High prevalence of foot diseases in Europe: results of the Achilles Project

Developing diagnostic criteria to differentiate fungal foot infections caused by Neoscytalidium dimidiatum and dermatophytes

Background

The predisposing factors and clinical presentations of fungal foot infections caused by non-dermatophytes and dermatophytes are challenging to differentiate. Definite diagnoses of non-dermatophyte infections at first visits facilitate their treatment.

Objectives

This study aimed to develop diagnostic criteria to differentiate fungal foot infections caused by Neoscytalidium dimidiatum and dermatophytes.

Methods

Diagnostic prediction research based on a retrospective, observational, cross-sectional study. The reviewed patients were aged ≥18 and underwent a mycological examination for fungal foot infections. A fungal culture at the initial visit was the gold standard for determining causative organisms.

Results

Analyses were carried out on the data from 371 patients. N. dimidiatum accounted for 184 (49.6%) infections, and dermatophytes caused the remaining 187 (50.4%) cases. Five significant predefined predictors were used to develop the diagnostic criteria and score. They were immunocompetence status, no family history of fungal infections, the absence of pruritus, the absence of other concurrent fungal skin infections, and agricultural work. The lower score cutoff was <8 (sensitivity 97.8% and specificity 25.7%). The higher cutoff was >11 (sensitivity 83.7% and specificity 57.8%). The score showed an area under the receiver operating characteristic curve of 0.755 and was well calibrated.

Conclusions

The criteria and score show promise for clinical use, with acceptable discriminative performance and good calibration. They will help physicians differentiate the causative organisms in patients with fungal foot infections at the first visit, enabling the determination of appropriate antifungal treatment.

Tinea Unguium and Tinea Pedis and Their Correlation With Diabetes Mellitus in the General Population in the Hail Region, Saudi Arabia: A Cross-Sectional Study

Background Tinea pedis or foot ringworm is an infection of the feet affecting the soles, interdigital clefts of toes, and nails, with a dermatophyte fungus. It is also called athlete's foot. Onychomycosis of the nail is caused by dermatophytes called Tinea unguium. An abnormal nail not caused by a fungal infection is a type of dystrophic nail. Onychomycosis can infect both fingernails and toenails, but onychomycosis of the toenail is much more prevalent. Aim The study aimed to assess the knowledge, perception, and awareness among a sample from Ha'il City, Saudi Arabia, of the definitions, risk factors, symptoms, diagnosis, complications, and treatment of both Tinea pedis and Tinea unguium, along withtheir correlation with diabetic patients. Material A cross-sectional survey was distributed throughout Ha'il City. An online questionnaire was designed and distributed via various social media apps, which included questions concerning participants' sociodemographic information, alongside questions regarding the risk factors, signs, symptoms, complications, and management of both Tinea pedis and Tinea unguium. Methods SPSS for Windows v22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for statistical analysis. Results The overall awareness of the study's participants about Tinea Pedis and Tinea unguium infection was low (34.82%).

Investigation of Nagashima-type palmoplantar keratoderma in China: A cross-sectional study of 234 patients

Nagashima-type palmoplantar keratoderma (NPPK) is the most prevalent hereditary palmoplantar keratoderma (PPK) in China, but there is a paucity of epidemiological data on the Chinese population. To explore the clinical and genetic characteristics, evaluate the demographic distribution, and estimate the burden of disease of NPPK. A total of 234 Chinese patients with NPPK were enrolled from two medical centers and an online PPK support group. Next-generation sequencing and Sanger sequencing were performed to screen out and confirm pathogenic mutations in SERPINB7. Clinical features and quality of life (QOL) were evaluated using self-completed questionnaires. In total, 14 pathogenic mutations were identified in SERPINB7 from the cohort. The top four recurrent mutations were c.796C>T (355, 75.9%), c.522dupT (66, 14.1%), c.650_653delCTGT (24, 5.1%), and c.455G>T (12, 2.6%), accounting for 97.6% of Chinese NPPK patients. Other mutations (11, 2.4%) include c.455-1G>T, c.336+2T>G, c.635delG and seven novel mutations c.2T>C, c.434delG, c.455-16A>G, c.656T>C, c.745-553T>G, c.832C>T, c.1036G>T. The estimated prevalence of NPPK in China was found to be 0.975/10 000 based on Chinese databases. Clinically, there were no apparent genotype-phenotype correlations in NPPK patients. Pediatric patients mainly presented with palmoplantar peeling, while adults presented with scale (p < 0.001). The most common comorbidities in NPPK patients were onychomycosis (40.0%), eczema (36.8%), and tinea pedis (30.3%). As for burden of disease, NPPK patients' QOL was decreased by a moderate degree. In this study, pathogenic mutations' allele frequencies in SERPINB7 were updated, and prevalence of NPPK in China was estimated. This large-scale cohort study provides evidence-based recommendations for patient management. Identification of new mutations are important for timely diagnosis of NPPK. Palmoplantar peeling in children can be used as a hallmark for early recognition of NPPK.

