair and scalp: straight hair (n = 16), squamous lesions (n = 2), and folliculitis abscess (n = 1) with a male predominance. Twenty-three patients had nail dermatophytosis (n = 15), candidiasis (n = 7), and ingrowing nails (n = 1). These conditions affected more often women (74%) than men (26%).

CONCLUSION

The prevalence of eczema and xerosis is low in our patients. Onychomycosis was the most frequent nail abnormality.

New therapeutic options for onychomycosis

INTRODUCTION

Onychomycosis is a fungal infection of the nail apparatus that affects 10 - 30% of the global population. Current therapeutic options for onychomycosis have a low to moderate efficacy and result in a 20 - 25% rate of relapse and reinfection. New therapeutic options are needed to broaden the spectrum of treatment options and improve the efficacy of treatment.

AREAS COVERED

This review discusses the emerging pharmacotherapeutics; including topical reformulations of terbinafine, new azole molecules for systemic and topical administration, topical benzoxaboroles and topical polymer barriers. The paper also discusses device-based options, which may be designed to activate a drug or to improve drug delivery, such as photodynamic therapy and iontophoresis; laser device systems have also begun to receive regulatory approval for onychomycosis.

EXPERT OPINION

Device-based therapeutic options for onychomycosis are expanding more rapidly than pharmacotherapy. Systemic azoles are the only class of pharmacotherapy that has shown a comparable efficacy to systemic terbinafine; however terbinafine remains the gold standard. The most notable new topical drugs are tavaborole, efinaconazole and luliconazole, which belong to the benzoxaborole and azole classes of drugs. Photodynamic therapy, iontophoresis and laser therapy have shown positive initial results, but randomized controlled trials are necessary to determine the long-term success of these devices.

Cutaneous manifestations of HIV-a detailed study of morphological variants, markers of advanced disease, and the changing spectrum

BACKGROUND

Cutaneous manifestations are early and easily identifiable markers of human immunodeficiency virus (HIV) infection. They can help in predicting severity and progress of the disease and can be correlated well with CD4 counts. This study was undertaken to study the cutaneous manifestations of HIV infection and to correlate them with CD4 counts. It also aimed to study the changing spectrum of these manifestations and describe cutaneous manifestations seen in advanced disease.

METHOD

A total of 234 HIV-positive patients not on anti-retroviral therapy, who attended the outpatient department or were admitted as inpatients at Military Hospital, Shillong during the period between May 2008 and October 2009 were included. Cutaneous, mucosal, and genitourinary manifestations in these patients were studied in detail and were correlated with CD4 counts.

RESULTS

Infections were the most common group of mucocutaneous manifestations, while onychomycosis was the commonly observed individual manifestation. A different set of cutaneous markers for advanced HIV disease was observed and new parameters for therapy were also arrived at.

CONCLUSION

Specific morphological variants of cutaneous markers may provide a better clue to early diagnosis of HIV and can help in diagnosing advanced stages of the disease. Fresh cutaneous markers are required for indicating cut-off levels of CD4 count at 350/μL for starting therapy.

Proximal Subungual Onychomycosis in a Patient with Classic Kaposi Sarcoma Caused by Trichophyton rubrum

A 58-year-old man presented with whitish patches on both great toenails for four weeks prior to visiting our hospital; the patches spread rapidly to other finger- and toe-nails. Prior to presentation, the patient had been diagnosed with idiopathic thrombocytopenic purpura two months ago and Kaposi's sarcoma three weeks ago. The patient was treated with human immunoglobulin for five days, and then received prednisolone 40 mg bid. Serology showed that the patient was negative for HIV and results of other laboratory tests were normal. The KOH slide preparation of the nail scraping showed long septated hyphae and numerous arthrospores. The fungus culture revealed whitish downy colonies on the front side and wine-red reverse pigmentation on Sabouraud's dextrose agar. Trichophyton rubrum was isolated on fungus culture and slide culture. The internal transcribed space (ITS) regions of ribosomal DNA of the cultured fungus were identical to Trichophyton rubrum. Proximal subungual onychomycosis (PSO) is the rarest form of onychomycosis. PSO initially presents as whitish patch(es) on the proximal side of the nail plate(s). Because PSO shows whitish to yellowish patches on the nail plate, the result of KOH examination of nail scrapings from the nail plate is almost always negative. Herein, we report on a case of multiple PSO in a patient with classic Kaposi sarcoma and suggest a method for easy KOH scraping on PSO.

