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ALTUN E, KUZUCULAR E, TOSUN Aİ. Comparison of diagnostic methods in onychomycosis. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1204419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: Onychomycosis is a chronic fungal infection of the nail bed, plate, or matrix. This study aimed to compare the sensitivity of three diagnostic methods in the diagnosis of onychomycosis.
Material and Method: This study included 39 patients with a clinical diagnosis of onychomycosis of the toenails, who presented to Medipol Mega University Hospital between May 2019 and August 2022. Using the nail samples taken from the patients, the results of the direct microscopic examination with standard potassium hydroxide (KOH), histopathological examination performed with periodic acid-Schiff (PAS) staining, and fungal agents that grew in fungal culture were noted.
Results: Eleven (28.2%) patients were female, and 28 (71.8%) were male, with the mean age being 43.1±13.9 years. Of the patients, 53.8% had distal subungual onychomycosis and 46.2% had total subungual onychomycosis. The mean disease duration was 38.8±24.5 (12-120) months. Fungal infection was detected on direct microscopic examination with standard KOH in 66.7% of the patients, culture growth in 38.5%, and PAS staining on histopathological examination in 71.8%, and the sensitivities of these methods were determined as 74.3%, 49.2%, and 80%, respectively, with the negative predictive values being 30.8%, 16.7%, and 36.4%, respectively.
Conclusion: Among the investigated methods, histopathological examination with PAS staining was found to have the highest sensitivity and negative predictive value in the diagnosis of onychomycosis.
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Affiliation(s)
- Ece ALTUN
- Department of Dermatology and Venereology, Istanbul Medipol University, Istanbul, Turkiye
| | - Elif KUZUCULAR
- Department of Pathology, Istanbul Medipol University, Istanbul, Turkiye
| | - Ayşe İstanbullu TOSUN
- Department of Medical Microbiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkiye
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2
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Gupta AK, Hall DC, Cooper EA, Ghannoum MA. Diagnosing Onychomycosis: What’s New? J Fungi (Basel) 2022; 8:jof8050464. [PMID: 35628720 PMCID: PMC9146047 DOI: 10.3390/jof8050464] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/05/2023] Open
Abstract
An overview of the long-established methods of diagnosing onychomycosis (potassium hydroxide testing, fungal culture, and histopathological examination) is provided followed by an outline of other diagnostic methods currently in use or under development. These methods generally use one of two diagnostic techniques: visual identification of infection (fungal elements or onychomycosis signs) or organism identification (typing of fungal genus/species). Visual diagnosis (dermoscopy, optical coherence tomography, confocal microscopy, UV fluorescence excitation) provides clinical evidence of infection, but may be limited by lack of organism information when treatment decisions are needed. The organism identification methods (lateral flow techniques, polymerase chain reaction, MALDI-TOF mass spectroscopy and Raman spectroscopy) seek to provide faster and more reliable identification than standard fungal culture methods. Additionally, artificial intelligence methods are being applied to assist with visual identification, with good success. Despite being considered the ‘gold standard’ for diagnosis, clinicians are generally well aware that the established methods have many limitations for diagnosis. The new techniques seek to augment established methods, but also have advantages and disadvantages relative to their diagnostic use. It remains to be seen which of the newer methods will become more widely used for diagnosis of onychomycosis. Clinicians need to be aware of the limitations of diagnostic utility calculations as well, and look beyond the numbers to assess which techniques will provide the best options for patient assessment and management.
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Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, Division of Dermatology, University of Toronto School of Medicine, Toronto, ON M5S 3H2, Canada
- Mediprobe Research Inc., London, ON N5X 2P1, Canada; (D.C.H.); (E.A.C.)