Updated Perspectives on the Diagnosis and Management of Onychomycosis

Onychomycosis is the most common nail disease encountered in clinical practice and can cause pain, difficulty with ambulation, and psycho-social problems. A thorough history and physical examination, including dermoscopy, should be performed for each patient presenting with nail findings suggestive of onychomycosis. Several approaches are available for definitive diagnostic testing, including potassium hydroxide and microscopy, fungal culture, histopathology, polymerase chain reaction, or a combination of techniques. Confirmatory testing should be performed for each patient prior to initiating any antifungal therapies. There are several different therapeutic options available, including oral and topical medications as well as device-based treatments. Oral antifungals are generally recommended for moderate to severe onychomycosis and have higher cure rates, while topical antifungals are recommended for mild to moderate disease and have more favorable safety profiles. Oral terbinafine, itraconazole, and griseofulvin and topical ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the Food and Drug Administration for treatment of onychomycosis in the United States and amorolfine 5% nail lacquer is approved in Europe. Laser treatment is approved in the United States for temporary increases in clear nail, but clinical results are suboptimal. Oral fluconazole is not approved in the United States for onychomycosis treatment, but is frequently used off-label with good efficacy. Several novel oral, topical, and over-the-counter therapies are currently under investigation. Physicians should consider the disease severity, infecting pathogen, medication safety, efficacy and cost, and patient age, comorbidities, medication history, and likelihood of compliance when determining management plans. Onychomycosis is a chronic disease with high recurrence rates and patients should be counseled on an appropriate plan to minimize recurrence risk following effective antifungal therapy.

Epidemiology of Onychomycosis in Chinese Mainland: A 30-year Retrospective Study

BACKGROUND

Onychomycosis was a common nail disease caused by dermatophytes, yeasts or molds. The prevalence of onychomycosis varied in different counties and it was necessary to understand the epidemiology in China.

OBJECTIVES

This study was conducted to investigate the epidemiology of onychomycosis in Chinese mainland in the past 30 years.

METHODS

A 30-year systemic review was carried out by searching publications investigating the prevalence of onychomycosis in Chinese mainland from 1991 to 2020.

RESULTS

A total of 90 articles involving more than 40,000 onychomycosis patients were enrolled in this study. The ratio of males to females was 1:1.32. Fingernail onychomycosis was found in 36.12% cases, toenail onychomycosis in 48.31%, and both fingernail and toenail onychomycosis in 15.57%. The most common clinical type of onychomycosis was distal lateral subungual onychomycosis (60.99%), followed by total dystrophic onychomycosis (18.91%), proximal subungual onychomycosis (10.19%) and superficial white onychomycosis (9.92%). Dermatophytes (60.59%) were the most frequently isolated pathogens, followed by yeasts (30.09%), molds (7.91%) and mixed infection (1.41%). The primary pathogens in dermatophytes, yeasts and molds were Trichophyton rubrum (49.93%), Candida albicans (10.99%) and Aspergillus (3.11%), respectively. Additionally, dermatophytes were more commonly affected males than females (63.69% vs. 51.57%), and mostly involved in toenail onychomycosis (75.63%). The infection of yeasts was higher in females than males (40.97% vs. 29.52%), often causing onychomycosis in fingernail than toenail (41.03% vs. 17.08%), and it was more common in warm and humid southern regions than northern area (34.07% vs. 24.41%).

CONCLUSION

The proportion of the causative agents changed over time, dermatophytes, especially T. rubrum had always been the predominant pathogen, followed by yeasts and molds. The distribution of fungal pathogens varied among clinical types, gender, infection sites and geography gender.

