1
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Nijenhuis-Rosien L, Kleefstra N, van Dijk PR, Wolfhagen MJHM, Groenier KH, Bilo HJG, Landman GWD. Laser therapy for onychomycosis in patients with diabetes at risk for foot ulcers: a randomized, quadruple-blind, sham-controlled trial (LASER-1). J Eur Acad Dermatol Venereol 2019; 33:2143-2150. [PMID: 30920059 DOI: 10.1111/jdv.15601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers. OBJECTIVE The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy. METHODS In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up. RESULTS From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe. CONCLUSION At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.
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Affiliation(s)
- L Nijenhuis-Rosien
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Innofeet, Zwolle, The Netherlands
| | - N Kleefstra
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands.,University of Groningen, Groningen, The Netherlands.,Medical Research Group Langerhans, Ommen, The Netherlands
| | - P R van Dijk
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M J H M Wolfhagen
- Laboratory of Medical Microbiology and Infectious Diseases, Isala, Zwolle, The Netherlands
| | | | - H J G Bilo
- Diabetes Centre, Isala, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands.,University of Groningen, Groningen, The Netherlands
| | - G W D Landman
- Medical Research Group Langerhans, Ommen, The Netherlands.,Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
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2
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Bajuk V, Leskovec NK, Ručigaj TP, Suhodolčan AB, Dolenc-Voljč M. Toenail alterations in chronic venous disease patients are not always of mycotic origin. Phlebology 2018; 34:421-426. [PMID: 30541415 DOI: 10.1177/0268355518818619] [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]
Abstract
Objective The prevalence of toenail alterations in chronic venous disease has only rarely been studied. We aimed to establish the frequency and clinical characteristics of toenail onychomycosis in chronic venous disease. Methods We included 80 adult patients, in all stages of chronic venous disease. Onychomycosis was confirmed by mycological examination. The clinical type of onychomycosis and the onychomycosis severity index were determined. Clinical characteristics of non-fungal nail changes were also analyzed. Results We included 58 women and 22 men, with a mean age of 67.0 years. Pathological toenail changes were observed in 83.8% of patients. Onychomycosis was confirmed in 33.8% of all patients and was more frequent in higher clinical stages of chronic venous disease (p = 0.009). Trichophyton rubrum was the leading causative pathogen. Disto-lateral onychomycosis was most commonly present. Average onychomycosis severity index was 23.1. Conclusion Onychomycosis accounted for 40% of all toenail alterations. Patients with chronic venous disease often have severe and difficult to treat toenail onychomycosis.
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Affiliation(s)
- Vid Bajuk
- 1 Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nada Kecelj Leskovec
- 1 Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tanja Planinšek Ručigaj
- 1 Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Mateja Dolenc-Voljč
- 1 Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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3
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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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4
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Lipner SR, Scher RK. Efinaconazole 10% topical solution for the topical treatment of onychomycosis of the toenail. Expert Rev Clin Pharmacol 2015; 8:719-31. [PMID: 26325488 DOI: 10.1586/17512433.2015.1083418] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Efinaconazole 10% topical solution is a new antifungal therapy for the topical treatment of mild to moderate toenail onychomycosis. In vitro and in vivo data have shown significant antifungal activity against dermatophytes, Candida spp. and nondermatophyte molds, and its mechanism of action is through inhibition of fungal lanosterol 14α-demethylase. In two parallel, double-blind, randomized, controlled, Phase III trials, complete cure rates were 17.8 and 15.2%, respectively, and mycological cure rates were 55.2 and 53.4%, respectively, for efinaconazole 10% topical solution, which were superior to vehicle, with minimal adverse events. This drug profile reviews the most recent basic science and clinical data for efinaconazole in the treatment of toenail onychomycosis.
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Affiliation(s)
| | - Richard K Scher
- a Department of Dermatology, Weill Cornell Medical College , NY, USA
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5
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Abstract
Efinaconazole 10% topical solution is a new triazole recently approved for the treatment of onychomycosis. It inhibits fungal lanosterol 14α-demethylase in the ergosterol biosynthesis pathway, has potent antifungal activity against dermatophytes, as well as activity against Candida spp. and non-dermatophyte molds, and showed promising results in clinical trials. This review summarizes the mechanism of action, in vitro and in vivo data, clinical trials, safety, and quality-of-life data of efinaconazole as it applies to the treatment of onychomycosis.