Barefoot running claims and controversies: a review of the literature

BACKGROUND

Barefoot running is slowly gaining a dedicated following. Proponents of barefoot running claim many benefits, such as improved performance and reduced injuries, whereas detractors warn of the imminent risks involved.

METHODS

Multiple publications were reviewed using key words.

RESULTS

A review of the literature uncovered many studies that have looked at the barefoot condition and found notable differences in gait and other parameters. These findings, along with much anecdotal information, can lead one to extrapolate that barefoot runners should have fewer injuries, better performance, or both. Several athletic shoe companies have designed running shoes that attempt to mimic the barefoot condition and, thus, garner the purported benefits of barefoot running.

CONCLUSIONS

Although there is no evidence that either confirms or refutes improved performance and reduced injuries in barefoot runners, many of the claimed disadvantages to barefoot running are not supported by the literature. Nonetheless, it seems that barefoot running may be an acceptable training method for athletes and coaches who understand and can minimize the risks.

Morphofunctional evaluation of thymus in hyperglycemic-hypoinsulinemic mice during dermatophytic infection

Many works have shown that the enhanced susceptibility to infection seen in diabetic patients can be related to the hyperglycemia-hypoinsulinemia (HH) observed in this condition. Herein, we evaluated the HH effects on the morphofunctional features of the thymus as well as on dermatophytic infection. We demonstrated that, not only the HH condition but also the dermatophytic infection induced transitory alterations in the thymus; it was characterized by loss of cortical-medullar definition and disorganization of the extracellular matrix. These mice also showed a decrease of CD4(+) CD8(+) thymocytes and a higher percentage of CD4(+) CD8(+) lymphocytes in the peripheral blood. After 7 days, the thymus and peripheral lymphocytes subsets returned to normal values. Interestingly, when the two conditions, HH condition and the infection, were associated, the mice showed a decrease in the percentage of CD4(+) CD8(-) blood lymphocytes that are involved in the modulation of immune response and have direct cytotoxic effects on the fungus. Taken together, our results showed that both conditions transitorily changed the thymus, but only when both these conditions are present do they trigger persistent changes that might be responsible for the higher susceptibility to dermatophytosis seen in HH patients.

Avaliação clínica e micológica de onicomicose em pacientes brasileiros com HIV/AIDS

INTRODUÇÃO: Onicomicoses são comuns em pacientes imunocomprometidos embora espécies emergentes tenham sido verificadas, modificado o perfil epidemiológico desta micose. Assim, o objetivo desta pesquisa é avaliar o perfil clínico e micológico da onicomicose em pacientes com infecção pelo HIV/AIDS. MÉTODOS: Amostras clínicas foram coletadas, processados para exame direto e a cultura mantida a temperatura de 30°C e 37ºC durante 15 dias. RESULTADOS: Dos 100 pacientes, 32 apresentavam onicomicose. Os agentes isolados foram Candida albicans, C. parapsilosis, C. tropicalis, C. guilliermondii, Trichophyton rubrum, T. mentagrophytes, Fusarium solani, Scytalidium hialinum, S. japonicum, Aspergillus niger, Cylindrocarpon destructans e Phialophora reptans. CONCLUSÕES: Onicomicoses em HIV/AIDS apresentam variadas manifestações clínicas e podem ser causadas por fungos emergentes. As peculiaridades apresentadas pelos diferentes agentes de origem fúngica justificam a necessidade de identificação ao nível da espécie, com a finalidade de orientar uma melhor abordagem terapêutica e minimizar a exposição desses pacientes a condições de risco de uma infecção disseminada.

CD4+ and CD8+ T cells mediated direct cytotoxic effect against Trichophyton rubrum and Trichophyton mentagrophytes

BACKGROUND

The cellular immune system is the most dominant factor in curing acute dermatophytosis. However, the exact immune mechanisms involved in generating this defense are complex and still obscure. The aim of this study was to investigate the fungicidal mechanism of T cells in the normal population versus patients with chronic fungal infections.

METHODS

Thirty patients were included in the study: 15 patients with chronic dermatophytosis and 15 normal healthy patients with a history of acute dermatophytosis. The procedures were performed as follows. 1) Proliferation and cytotoxic activity of lymphocytes cultured with various dermatophytes homogenate such as, Trichophyton rubrum, Trichophyton mentagrophytes and Microsporum gypseum. 2) CD4(+) and CD8(+) T cells were separated by magnetic beads before culture with fresh spores of either T. mentagrophytes or T. rubrum. 3) Routine histology and ultrastructural study were performed to illustrate the mode of activity of the T cells against the dermatophytes.