The Changing Face of Epidemiology of Dermatophytoses in Chinese Mainland: A 30 years Nationwide Retrospective Study from 1991 to 2020

BACKGROUND

Dermatophytoses are the most common infectious skin disease. Its epidemiology varies in different countries and regions, and its prevalence in China is still unknown.

OBJECTIVES

We aimed to reveal the epidemiological features of dermatophytoses in Chinese mainland in the past thirty years.

METHODS

From 1991 to 2020, a 30-year retrospective epidemiological study was carried out. All published literatures containing dermatophytoses and dermatophytes were collected and analyzed.

RESULTS

A total of more than 180,000 cases in 124 articles from more than 100 hospitals were included and analyzed. Among dermatophytoses, tinea cruris (24.92%) was the predominant clinical type, followed by tinea pedis (22.97%) and tinea corporis (18.12%). In recent 10 years, tinea pedis (25.40%) was more common than tinea cruris (22.39%) and became the most common infection. Among dermatophytes, T. rubrum (69.48%) has always been the most common isolates, followed by T. mentagrophytes (16.45%) and M. canis (8.09%). Other species were found below 3%. In superficial mycoses, dermatophytes accounted for 75.52%, higher than that of yeasts/yeast-like (21.83%) and molds (2.65%). The prevalence of tinea capitis was lower in economically developed eastern region than that in central and western regions. Tinea cruris was more common in warm zones than cold zones.

CONCLUSIONS

The top three dermatophytoses are tinea cruris, tinea pedis and tinea corporis, while the top three dermatophytes are T. rubrum, T. mentagrophytes and M. canis. The distribution of dermatophytoses may be influenced by socioeconomic status and geographical-meteorological conditions.

A Position Sensing Glove to Aid Ankle-Foot Orthosis Diagnosis and Treatment

A position sensing glove called SmartScan, which creates a 3D virtual model of a real object, is presented. The data from the glove is processed by a volume minimization algorithm to validate the position sensor data. This allows only data from the object’s surface to be retained. The data validation algorithm allows the user to progressively improve an image by repeatedly moving their hand over the object. In addition, the user can choose their own balance between feature resolution and invalid data rejection. The SmartScan glove is tested on a foot model and is shown to be robust against motion artifacts, having a mean accuracy of 2.9 mm (compared to a 3D model generated from optical imaging) without calibration.

Impact of quality of life related to foot problems: a case-control study

Foot problems are highly prevalent conditions, being a frequent reason for medical and podiatric consultation. The aim of this study was to compare the differences of quality of life (QoL) related to foot health in people with and without the presence of foot problems. A case–control study was carried out in an outpatient centre, where a clinician recorded data related to sociodemographic and clinical characteristics. In addition, self-reported data on foot health-related quality of life were recorded using the Spanish version of the Foot Health Status Questionnaire. The sample consisted of 498 participants (249 cases and 249 controls), with a median age of 30 years and an interquartile range of 23 years. The differences between the groups were statistically significant for gender, age, footwear, general health, foot health, and physical activity. Cases showed lower scores for the domain of footwear, physical activity and vitality compared to controls. Foot pathologies have a negative impact on quality of life related to foot health, and the domains of footwear, general health and physical activity seem to be the factors that are associated with the presence of alterations and foot deformities.

Multiplex RT-PCR provides improved diagnosis of skin and nail dermatophyte infections compared to microscopy and culture: a laboratory study and review of the literature

Dermatophytes are the most common cause of superficial mycosis, estimated to affect 20% to 25% of the general population. We assessed the performance of a novel real-time polymerase chain reaction (RT-PCR) multiplex assay for diagnosis of dermatophytosis. To evaluate sensitivity and specificity, 10 known bacteria and 10 known fungi commonly found on skin, as well as 105 samples with culture confirmed dermatophytosis were tested using Dermatophyte and Fungi assay (AusDiagnostics, Sydney, Australia), a novel multiplex assay for diagnosis of dermatophytosis in skin and nail. This was followed by prospective evaluation of 195 clinical samples for dermatophytosis by both conventional methods and RT-PCR. RT-PCR showed almost two-fold higher sensitivity and high specificity in the diagnosis of skin and nail dermatophytosis compared to traditional microscopy and culture. In addition, RT-PCR demonstrated markedly reduced turnaround time from 4 to 6 weeks to 4 to 6 hours and ability for high throughput.