- Correspondence: ; Tel.: +1-519-851-9715; Fax: +1-519-657-4233
| | - Deanna C. Hall
- Mediprobe Research Inc., London, ON N5X 2P1, Canada; (D.C.H.); (E.A.C.)
| | | | - Mahmoud A. Ghannoum
- Center for Medical Mycology, Department of Dermatology, Case Western Reserve University, Cleveland, OH 44106, USA;
- Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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3
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Abstract
This article discusses the histologic findings in key nail unit diseases, including inflammatory, infectious, and neoplastic conditions. The emphasis is on clinicopathologic correlates, best practices to demonstrate the relevant histopathologic features, and pitfalls in diagnosis. Understanding the pathology of these disorders enhances clinical acumen and may affect the choice of biopsy procedures and treatment measures, with the outcome of better clinical care for patients with nail disease.
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Affiliation(s)
- Beth S Ruben
- Palo Alto Medical Foundation Medical Group, Dermatology, 795 El Camino Real, Clark Building, 2nd Floor, Palo Alto, CA 94301, USA.
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4
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Lecerf P, Abdy S, Vollono L, Pastushenko I, Richert B, André J. Direct examination, histopathology and fungal culture for the diagnosis of onychomycosis: A retrospective, comparative study on 2245 specimens. Mycoses 2020; 64:187-193. [PMID: 33075162 DOI: 10.1111/myc.13201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Onychomycosis affects 5.5% of the general population and represents up to 50% of all nail diseases. Diagnosis and pathogen identification are essential in order to plan an adequate treatment. Many diagnostic techniques are available, and however, no solid data regarding comparison between different techniques over a large number of specimens are available to date. OBJECTIVES To compare sensitivity and specificity of direct examination, histopathology and fungal culture in our referral mycology laboratory. METHODS Nail specimens received at the cutaneous pathology and mycology laboratory of the University Hospital Saint-Pierre (Brussels, Belgium) between 1 January and 15 May 2018 were retrospectively analysed. All specimens were submitted to direct examination and culture. In cases of adequate specimen size, histopathology was performed. Fungal culture was considered the gold standard for diagnosis. RESULTS A total of 2245 nail samples were included in the study. Onychomycosis was diagnosed in 1266 specimens. Sensitivity and positive predictive value were found to be higher for direct examination compared to histopathology, while sensitivity of direct examination was found to be lower. Combined approach with all the three techniques showed the highest rate of positivity, followed by the association of direct examination and histopathology. CONCLUSIONS To our knowledge, this study included the largest number of nail specimens to date, allowing a comparison between direct examination, culture and histopathology. Direct examination showed to be the most performing technique in routine practice. Histopathology represents the most effective option in cases where both specimen size and laboratory resources are adequate. Our paper adds to the literature the 'real-life' experience of the mycology laboratory of a referral centre for nail diseases.
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Affiliation(s)
- Pauline Lecerf
- Dermatology Department, University Hospitals Brugmann & Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium.,Queen Fabiola Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Salome Abdy
- Dermatology Department, University Hospitals Brugmann & Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium.,Queen Fabiola Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Laura Vollono
- Dermatology Unity, Department of "Medicina Dei Sistemi", Tor Vergata University, Rome, Italy
| | - Ievgenia Pastushenko
- Laboratory of Stem Cells and Cancer, Université Libre de Bruxelles, Brussels, Belgium
| | - Bertrand Richert
- Dermatology Department, University Hospitals Brugmann & Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium.,Queen Fabiola Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Josette André
- Dermatology Department, University Hospitals Brugmann & Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium.,Queen Fabiola Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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5
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Shalin SC, Ferringer T, Cassarino DS. PAS and GMS utility in dermatopathology: Review of the current medical literature. J Cutan Pathol 2020; 47:1096-1102. [PMID: 32515092 DOI: 10.1111/cup.13769] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/06/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022]
Abstract
The American Society of Dermatopathology has established an Appropriate Use Criteria (AUC) Committee with the intention of establishing evidence-based recommendations regarding the appropriateness of various ancillary tests commonly utilized by dermatopathologists. Periodic acid Schiff (PAS) and Grocott (or Gomori) methenamine silver (GMS) stains represent some of the most commonly employed ancillary tests in dermatopathology. The utility of these tests was targeted for evaluation by the AUC. This literature review represents a comprehensive evaluation of available evidence for the utility of PAS and/or GMS staining of skin and nail biopsies. In concert with expert opinion, these data will be incorporated into future recommendations by the AUC for PAS and GMS staining in routine dermatopathology practice.