RESULTS

The study showed that both CD4 and CD8 possess cytotoxic activity against dermatophytes. However, the results demonstrated a suppression of lymphocyte proliferation response and a significant lower cytotoxic effect in chronic patients. Ultra structure and histological evaluation of the culture of hyphae with CD4(+) or CD8(+) T cells showed more prominently destructive effects in the culture of cells that had been obtained from normal population than those of patients with long-lasting fungal infections.

CONCLUSION

The study suggests a selective impairment of lymphocyte function against dermatophytes, in patients with chronic dermatophytoses.

Candidal onychomycosis: a mini-review

Onychomycosis is a common fungal infection affecting nails. The primary cause for onychomycosis is dermatophytes, while Candida species have emerged as second-line pathogens. Onychomycosis due to Candida (candidal onychomycosis) is increasingly found in individuals having defective immunity consequential to aging, diabetes mellitus, vascular diseases, HIV infection and drug therapies such as immunosuppressives and broad-spectrum antibiotics. Breached local immunity at the nail complex due to trauma, chronic exposure to moisture and chemicals including smoke, detergents, soap, etc., also contribute to candidal onychomycosis. Adhesion, filamentation, secretion of extracellular enzymes and the development of antifungal resistance are some of the virulence mechanisms of Candida species associated with onychomycosis. Diagnosis of onychomycosis depends on history and clinical examination, direct microscopic investigation, mycological culture and histopathology. Restoration of immune defenses, elimination of fungi using appropriate drug therapy and improvement of nail hygiene with the removal of predisposing factors are key aspects in the management of candidal onychomycosis.

The prevalence of dermatophyte infection in patients infected with human immunodeficiency virus

BACKGROUND

It is not known whether human immunodeficiency virus (HIV) infection is associated with an increased susceptibility to dermatophytes.

METHODS

In this study, we determined the prevalence of cutaneous fungal infection in a cohort of HIV-infected patients and HIV-negative controls, and examined the factors associated with an increased risk of infection.

RESULTS

Using a multiple regression analysis, we found that the strongest independent predictor of cutaneous fungal infection in both groups was a self-reported history of homosexual sex. There was no relationship between HIV infection or reduced CD4 count and the prevalence of dermatophyte infection.

CONCLUSIONS

HIV infection is not independently associated with an increased risk of cutaneous fungal disease.

Onychomycosis in inflammatory bowel diseases

BACKGROUND

As far as we have sought for in Medline and PubMed, not one study until now has evaluated the prevalence of onychomycosis in patients with inflammatory bowel disease (IBD). As there are great evidence of immunological disturbances linked to IBD, a possible relationship of this nail infection in association with those diseases and the possible risk factors might be relevant in IBD patients.

METHODS

A case-control prospective study using combined direct smear and cultures for fungus was performed. Sociodemographics, clinical and laboratorial data were recorded at baseline and samples of suspected nails were collected from 141 IBD (61 men and 80 women) and from a group of 100 non-IBD subjects (41 men and 59 women). Direct smear and cultures were performed on each suspected case to exclude other onychodystrophies.

RESULTS

The incidence of onychomycosis in IBD patients was highly significant in comparison to non-IBD patients (14.9% vs. 6%, respectively, P < 0.05). The risk factors predisposing IBD patients to onychomycosis were older age (P = 0.02) and leucopoenia in those using azathioprine therapy (P = 0.04) beyond a trend to lymphopenia (P = 0.06). The dermatophytes predominated (76.2%) over yeasts (19%) and moulds (4.8%).

CONCLUSION

The prevalence of onychomycosis in IBD patients was expressively high (14.9%) in comparison with non-IBD patients. Considering the sociodemographic factors, any one but two were related to fungal onychomycosis incidence. Therefore, as far as we are concerned, IBD must be included in the high-risk underlying conditions for onychomycosis occurrence.

[Frequent and rare dermatological diseases in HIV patients]

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.

Onychomycosis: a 3-year clinicomycologic hospital-based study

BACKGROUND

Despite onychomycosis being an established entity, only a few studies are available from the Indian subcontinent. The authors investigated the comprehensive pattern of the condition.