Photodynamic Eradication of Trichophyton rubrum and Candida albicans

Conventional methods of onychomycosis treatment are ineffective in some cases because the cure of onychomycosis very often depends on the patient’s individual response to the treatment; therefore, there is a crucial need to research and develop new methods of onychomycosis therapy. One of the most innovative treatments is photodynamic therapy (PDT) using photosensitizers (PSs). However, effective treatment depends on the correct choice of photosensitizer and substances that improve the characteristics of the final formulation. The aim of our work was to find an effective formulation for the treatment of onychomycosis. To achieve this goal, we tested the effect of three types of PSs, rose Bengal (RB), malachite green oxalate (MGO), and methylene blue (MB), on Candida albicans. The most effective PS was RB, and so the study was continued with Trichophyton rubrum. Additional comparative studies were carried out on substances included in the formulation (urea and thiourea), focusing on their antifungal activity, which can improve penetration through the nail plate. The composition of the formulation that achieved 100% eradication of Trichophyton rubrum under our conditions consisted of 150 μM RB, 5% urea, and 0.5% thiourea in glycerol/water (70/30%, w/w) solution. A white luminescent lamp was used as a light source (1.9 ± 0.1 mW cm⁻²). Stability of the formulation was checked. The selected formulation shows potential for future simplification and acceleration of PDT treatment of onychomycosis.

Foot Health Assessment and Problem Identification in a Dominican Batey Community: A Descriptive Study

PURPOSE

Foot problems can adversely impact foot function and quality of life. Foot problems are often overlooked, particularly in populations with limited health care access. Little is known about the foot health of Haitian immigrants who live and work in the bateyes (rural sugarcane villages) of the Dominican Republic. These immigrant workers may experience foot problems that could affect foot function and the ability to work and provide for their families.

DESIGN

Cross-sectional, exploratory, descriptive study design.

SUBJECTS AND SETTING

A convenience sample of adults was recruited from an ongoing community-based participatory research project evaluating a mobile hypertension screening and treatment clinic program in 11 Dominican batey communities.

METHODS

Foot health was assessed using the Foot Problems Checklist, a 24-item survey instrument developed for this study based on a review of the literature and foot clinician expertise. A certified foot care nurse recorded foot health data on the Foot Problems Checklist via visual and physical inspection.

RESULTS

Study participants were 25 females and 16 males, aged 18 to 90 years, and all had at least one foot health problem. The most common foot problems were calluses (78%), dry skin (76%), thick nails (59%), jagged nails (29%), long/overgrown nails (17%), and skin fissures (12%).

CONCLUSIONS

While the foot problems we observed were not considered serious, they could become progressively debilitating and be prevented with proper self-management guided by appropriate knowledge and skills and available supplies. We recommend the development and testing of foot care self-management interventions deliverable via mobile clinics to increase access and improve foot health outcomes.

Successful Treatment of Hard Corns in Two Patients Using Microwave Energy

Corns are a common foot problem accounting for nearly half of all problems seen within podiatry and chiropody clinics. Hard corns are concentrated areas of hyperkeratosis within the stratum corneum, typically found on the weight-bearing (plantar) surfaces of the feet. For many patients, they are a source of pain and have been shown to negatively affect a patient's activity and quality of life. Most of the currently available treatments are short-lived in their effectiveness, with corns frequently being recurrent, requiring repeated visits to remove the painful lesions. The use of handheld microwave devices indicated for surface applications has demonstrated effectiveness in clearing recalcitrant plantar warts and significantly reducing the pain associated with them. The authors report 2 cases of patients with persistent and painful plantar corns who underwent microwave treatment of their plantar corns with a successful, lasting reduction in pain levels after the intervention. Further work is required to fully assess the potential of this treatment modality in the management of painful plantar corns.