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Affiliation(s)
- Sara C Shalin
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Tammie Ferringer
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania, USA.,Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - David S Cassarino
- Department of Pathology and Laboratory Medicine, Southern California Permanente Medical Group, Los Angeles, California, USA
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6
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[Evaluation of the usefulness of nail biopsy in the diagnosis of onychomycosis]. Rev Iberoam Micol 2019; 36:72-78. [PMID: 31153723 DOI: 10.1016/j.riam.2018.06.001] [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: 03/07/2017] [Revised: 05/07/2018] [Accepted: 06/08/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Onychomycosis affects between 2% to 30% of the world population. Nail biopsy may help in making a diagnosis and can distinguish between invasion and colonisation. AIMS To evaluate the diagnostic usefulness of nail biopsy with Periodic acid-Schiff (PAS) staining for onychomycosis, compared to direct KOH examination, culture and its combination in a reference laboratory in Colombia. METHODS The study included 66 patients in whom a blind and independent reading of the three tests was performed. The usefulness was defined based on the validity (sensitivity, specificity, Youden's index, likelihood ratios), performance (predictive values) efficiency (proportion of correctly diagnosed patients), and reproducibility (kappa coefficient). RESULTS The mean age of the patients was 55±16 years, and included 76% women. The direct tests with KOH were positive in 66.7% (n=44), 62.1% (n=41) were positive with culture, and 56.1% (n=37) with the biopsy. The main causal agents were non-dermatophytes moulds in 36.4% (n=24). The most frequent species were Neoscytalidium dimidiatum (n=11), Trichophyton rubrum (n=11), and Candida parapsilosis (n=13). The sensitivity of nail biopsy, when compared to the standard (KOH and/or culture), was 71%, specificity 83%, Youden's index 0.54, positive likelihood ratio 4.25, negative likelihood ratio 0.35, positive predictive value 92%, negative predictive value 52%, efficiency 74% and kappa coefficient 0.45. When biopsy was evaluated only in patients with onycholysis of the nail plate greater than 50%, all the parameters of diagnostic usefulness increased. CONCLUSIONS The overall usefulness of the biopsy was moderate for patients with more severe symptomatology, which makes its use advisable in cases of extensive onycholysis, and when discriminating colonisation from invasion is required.
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Inhibitory Effects of Berberine Hydrochloride on Trichophyton mentagrophytes and the Underlying Mechanisms. Molecules 2019; 24:molecules24040742. [PMID: 30791402 PMCID: PMC6412246 DOI: 10.3390/molecules24040742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND T. mentagrophytes can infect all mammals, including rabbits, causing serious infections with remarkable economic losses for rabbit farmers. Berberine is an alkaloid that is effective against a variety of microbial infections such as T. mentagrophytes. Growth curve by dry weight determination and in-vivo antifungal assay were carried out to clarify the inhibitory effect of berberine hydrochloride against T. mentagrophytes. Transcriptomics analyses were also carried out for better understanding of the underlying mechanisms. RESULTS The growth rate of T. mentagrophytes was significantly higher in control condition than under berberine hydrochloride or clotrimazole for 60 h. The growth rate of T. mentagrophytes was significantly slighter higher in berberine condition (1 mg) than under clotrimazole for 46 h. T. mentagrophytes seriously shrunk after berberine or clotrimazole treatment, as observed by TEM and in SEM. Significant recovery was evident in three berberine groups on day 6 compared with the DMSO group. Results from transcriptomics analyses showed 18,881 identified unigenes, including 18,754 and 12,127 in the NT and SwissProt databases. Among these, 12,011, 9174, and 11,679 unigenes belonged to 3 Gene Ontology (GO), 43 KEGG, and 25 KOG categories, respectively. Interestingly, we found that down-regulation of 14α-demethylase exposed to various medicines was slightly different, i.e., berberine hydrochloride (fold change -3.4956) and clotrimazole (fold change -2.1283) caused various degrees of alteration. CONCLUSIONS Berberine hydrochloride could inhibit the growth of T. mentagrophytes. Berberine hydrochloride could also cure dermatosis induced by T. mentagrophytes. Down-regulation of 14α-demethylase exposed to various medicines was slightly different and might be one of the anti-resistance mechanisms of berberine hydrochloride in T. mentagrophytes. The present investigation provides considerable transcript sequence data that would help further assess the antifungal mechanisms against T. mentagrophytes, for antifungal medicine development.