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Affiliation(s)
- Shari R Lipner
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
| | - Richard K Scher
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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6
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Nijenhuis-Rosien L, Kleefstra N, Wolfhagen MJ, Groenier KH, Bilo HJG, Landman GWD. Laser therapy for onychomycosis in patients with diabetes at risk for foot complications: study protocol for a randomized, double-blind, controlled trial (LASER-1). Trials 2015; 16:108. [PMID: 25872590 PMCID: PMC4381488 DOI: 10.1186/s13063-015-0622-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/27/2015] [Indexed: 11/25/2022] Open
Abstract
Background In a sham-controlled double-blind trial, we aim to establish the efficacy and safety of the local application of laser therapy in patients with diabetes, onychomycosis and risk factors for diabetes-related foot complications. Onychomycosis leads to thickened and distorted nails, which in turn lead to increased local pressure. The combination of onychomycosis and neuropathy or peripheral arterial disease (PAD) increases the risk of developing diabetes-related foot complications. Usual care for high-risk patients with diabetes and onychomycosis is completely symptomatic with frequent shaving and clipping of the nails. No effective curative local therapies exist, and systemic agents are often withheld due to concerns for side effects and interactions. Methods/Design The primary aim is to evaluate the efficacy of four sessions of Nd:YAG 1064 nM laser application on the one-year clinical and microbiological cure rate in a randomized, double-blind, sham-controlled design with blinded outcome assessment. Mandatory inclusion criteria are diagnosis of diabetes, risk factors for developing foot ulcers defined as a modified Simm’s classification score 1 or 2 and either neuropathy or PAD. A total of 64 patients are randomized to intervention or sham treatment performed by a podiatrist. Discussion This study will be the first double-blind study that investigates the effects of local laser therapy on onychomycosis, specifically performed in patients with diabetes with additional risk factors for foot complications. Trial registration Clinical trials.gov as NCT01996995, first received 22 November 2013.
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Affiliation(s)
- Leonie Nijenhuis-Rosien
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Innofeet Voetencentrum Nijenhuis Podiatry, Simon Stevinweg 13, 8013 NA, Zwolle, the Netherlands.
| | - Nanne Kleefstra
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands. .,Langerhans Medical Research Group, Postbus 21, 4254 ZG, Sleeuwijk, the Netherlands.
| | - Maurice J Wolfhagen
- Department of Medical Microbiology, Isala, Dr. van Heesweg 2, 8025 AB, Zwolle, the Netherlands.
| | - Klaas H Groenier
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of General Practice, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | - Henk J G Bilo
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands. .,Department of General Practice, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | - Gijs W D Landman
- Diabetes Centre, Isala, Dr Spanjaardweg 11, 8025 BT, Zwolle, the Netherlands. .,Department of Internal Medicine, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, the Netherlands.
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7
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Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Res 2011; 4:26. [PMID: 22136082 PMCID: PMC3248359 DOI: 10.1186/1757-1146-4-26] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/04/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Effective treatment of tinea pedis and onychomycosis is crucial for patients with diabetes as these infections may lead to foot ulcers and secondary bacterial infections resulting in eventual lower limb amputation. Although numerous studies have assessed the effectiveness of antifungal drug and treatment regimens, most exclude patients with diabetes and examine otherwise healthy individuals. While these studies are useful, results cannot necessarily be extrapolated to patients with diabetes. The purpose of this study was to therefore identify the best evidence-based treatment interventions for tinea pedis or onychomycosis in people with diabetes. METHODS The question for this systemic review was: 'what evidence is there for the safety and/or efficacy of all treatment interventions for adults with tinea pedis and/or onychomycosis in people with diabetes'? A systematic literature search of four electronic databases (Scopus, EbscoHost, Ovid, Web of Science) was undertaken (6/1/11). The primary outcome measure for safety was self-reported adverse events likely to be drug-related, while the primary outcome measures assessed for 'efficacy' were mycological, clinical and complete cure. RESULTS The systematic review identified six studies that examined the safety and/or efficacy of treatment interventions for onychomycosis in people with diabetes. No studies were identified that examined treatment for tinea pedis. Of the studies identified, two were randomised controlled trials (RCTs) and four were case series. Based on the best available evidence identified, it can be suggested that oral terbinafine is as safe and effective as oral itraconazole therapy for the treatment of onychomycosis in people with diabetes. However, efficacy results were found to be poor. CONCLUSIONS This review indicates that there is good evidence (Level II) to suggest oral terbinafine is as safe and effective as itraconazole therapy for the treatment of onychomycosis in people with diabetes. Further research is needed to establish the evidence for other treatment modalities and treatment for tinea pedis for people with diabetes. Future efforts are needed to improve the efficacy of treatment intervention.