Dermatophytes and Dermatophytosis in Cluj-Napoca, Romania-A 4-Year Cross-Sectional Study

Dermatophytes are filamentous keratinophilic fungi which affect nails, skin, and hair. Their variable distribution in the world justifies local epidemiological studies. During recent decades, few studies have been published regarding the epidemiology and etiology of dermatophytosis in Romania. The aim of this study was to identify the dermatophytes isolated from superficial fungal infections. To the best of our knowledge, this is the first such study conducted in the area of North-Western Romania. Over the past four years, samples collected from outpatients with suggestive lesions for dermatophytoses (nails, skin, hair), who addressed several private practice dermatologists from Cluj-Napoca, Romania, were sent to a specialized laboratory and examined by microscopy and culture. A total of 350 samples from 322 patients were examined. One hundred samples (28.6%) collected from 90 patients (27.9%) were positive by direct microscopy and/or culture. Among the 63 positive cultures (18%), 44 dermatophytes (69.8%), 2 molds (3.2%), and 17 yeasts (27%) were isolated. The main dermatophyte species identified were Trichophyton rubrum (mostly from onychomycosis) and Microsporum canis (from tinea capitis and tinea corporis in children). Yeasts (Candida species) were isolated from nails, especially from women.

Methylene blue vs methyl aminolevulinate photodynamic therapy in combination with oral terbinafine in the treatment of severe dermatophytic toenail onychomycosis: Short- and long-term effects

BACKGROUND

Photodynamic therapy (PDT) kills target microorganisms via reactive oxygen species (ROS) production. PDT seems to be a good alternative treatment option for onychomycosis.

OBJECTIVE

To compare the efficacy of combined therapies based on oral terbinafine (TN) plus adjunctive PDT mediated by methylene blue (MB) (TN + MB/PDT) or methyl aminolevulinate (MAL) (TN + MAL/PDT) in the treatment of onychomycosis.

METHODS

Twenty patients affected by severe dermatophyte onychomycosis in the nails of the big toe (>60% disease involvement of target nail) received oral TN for 12 weeks and concomitantly were randomly allocated to receive nine sessions, separated by 2-week intervals, of urea (40%) plus a PDT protocol mediated by MB (TN + MB/PDT: group I) or mediated by MAL (TN + MAL/PDT: group II). Clinical and mycological efficacy was evaluated at 16-, 40- and 52-week follow-up.

RESULTS

Both protocols showed a significant decrease in Onychomycosis Severity Index (OSI) scores (P < .05), from 24.2 ± 4.6 to 0.7 ± 0.6 (group I)) and from 18.5 ± 10.1 to 2.1 ± 2.0 (group II). No side effects or complications were reported in any of the combinations used. Mycological cure rates were significantly higher during the last third of the evaluated period of time, reaching 100% and 90% in group I and group II, respectively, at the 52-week follow-up. In both modalities, complete cure was achieved in 70% of the patients at the 52-week follow-up.

CONCLUSIONS

TN + MB/PDT and TN + MAL/PDT show similar outcomes in the treatment of toenails with severe onychomycosis. PDT is an effective method to accelerate the TN-mediated healing process.

Validated 60-Second General Foot Screen: A Pilot Trial and Guide to Diagnoses and Treatment

GENERAL PURPOSE

To provide information on a 60-second General Foot Screen to assist in the prevention and/or identification and management of common foot problems.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Use the 60-second General Foot Screen to assist healthcare professionals in the recognition of common foot problems.2. Identify risk factors, causes, and treatment of selected foot problems.

ABSTRACT

Foot health is important to overall patient health. Early diagnosis and treatment of diabetes, neuropathy, fungal foot infections, foot deformity, and vascular disease/lower leg edema can improve patient quality of life. One way to achieve this is effective screening. To this end, researchers piloted a validated 10-item screening tool to assess foot health on 120 patients; 74.17% had at least one positive abnormality, demonstrating the critical importance of these early findings. Only 25.83% of individuals had completely low-risk feet. This easy-to-use tool can assist healthcare professionals in the recognition and treatment of common foot problems. The article also outlines the early signs of disease by screening item and provides a guide to treatment to enable effective prevention and quality care.