AIM

To investigate the epidemiologic, clinical, and mycologic factors associated with onychomycosis in 50 patients using a prospective study design.

METHODS

Fifty patients with potassium hydroxide-positive tests were evaluated according to a predetermined protocal recording details of epidemiologic, clinical, and mycologic characteristics. The collected data were analyzed to determine the correlation of various parameters.

RESULTS

Distal and lateral subungual onychomycosis, total dystrophic onychomycosis, and superficial white onychomycosis variants of onychomycosis were identified, mostly in men 21-30 years of age (mean age, 34.5 years). Epidemiologic characteristics were instrumental to either initiate, perpetuate, or disseminate the disease process. Trichophyton rubrum and Trichophyton mentagrophytes were the main causative dermatophytes; yeasts and molds were less common.

CONCLUSIONS

Recognition of onychomycosis is less difficult providing the clinician is aware of the entity. Should the etiologic diagnosis be made, its eradication is desirable to surmount its implication in the society at large.

Diagnosing Onychomycosis

Onychomycosis is the most prevalent nail disease, representing nearly half of all clinically diagnosed onychopathies. Given the pervasive nature of the disease and that successful treatment depends on the proper identification of the causative organism,accurate and reliable methods of diagnosis are necessary. This article discusses the efficacy of the various methods used for the diagnosis of onychomycosis.

Onychomycosis: beyond cosmetic distress

Onychomycosis, or fungal infection of the nail, is the most common nail disease affecting children (although to a lesser extent) as well as adults. The distress it provokes is not only of a cosmetic kind; it may impair the quality of life. The different clinical types of onychomycosis should be differentiated from similar-looking nail diseases. As far as therapy is concerned, the appearance of new antifungal drugs in the 1990s makes our job easier, but it does not allow us to cure 100% of the patients. Relapses still exist. The aim of this article is to help dermatologists achieve a tailor-made treatment for their patients. The clinical type, the compulsory mycological investigations, the age of the patient, his medical history (drug intake), as well as the use of nail cosmetics, must be considered.

Dermatophytosis: the management of fungal infections

Dermatophytosis is an infection of the hair, skin, or nails caused by a dermatophyte, which is most commonly of the Trichophyton genus and less commonly of the Microsporum or Epidermophyton genera. Tinea capitis, tinea pedis, and onychomycosis are common dermatologic diseases that may result from such an infection. The treatment of fungal infections caused by a dermatophyte has been successful when treated with oral or topical antifungal agents. Terbinafine, itraconazole, and fluconazole are oral antimycotics that are effective in the treatment of superficial mycoses, although, depending on the severity of the infection, a topical antifungal may be sufficient.

Un nuevo enfoque sobre la epidemiología de las onicomicosis

Onychomycoses represent a group of nail affections caused by one or more fungi. Whether aging represents a risk factor for developing onychomycosis, remains a question. In the present work, we studied the variations in frequency and prevalence of onychomycoses and non-mycotic onychodystrophies according to age. Our results show that there is an increase in the frequency and prevalence of onychomycoses and non-mycotic onychodystrophies predominantly in patients over forty years of age.

Patients at risk of onychomycosis - risk factor identification and active prevention

OBJECTIVES

The aims of this workshop were to identify risk factors for onychomycosis and to reach consensus on the management of high-risk groups to allow the development of guidelines to help doctors recognize risk factors that complicate treatment.

RESULTS AND CONCLUSIONS

Previous Trichophyton rubrum infection, older age, abnormal nail morphology, immunodeficiency and genetic factors were identified as risk factors for initial infections. Risk factors for recurrence (relapse and re-infection) are largely the same. The experts agreed that the prevention of onychomycosis and its recurrence should be based on the correct treatment of tinea pedis, screening family members and adequate patient education. In addition, generic management recommendations for each high-risk group were discussed: * Immunosuppressed patients Usual dose and treatment length not appropriate Follow-up required Beware of drug interactions * Diabetics Prophylactic foot care combined with nail treatment Good opportunity for patient education, footwear, foot care, etc. Beware of drug interactions * Psoriatics and patients with abnormal nails Dermatophyte eradication does not restore normal nails * Children High failure rate possibly due to compliance problems.