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Affiliation(s)
- Lisa Matricciani
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Kerwin Talbot
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Sara Jones
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
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8
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Özcan D, Seçkin D, Demirbilek M. In vitro antifungal susceptibility of dermatophyte strains causing tinea pedis and onychomycosis in patients with non-insulin-dependent diabetes mellitus: a case-control study. J Eur Acad Dermatol Venereol 2010; 24:1442-6. [DOI: 10.1111/j.1468-3083.2010.03666.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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9
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Ko JY, Lee HE, Jae H, Oh DH, Kim JS, Yu HJ. Cure rate, duration required for complete cure and recurrence rate of onychomycosis according to clinical factors in Korean patients. Mycoses 2010; 54:e384-8. [DOI: 10.1111/j.1439-0507.2010.01928.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Dai T, Tegos GP, Rolz-Cruz G, Cumbie WE, Hamblin MR. Ultraviolet C inactivation of dermatophytes: implications for treatment of onychomycosis. Br J Dermatol 2008; 158:1239-46. [PMID: 18410410 DOI: 10.1111/j.1365-2133.2008.08549.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Onychomycosis responds to systemic antifungals and sometimes to topical lacquers, but alternative treatments are desirable. Topical application of germicidal ultraviolet (UV) C radiation may be an acceptable and effective therapy for infected nails. OBJECTIVES To test the ability of UVC to inactivate dermatophyte suspensions in vitro and to sterilize a novel ex vivo model of nail infection. METHODS Trichophyton rubrum, T. mentagrophytes, Epidermophyton floccosum and Microsporum canis suspensions were irradiated with UVC (254 nm) at a radiant exposure of 120 mJ cm(-2) and surviving colony-forming units quantified. T. rubrum infecting porcine hoof slices and human toenail clippings was irradiated with UVC at radiant exposures of 36-864 J cm(-2). RESULTS In vitro studies showed that 3-5 logs of cell inactivation in dermatophyte suspensions were produced with 120 mJ cm(-2) UVC irradiation. Depending on factors such as the thickness and infectious burden of the ex vivo cultures, the radiant exposure of UVC needed for complete sterilization was usually in the order of tens to hundreds of J cm(-2). Resistance of T. rubrum to UVC irradiation did not increase after five cycles of subtotal inactivation in vitro. CONCLUSIONS UVC irradiation may be a less invasive treatment option for onychomycosis, when the appropriate consideration is given to safety.
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Affiliation(s)
- T Dai
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
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11
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Gupta S, Koirala J, Khardori R, Khardori N. Infections in Diabetes Mellitus and Hyperglycemia. Infect Dis Clin North Am 2007; 21:617-38, vii. [PMID: 17826615 DOI: 10.1016/j.idc.2007.07.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Infections in diabetes mellitus are relatively more common and serious. Diabetic patients run the risk of acute metabolic decompensation during infections, and conversely patients with metabolic decompensation are at higher risk of certain invasive infections. Tight glycemic control is of paramount importance during acute infected or high stress state. Infections in diabetic patients result in extended hospital stays and additional financial burden. Given the risks of not alleviating the metabolic dysregulation and the benefits of decent glycemic control, it is necessary that besides antimicrobial therapy, equal emphasis be placed on intensified glycemic control.
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Affiliation(s)
- Smita Gupta
- Division of Endocrinology, Metabolism and Molecular Medicine, Southern Illinois University School of Medicine, 701 North First Street, D-405B, PO Box 19636, Springfield, IL 62794-9636, USA.