Internal environment of footwear is a risk factor for tinea pedis

The relation between tinea pedis and the internal environment of footwear has not been scientifically proven. This study aimed to determine whether the internal environment of footwear affects the incidence of tinea pedis and tinea unguium. This cross-sectional, observatory study involved 420 outpatients who were categorized into non-tinea, tinea pedis or tinea unguium groups based on mycological analysis. External climatic conditions, and temperature, humidity and dew points inside the patients' footwear were recorded. Univariate and multivariate analyses were used to determine independent risk factors for tinea pedis and tinea unguium. A significant correlation was found between high temperature/high humidity and dew point of the internal environment of the footwear and the season. Furthermore, those who wore footwear with internal environments characterized by high temperature, high humidity, high-temperature/high-humidity and high dew point values had a significantly higher incidence of tinea pedis. The internal dew point correlated with the incidence of tinea pedis, whereas the external temperature correlated with the incidence of tinea unguium. The internal humidity and dew point of footwear as well as the frequency with which footwear with a high-temperature/high-humidity internal environment were worn was significantly higher in men than in women. In conclusion, the internal environment of footwear is a risk factor for tinea pedis, and this environment is affected by the season. Moreover, the frequency of tinea pedis among men is related to the internal environment of footwear. The dew point is an appropriate index for evaluating temperature and humidity in relation to tinea pedis.

A Mouse Model of Trichophyton Inflammation Based on Trichophytin-induced Contact Hypersensitivity

The prevalence of Trichophyton-induced superficial skin mycosis is very high among human patients. Dermatophytes generally infect the epidermis, especially the stratum corneum, forming scales, hyperkeratosis, and vesicles. The important roles played by the immune system in Trichophyton infection are detection of fungal invasion and elimination of fungi.These immune mechanisms are presumed to involve not only innate immunity but also acquired immunity. Therefore, there is a substantial need for studies on treatment methods based on new basic knowledge, and the elucidation of immunological mechanisms of Trichophyton-induced inflammatory reactions is especially important.However, since Trichophyton cannot colonize on the mouse skin, we tried to develop a model for Trichophyton inflammation induced by trichophytin extracted from Trichophyton mentagrophytes using a method based on contact hypersensitivity.Trichophytin is a crude extract that mainly contains fungal cell wall constituents including β-glucan and zymosan. In this model, TLR2, TLR4, and dectin-1 were highly expressed, and production of IL-17A and IL23 was observed. This indicates that we succeeded in inducing fungal-specific inflammation in the mice.In this review, we introduce a mouse Trichophyton inflammation model developed to investigate the immunological mechanisms of Trichophyton-induced inflammatory reactions. In addition, we report results of evaluation of anti-inflammatory and anti-itching effects of anti-fungal agents using the inflammation model.

Zombie Cells, Composite Cells of Fungal-Human Keratinocytes of Plantar Hyperkeratosis-Like Lesions

Foot hyperkeratosis is common. They often coincide with fungal infections, are difficult to cure and relapse rates are high. In this case study, longstanding and intractable plantar hyperkeratotic lesions were investigated for potential causative agents by histological examinations, by using human cell culture medium to grow the infected skin tissue, by sequencing ribosomal DNA and whole genome. Aspergillus sydowii was identified as the pathogen in the hyperkeratotic lesions. A peculiars intracellular infection of the fungus appeared to merge with anucleated epithelial cells of the skin, in which not fungal cells but basophilic nucleus-like bodies and abundant fungal proteins were seen in the cells. The composite fungal-human zombie-like cells were found to grow in the culture and in hyperkeratotic lesions, and some were readily transformed to natural fungus. Such zombie cells might play roles in the pathogenesis and recurrences of plantar hyperkeratotic lesions, resistance to antifungal drugs and relapses of the fungal infections.

Epidemiological and Mycological Aspects of Onychomycosis in Dakar (Senegal)