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8
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Karaman BF, Açıkalın A, Ünal İ, Aksungur VL. Diagnostic values of KOH examination, histological examination, and culture for onychomycosis: a latent class analysis. Int J Dermatol 2018; 58:319-324. [DOI: 10.1111/ijd.14255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/22/2018] [Accepted: 08/31/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Arbil Açıkalın
- Department of Pathology; Faculty of Medicine; Çukurova University; Adana Turkey
| | - İlker Ünal
- Department of Biostatistics; Faculty of Medicine; Çukurova University; Adana Turkey
| | - Varol L. Aksungur
- Department of Dermatology; Faculty of Medicine; Çukurova University; Adana Turkey
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9
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Velasquez-Agudelo V, Cardona-Arias JA. Meta-analysis of the utility of culture, biopsy, and direct KOH examination for the diagnosis of onychomycosis. BMC Infect Dis 2017; 17:166. [PMID: 28222676 PMCID: PMC5320683 DOI: 10.1186/s12879-017-2258-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/10/2017] [Indexed: 12/14/2022] Open
Abstract
Background Onychomycosis is a highly prevalent disease worldwide. There is no standard test for its diagnosis, which remains costly, wasteful, and is sometimes delayed. The diagnostic tests for this disease are few and discordant. The objective was to evaluate the diagnostic validity, performance, and accuracy of culture, nail clipping with Periodic Acid-Schiff –PAS- staining (biopsy), and direct potassium hydroxide (KOH) examination for the study of onychomycosis. Methods A systematic review was conducted via meta-analysis using 5 databases and 21 search strategies. An ex ante protocol was applied with inclusion and exclusion criteria. Quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool, and the sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratios, receiver operating characteristic (ROC) curves, and proportion of correctly diagnosed patients were evaluated with the meta-analysis of studies of evaluations of diagnostic and screening tests (Meta-DiSc) and Epidat using a random effects model. Results The efficiency or accuracy of the three tests is influenced by the methodological quality of the studies. These values are lower for KOH and culture and higher for biopsy in moderate quality studies. Conclusion The diagnostic tests evaluated in this meta-analysis independently showed acceptable validity, performance, and efficiency, with nail clipping with PAS staining outperforming the other two tests.
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Affiliation(s)
- Verónica Velasquez-Agudelo
- Biological Research Corporation (Corporación para Investigaciones Biológicas - CIB), Medellín, Colombia.,Experimental Medical Mycology Research Group, CIB, Medellín, Colombia
| | - Jaiberth Antonio Cardona-Arias
- School of Microbiology, University of Antioquia (Universidad de Antioquia), Calle 67 Número 53 - 108, Bloque 5, oficina 103, Medellín, Colombia. .,Faculty of Medicine, Cooperative University of Colombia (Universidad Cooperativa de Colombia), Medellín, Colombia.