Optimal management of fungal infections of the skin, hair, and nails

Superficial fungal infections are chronic and recurring conditions. Tinea capitis is a scalp infection, primarily affecting prepubescent children. Ringworm infections, such as tinea corporis and tinea cruris, involve the glabrous skin. Tinea nigra is a rare mycotic infection that may be related to travel abroad. Piedra, black or white, is limited to the hair shaft without involvement of the adjacent skin. Pityriasis (tinea) versicolor and seborrheic dermatitis are dermatoses associated with yeasts of the genus Malassezia that affect the lipid-rich areas of the body. The taxonomy of the Malassezia yeasts has been revised to include nine species, eight of which have been recovered from humans. Tinea pedis, an infection of the feet and toes, is one of the most common forms of dermatophytosis. Onychomycosis is a fungal infection affecting the nail bed and nail plate; it may be chronic and can be difficult to treat. In instances where the superficial fungal infection is severe or chronic, an oral antifungal agent should be considered. Terbinafine, itraconazole, and fluconazole are oral antifungals that are effective in the treatment of superficial mycoses.

Risk factors associated with onychomycosis

OBJECTIVE

To examine possible risk factors related to onychomycosis.

BACKGROUND

Onychomycosis is a common disease with multifactorial aetiology, but little is known about the risk factors for this disease.

PATIENTS AND METHODS

Questions related to signs, symptoms and possible risk factors associated with onychomycosis were sent to 3992 persons aged 16 years and older selected randomly from the Icelandic National Registry. Patients with suspected onychomycosis, based on photographs, were offered mycological examination. Data from the questionnaire and the results of mycological examination were used to calculate the odds ratio (OR) for several factors that might be associated with onychomycosis.

RESULTS

Two thousand four hundred and eighty-six subjects responded to the questionnaire. Prevalence for mycologically determined onychomycosis was 11.1% in the Icelandic population. A history of the following factors more than doubled the risk of onychomycosis: cancer (OR 3.44; 95% CI 1.15-10.35), psoriasis (OR 2.44; 95% CI 1.61-3.72), tinea pedis interdigitalis (OR 3.93; 95% CI 3.11-4.95), the moccasin form of tinea pedis (OR 4.26; 94% CI 3.34-5.45), parents with onychomycosis (OR 2.59; 95% CI 1.89-3.53), children with onychomycosis (OR 3.48; 95% CI 2.05-5.88), spouse with onychomycosis (OR 2.53; 95% CI 1.72-3.72), regular swimming activity (OR 2.57; 95% CI 2.00-3.30) and age 50 years or older (OR 2.74; 95% CI 2.19-3.42).

CONCLUSIONS

Several risk factors are associated with onychomycosis. Knowledge of these risk factors is important when treating and educating patients with onychomycosis.

The Effect of Highly Active Antiretroviral Therapy on Dermatologic Disease in a Longitudinal Study of HIV Type 1–Infected Women

The effect of highly active antiretroviral therapy (HAART) on skin diseases was evaluated in 878 human immunodeficiency virus type 1 (HIV-1)-infected women in the Women's Interagency HIV Study, a multicenter prospective study. HIV-1-infected women receiving HAART were less likely to have eczema, folliculitis, tinea pedis, and xerosis than were women who had not initiated HAART, independent of CD4+ cell count. Participants who had a prior history of a nadir CD4+ cell count of <200 cells/microL and recent CD4+ cell counts of 200-349 cells/microL were more likely to have eczema and xerosis than were women with a nadir CD4+ cell count of >200 cells/microL and recent CD4+ cell counts of >349 cells/microL. An HIV-1 RNA load of >100,000 copies/mL was associated with increased prevalence of herpes zoster infection (odds ratio, 6.10; 95% confidence interval, 2.00-18.65). History of injection drug use was associated with a higher prevalence of onychomycosis, tinea pedis, and xerosis. Molluscum contagiosum was more prevalent among younger women.

Onychomycosis in children: a brief overview with treatment strategies

Onychomycosis in children is uncommon. In those children that are affected, a family history of onychomycosis is not uncommon, giving importance to the examination of the entire family for fungal nail infections. In the United States, the newer oral antifungal agents itraconazole, fluconazole, and terbinafine, and the topical nail lacquers ciclopirox and amorolfine are not approved for this indication. More data are needed on the use of these antifungal agents for the treatment of onychomycosis in children.

Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis

The recent advances in pityriasis versicolor, seborrheic dermatitis, tinea capitis and onychomycosis are reviewed. Some highlighted points include the new classification of Malassezia species, and the association of Malassezia species with seborrheic dermatitis. The use of terbinafine, fluconazole, and itraconazole for the treatment of tinea capitis is discussed. The management of onychomycosis, highlighting the high efficacy rates obtained with terbinafine when used to treat dermatophyte toenail onychomycosis, is discussed. The use of combination therapies in some circumstances to maximize cure rates is reviewed.

How to improve cure rates for the management of onychomycosis

To improve the treatment of onychomycosis clinicians need to identify correctly the causative organism, choose a therapy that is effective against the pathogen, and take into consideration the pharmacokinetics (eg, bioavailability, drug interactions) of the oral agent. In addition, variations of the standard regimens may need to be considered (ie, booster or supplemental therapy). To reduce the recurrence of onychomycosis, once mycologic cure has been achieved, clinicians should educate their patients about proper foot care. Familiarity with the symptoms and signs of tinea pedis and onychomycosis may enable patients to seek appropriate care when the disease is at an early stage.

The use of topical therapies to treat onychomycosis

The management of onychomycosis using topical agents has improved with the introduction of ciclopirox and amorolfine nail lacquers; other topical agents may be less effective. The combination of a nail lacquer with an oral antifungal agent may further improve efficacy rates in certain clinical presentations (eg, among those individuals with severe onychomycosis). Topical agents have a favorable adverse events profile. Further studies are required on the treatment of onychomycosis with nail lacquers.

Clinical and mycological study of occult tinea pedis and tinea unguium in dermatological patients from Tokyo

An epidemiological investigation was conducted to determine the prevalence and circumstances of untreated, unsuspected tinea pedis and tinea unguium, morbid conditions that could be termed occult athlete's foot, in patients visiting a dermatology clinic in Tokyo, Japan, for the first time, for other complaints. All subjects completed a questionnaire covering comprehensive anamnestic details, and were examined for disposition of toes, presence of signs suggestive of tinea pedis, other diseases of the foot, score of clinical signs and symptoms, potassium hydroxide (KOH) test, severity score, and mycological culture. The results showed that the prevalence of occult athlete's foot was 25%, and that 59% of those cases were complicated by tinea unguium. The characteristics of patients with occult athlete's foot included a higher proportion of men and a tendency toward a low clinical score together with a high severity score. In the patient background, a strong correlation was observed between a positive KOH test result and characteristics such as age, disposition of toes, and predisposing disease.

Fungal nail infections: far more than an aesthetic problem

Onychomycosis (fungal nail infection) is common and causes considerable discomfort and pain for many otherwise health patients. However, onychomycosis is especially prevalent in some patient groups seen regularly by community nurses (e.g. the elderly and people with diabetes, human immunodeficiency virus (HIV) infection or psoriasis). This article discusses the causes and types of onychomycosis, and examines in detail the various treatments available. Both the infection and its treatment can cause several clinical problems including drug interactions, difficulties with differential diagnosis and compromise of clinical outcomes. In particular, onychomycosis can undermine foot care in people with diabetes. The role of community nurses in treating and preventing onychomycosis is discussed.

Ciclopirox nail lacquer solution 8% in the 21st century

Ciclopirox nail lacquer solution 8% has been shown to be effective in the treatment of dermatophyte onychomycosis of mild to moderate severity Other studies report the effectiveness of ciclopirox nail lacquer in onychomycosis caused by Candida sp and nondermatophyte molds. Ciclopirox nail lacquer may also be valuable in the treatment of early cases of reinfection/relapse. Ciclopirox nail lacquer solution 8% may be an important adjunct to oral antifungal therapy in certain presentations that might be poorly responsive to oral antifungal therapy alone (eg, lateral onychomycosis, longitudinal spike, dermatophytoma, and extensive onycholysis). In some cases, surgical therapies may need to be considered in addition to, or in preference to, topical nail lacquer treatment. The use of ciclopirox nail lacquer solution 8% as an adjunct to oral antifungal therapy may widen the spectrum of activity of the combination because of the broad spectrum of coverage provided by the lacquer. The use of combination therapy may be synergistic in terms of efficacy, enabling a reduction in the duration and cumulative dosage of oral therapy. This could result in a decrease in the frequency and severity of systemic adverse effects associated with the oral antimycotics and the need to be vigilant about drug interactions. Studies need to be conducted to determine the place of combination oral and topical lacquer therapy in the management of onychomycosis.