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12
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Finnen MJ, Hennessy A, McLean S, Bisset Y, Mitchell R, Megson IL, Weller R. Topical application of acidified nitrite to the nail renders it antifungal and causes nitrosation of cysteine groups in the nail plate. Br J Dermatol 2007; 157:494-500. [PMID: 17627796 DOI: 10.1111/j.1365-2133.2007.08063.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Topical treatment of nail diseases is hampered by the nail plate barrier, consisting of dense cross-linked keratin fibres held together by cysteine-rich proteins and disulphide bonds, which prevents penetration of antifungal agents to the focus of fungal infection. Acidified nitrite is an effective treatment for tinea pedis. It releases nitric oxide (NO) and other NO-related species. NO can react with thiol (-SH) groups to form nitrosothiols (-SNO). OBJECTIVES To determine whether acidified nitrite can penetrate the nail barrier and cure onychomycosis, and to determine whether nitrosospecies can bind to the nail plate. METHODS Nails were treated with a mixture of citric acid and sodium nitrite in a molar ratio of 0.54 at either low dose (0.75%/0.5%) or high dose (13.5%/9%). Immunohistochemistry, ultraviolet-visible absorbance spectroscopy and serial chemical reduction of nitrosospecies followed by chemiluminescent detection of NO were used to measure nitrosospecies. Acidified nitrite-treated nails and the nitrosothiols S-nitrosopenicillamine (SNAP) and S-nitrosoglutathione (GSNO) were added to Trichophyton rubrum and T. mentagrophytes cultures in liquid Sabouraud medium and growth measured 3 days later. Thirteen patients with positive mycological cultures for Trichophyton or Fusarium species were treated with topical acidified nitrite for 16 weeks. Repeat mycological examination was performed during this treatment time. RESULTS S-nitrothiols were formed in the nail following a single treatment of low- or high-dose sodium nitrite and citric acid. Repeated exposure to high-dose acidified nitrite led to additional formation of N-nitrosated species. S-nitrosothiol formation caused the nail to become antifungal to T. rubrum and T. mentagrophytes. Antifungal activity was Cu(2+) sensitive. The nitrosothiols SNAP and GSNO were also found to be antifungal. Topical acidified nitrite treatment of patients with onychomycosis resulted in > 90% becoming culture negative for T. rubrum. CONCLUSIONS Acidified nitrite cream results in the formation of S-nitrosocysteine throughout the treated nail. Acidified nitrite treatment makes a nail antifungal. S-nitrosothiols, formed by nitrosation of nail sulphur residues, are the active component. Acidified nitrite exploits the nature of the nail barrier and utilizes it as a means of delivery of NO/nitrosothiol-mediated antifungal activity. Thus the principal obstacle to therapy in the nail becomes an effective delivery mechanism.
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Affiliation(s)
- M J Finnen
- Prostrakan Pharmaceuticals, Buckholm Mill Brae, Galashiels TS1 2HB, UK
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13
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Sumikawa M, Egawa T, Honda I, Yamamoto Y, Sumikawa Y, Kubota M. Effects of foot care intervention including nail drilling combined with topical antifungal application in diabetic patients with onychomycosis. J Dermatol 2007; 34:456-64. [PMID: 17584323 DOI: 10.1111/j.1346-8138.2007.00310.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We performed periodical foot care intervention including nail drilling combined with topical antifungal application for 6 months or more in 24 diabetic patients with onychomycosis who were not receiving oral antifungals, and evaluated its effects. The type of onychomycosis was superficial white onychomycosis (SWO) in eight patients, and distal-lateral subungual onychomycosis (DLSO) in 16. The state of onychomycosis was evaluated according to the Scoring Clinical Index for Onychomycosis (SCIO). Of the eight patients with SWO, none showed aggravation of the onychomycosis state, and two were cured 6 months after the initiation of intervention and two after 1 year (total of four patients, 50%). In the patients with DLSO, the SCIO score was 18.1 +/- 6.5 before intervention but significantly decreased to 14.6 +/- 6.6 6 months after intervention. In 12 patients who we were able to consecutively follow up for 1 year, the SCIO score also significantly decreased compared with the score before intervention. Thus, foot care intervention including nail drilling combined with topical antifungal application had effects on onychomycosis and achieved cure in some patients with SWO. In addition, intervention increased patients' awareness of foot care, showing educational effects. Therefore, foot care intervention including nail drilling may be useful.