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10
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Jung MY, Shim JH, Lee JH, Lee JH, Yang JM, Lee DY, Jang KT, Lee NY, Lee JH, Park JH, Park KK. Comparison of diagnostic methods for onychomycosis, and proposal of a diagnostic algorithm. Clin Exp Dermatol 2015; 40:479-84. [DOI: 10.1111/ced.12593] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. Y. Jung
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J. H. Shim
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J. H. Lee
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J. H. Lee
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J. M. Yang
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - D.-Y. Lee
- Department of Dermatology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - K.-T. Jang
- Department of Pathology; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - N. Y. Lee
- Laboratory Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J.-H. Lee
- Laboratory Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - J.-H. Park
- Department of Dermatology; Kangbuk Samsung Hospital; Seoul Korea
| | - K. K. Park
- Division of Dermatology; Loyola University Medical Center; Maywood IL USA
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11
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Kim WJ, Kim TW, Mun JH, Song M, Kim HS, Ko HC, Kim BS, Park CW, Lee SJ, Lee MH, Lee KS, Kye YC, Suh KS, Chung H, Lee AY, Kim KH, Lee SK, Park KC, Lee JY, Choi JH, Lee ES, Lee KH, Choi EH, Seo JK, Choi GS, Park HJ, Yun SK, Seo SJ, Yoon TY, Kim KH, Yu HJ, Ro YS, Kim MB. Tinea incognito in Korea and its risk factors: nine-year multicenter survey. J Korean Med Sci 2013; 28:145-51. [PMID: 23341725 PMCID: PMC3546093 DOI: 10.3346/jkms.2013.28.1.145] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/31/2012] [Indexed: 11/20/2022] Open
Abstract
Tinea incognito (TI) is a dermatophytic infection which has lost its typical clinical appearance because of improper use of steroids or calcineurin inhibitors. The incidence of TI is increasing nowadays. We conducted retrospective review on 283 patients with TI from 25 dermatology training hospitals in Korea from 2002-2010 to investigate the demographical, clinical, and mycological characteristics of TI, and to determine the associated risk factors. More than half (59.3%) patients were previously treated by non-dermatologists or self-treated. The mean duration of TI was 15.0 ± 25.3 months. The most common clinical manifestations were eczema-like lesion, psoriasis-like, and lupus erythematosus-like lesion. The trunk and face were frequently involved, and 91 patients (32.2%) also had coexisting fungal infections. Among 67 isolated strains, Trichophyton rubrum was the most frequently detected (73.1%). This is the largest study of TI reported to date and the first investigational report concerning TI in Korea. We suggest that doctors should consider TI when a patient has intractable eczema-like lesions accompanied by tinea pedis/unguium. Furthermore, there should be a policy change, which would make over-the-counter high-potency topical steroids less accessible in some countries, including Korea.
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Affiliation(s)
- Won-Jeong Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Tae-Wook Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Je-Ho Mun
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Margaret Song
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hoon-Soo Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byung-Soo Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chun Wook Park
- Department of Dermatology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seok-Jong Lee
- Department of Dermatology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Mu Hyoung Lee
- Department of Dermatology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kyu Suk Lee
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Korea
| | - Young Chul Kye
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Kee Suck Suh
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Hyun Chung
- Department of Dermatology, The Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Ai Young Lee
- Department of Dermatology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ki Ho Kim
- Department of Dermatology, Dong-A University College of Medicine, Busan, Korea
| | - Sook Kyung Lee
- Department of Dermatology, Maryknoll Medical Center, Busan, Korea
| | - Kyoung Chan Park
- Department of Dermatology, Seoul National University Bundang Hostpital, Seongnam, Korea
| | - Jun Young Lee
- Department of Dermatology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jee Ho Choi
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-So Lee
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| | - Kwang Hoon Lee
- Department of Dermatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eung Ho Choi
- Department of Dermatology, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong Keun Seo
- Department of Dermatology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Gwang Seong Choi
- Department of Dermatology, Inha University College of Medicine, Incheon, Korea
| | - Hai Jin Park
- Department of Dermatology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Seok Kweon Yun
- Department of Dermatology, Chonbuk National University Medical School, Jeonju, Korea
| | - Seong Jun Seo
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae Young Yoon
- Department of Dermatology, Chungbuk National University School of Medicine, Cheongju, Korea
| | - Kwang Ho Kim
- Department of Dermatology, Hallym University College of Medicine, Anyang, Korea
| | - Hee Joon Yu
- Department of Dermatology, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Young Suck Ro
- Department of Dermatology, Hanyang University College of Medicine, Seoul, Korea
| | - Moon-Bum Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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