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Affiliation(s)
- Masuko Sumikawa
- Department of Nursing, School of Health Science, Faculty of Medicine, Kyoto University, Kyoto, Japan.
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14
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Bonifaz A, Paredes V, Fierro L. Onychocryptosis as consequence of effective treatment of dermatophytic onychomycosis. J Eur Acad Dermatol Venereol 2007; 21:699-700. [PMID: 17447997 DOI: 10.1111/j.1468-3083.2006.01994.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Torres-Rodríguez JM, Sellart-Altisent M. Celulitis y onicomicosis proximal de ambos ortejos mayores producida por Fusarium solani. Rev Iberoam Micol 2006; 23:241-4. [PMID: 17388651 DOI: 10.1016/s1130-1406(06)70053-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We report a case of proximal fold cellulitis in both big toes, associated with a bilateral proximal onychomycosis and an intertrigo of the fourth space due to Fusarium solani. The infection occurred in an immunocompetent man with diabetes mellitus type II. Apparently, the infection was acquired in a tropical country and once the patient was in Spain the infection progressed causing nail detachment (onychomadesis). Seven months later a relapse that affected the left toenail occurred. The patient was treated topically with chemical toenail avulsion contained 40% urea associated with bifonazole followed by ciclopirox-olamine nail lacquer for 12 months. Complete cure without relapse was observed after 10 years of follow-up. In vitro antifungal susceptibility study demonstrated that two of the recovered isolates were both resistant to itraconazole and voriconazole.
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Affiliation(s)
- Josep M Torres-Rodríguez
- URMIM (Unidad de Investigación de Enfermedades Infecciosas y Micología), IMIM, Facultad de Medicina, Universitat Autònoma de Barcelona, c/ Dr. Aiguader, 80, 08003 Barcelona, Spain.
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16
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Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJM. Evidence-Based Protocol for Diabetic Foot Ulcers. Plast Reconstr Surg 2006; 117:193S-209S; discussion 210S-211S. [PMID: 16799388 DOI: 10.1097/01.prs.0000225459.93750.29] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations. METHODS The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed. RESULTS The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds. CONCLUSIONS In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.
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Affiliation(s)
- Harold Brem
- Department of Surgery, Wound Healing Program, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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17
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Abstract
The skin is a target organ of several hormones. Specific diseases appear in consequence of hypo- or hypersecretion of endocrine organs, particularly in the elderly patient. There, knowledge of skin alterations is important not only for dermatologists, but also for endocrinologists and other physicians, because a clinical diagnosis of the underlying disease is often possible. In this review, a number of representative skin diseases having an endocrinological basis are described. These include acanthosis nigricans, diseases due to alterations of androgen metabolism, carcinoid syndrome, diseases due to alterations of corticosteroid metabolism, diseases in association with diabetes mellitus, diseases due to alterations of estrogen metabolism, genetic syndromes including dermatological and endocrine symptoms, the glucagonoma syndrome, diseases due to dysfunctions of growth hormone secretion, diseases in association with Merkel cells of the skin, diseases due to dysfunctions of the thyroid gland, diseases to alteration of vitamin D metabolism, and vitiligo and disorders of pigmentation.
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Affiliation(s)
- Walter Krause
- Department of Dermatology, Philipps University, Marburg, Germany.
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18
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Kulac M, Acar M, Karaca S, Cetinkaya Z, Albayrak R, Haktanir A, Demirel R. Venous insufficiency in patients with toenail onychomycosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:1085-9. [PMID: 16040823 DOI: 10.7863/jum.2005.24.8.1085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Onychomycosis is a common fungal infection of the toenails and can originate secondary to vascular abnormalities. The aim of this study was to evaluate the relationship between onychomycosis and venous insufficiency. METHODS Forty-two patients with onychomycosis and 39 healthy control subjects who had normal toenails were enrolled in the study. Doppler examinations were performed with a commercially available scanner and a 7.5-MHz linear probe. Major superficial and deep veins of the lower limb, including long and short saphenous, femoral, and popliteal veins, were examined. Venous insufficiency was assessed with the Valsalva test. With the Doppler examination, retrograde flow of more than 1 second was accepted as venous insufficiency. RESULTS Venous insufficiency was detected more frequently in patients with onychomycosis than in the control group (15 [35.7%] of 42 and 6 [15.4%] of 39, respectively; P = .037). Reflux was bilateral in 4 (26.7%) of 15 patients with onychomycosis, and in those 4 patients the onychomycosis was also bilateral. In 7 (46.7%) of 15 patients, onychomycosis and venous insufficiency were detected ipsilaterally, whereas there were no onychopathic features contralaterally. Although unilateral insufficiency was present in 4 (26.7%) of 15 patients, these patients had bilateral onychomycosis. CONCLUSIONS We found a significant relationship between onychomycosis and venous insufficiency; therefore, we recommend a routine venous Doppler examination for patients with onychomycosis to diagnose or rule out venous insufficiency.
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Affiliation(s)
- Mustafa Kulac
- Department of Dermatology, Afyon Kocatepe University, Faculty of Medicine, Kirmizi Hastane, Turkey
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19
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Abstract
Each year, 82,000 limb amputations are performed in patients with diabetes mellitus. The majority of these amputations could be avoided by following strict protocols. The collective experience treating patients with neuropathic diabetic foot ulcers of 4 major diabetic foot programs in the United States and Europe were analyzed. The following protocol has been developed for patients with diabetic foot ulcers: (1) measurement of the wound by planimetry; (2) optimal glucose control; (3) surgical debridement of all hyperkeratotic, infected, and nonviable tissue; (4) systemic antibiotics for deep infection, drainage, and cellulitis; (5) offloading; (6) moist-wound environment; and (7) treatment with growth factors and/or cellular therapy if the wound is not healing after 2 weeks with this protocol and a new epithelial layer is not forming. In addition, the pathogenesis of diabetic foot ulcers is discussed, as well as the associated costs and complications, including amputation. Debridement, wound-bed preparation, antibiotics, various types of dressings, biological therapies, growth factors, and offloading are described as treatment modalities for patients with diabetic foot ulcers. In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensure rapid healing and minimize morbidity, mortality, and costs, as well as eliminate amputation in the absence of ischemia and osteomyelitis.
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Affiliation(s)
- Harold Brem
- Department of Surgery, Columbia University College of Physicians & Surgeons, 5141 Broadway, New York, New York 10034, USA.
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20
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Abstract
Superficial fungal infections of the foot (tinea pedis and onychomycosis) are common among elderly patients. Although most authorities believe that patients with diabetes mellitus have an increased predisposition to dermatophytic infections, some controversies still remain. Because these infections disrupt the skin integrity and provide an avenue for bacterial superinfection, elderly diabetic patients with dermatophytic infection should be promptly treated with an antifungal agent. For most dermatophytic infections of the foot, topical agents are usually effective and less expensive than oral agents. Laboratory diagnosis of fungal infection prior to institution of therapy is recommended. Proper technique for obtaining the specimen is important to ensure a higher chance of isolating the infecting fungus. Commonly used anti-dermatophytic agents that are also active against the yeasts include the imidazoles, the allylamines-benzylamines and the hydroxypyridones, which are also effective against most of the moulds. Oral therapy for tinea pedis, although not well studied, should be limited to patients with more extensive infections, such as vesicobullous and moccasin type, resistant infections or chronic infections. In addition, oral agents should also be considered in diabetic and immunosuppressed patients. On the other hand, treatment of onychomycosis of the foot usually requires systemic therapy. Griseofulvin is the least effective agent when compared with the newer agents. Terbinafine, itraconazole and fluconazole have been shown to have acceptable cure rates. More recently, topical treatment of the nail with 8% ciclopirox nail lacquer, bifonazole with urea and amorolfine have been reported to be successful. Over the past decade, fungal foot infections of the skin and nail are more effectively treated with the introduction of numerous topical and oral agents.
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Affiliation(s)
- James S Tan
- Department of Internal Medicine, Northeastern Ohio Universities College of Medicine, Ohio, USA.
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21
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Current literature in diabetes. Diabetes Metab Res Rev 2003; 19:333-40. [PMID: 12879412 DOI: 10.1002/dmrr.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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