Onychomycosis is a fungal nails infection often caused by yeasts, dermatophytes and molds. It is an important public health concern due to its high prevalence, the problem of diagnostics, and the poor response to treatments. The objective of this study was to evaluate the epidemiological and microbiological profile of onychomycosis diagnosed at the Laboratory of Parasitology-Mycology of the National University Hospital of Fann in Dakar, Senegal, from 2012 to 2016. A retrospective and descriptive study was performed from January 2012 to December 2016 in a patient attending the laboratory of Parasitology-Mycology at the Fann teaching hospital. Socio-demographic, clinical and biological data were collected from the bench registers. Samples from the lesions were tested using direct microscopy and cultured on a Sabouraud-Chloramphenicol and Sabouraud-Chloramphenicol-Actidione medium. A descriptive analysis was done using Stata IC 12 software. The significance level of different tests was set at 5% two-side. A total of 469 patients were included in this study. The mean age of the study population was 33.2 ± 15.2 years, and the sex ratio was 0.52. The prevalence of onychomycosis was 48.4% (227/469). The main clinical presentations were disto-lateral subungual onychomycosis (37.9%) and onyxis (46.5%). Identified fungal species were Candida albicans (42.7%), Candida spp. (39.5%), Trichophyton soudanense (10.1%), Fusarium spp. (5.3%), and Candida tropicalis (2.6%). Candida albicans was more frequent in subjects over 15 years of age (43.6%) and women (45%). However, Trichophyton soudanense was higher in patients under 15 years old (17.4%) as well as in male subjects (18.8%). In conclusion, onychomycosis is a common cause of consultation in health facilities. Candida albicans and Trichophyton Soudanense are the main fungal species causing onychomycosis. A better understanding of the epidemiology of onychomycosis as well as the spectrum of the pathogen could contribute to improve the management of the infection.

Factors associated with onychomycosis in nail psoriasis: a multicenter study in Pakistan

BACKGROUND

Treatment of psoriatic nail disease is challenging, and dystrophic psoriatic nails can get secondarily infected with fungi.

METHODS

This 2-year, matched case-control study was conducted at three tertiary care centers of Karachi, Pakistan. Data were collected from patients with nail psoriasis as cases with age- and gender-matched controls. A detailed questionnaire was filled for all study participants. Nail Psoriasis Severity Index (NAPSI) scoring tool was used to assess dystrophy. Fungal infection was inferred by nail clippings for fungal hyphae and culture.

RESULTS

Among 477 participants, 159 cases and 318 controls completed the study. Their mean age was 44 years, and one-third were female. Fungal culture positivity was statistically significant in cases as compared to the control group (P < 0.001). The most frequent species identified was Candida parapsilosis in both cases and controls. Body mass index, NAPSI scoring, socioeconomic status, elevated diastolic blood pressure, smoking status psoriasis among first-degree relatives, and longstanding disease of more than 10 years were significant factors in univariable analysis. Multivariable logistic regression identified independent factors like low to middle socioeconomic status, history of psoriasis in first-degree relative, current smoker, and obesity.

CONCLUSION

We found nearly one-third of the psoriatic patients with nail involvement having concomitant fungal infection. We emphasize that nail clipping for fungal smear and culture should be advised to those patients with coexisting factors found significant in our study results. This opinion can be incorporated in psoriasis management guidelines for improving treatment of psoriatic nails.

Evaluation of foot health related quality of life in individuals with foot problems by gender: a cross-sectional comparative analysis study

OBJECTIVE

Foot problems (FP) may be considered to be a prevalent conditions in people but there is limited evidence of their effect on the quality of life (QoL) related to foot health in men and women. The aim of this study was to assess the impact of FPs on both overall foot health and QoL, stratified by gender.

DESIGN

A cross sectional study.

SETTING

Clinic of Podiatric Medicine and Surgery at University of A Coruña in the city of Ferrol (Spain).

SUBJECTS

The sample consisted of 1647 participants with FP; the total population of the sample had a mean age of 43.24±19.89 years, with mean ages 44.09±21.36 years and 42.94±19.34 years for men and women, respectively.

METHODS

Measurement of sociodemographic characteristics include age, sex and body mass index. The Foot Health Status Questionnaire (FHSQ) was used to evaluate the general health and foot health. Differences between groups were evaluated by means of a t-test for independent samples.

RESULTS

Women with FP showed significantly lower scores in the domains of Foot Pain, Foot Function, Footwear, General Foot Health, Physical Activity and Vigour, and there was no difference compared with men in the domains of Overall Health and Social Capacity.

CONCLUSIONS

Women with FP present a negative impact on QoL related to foot health as compared with men except in the domains of Overall Health and Social Capacity, which appears to be associated with the presence of foot conditions.

Itching in a trichophytin contact dermatitis mouse model and the antipruritic effect of antifungal agents

BACKGROUND

Tinea is an infectious disease by dermatophytes, of which Trichophyton species accounts for the overwhelming majority of case. Tinea often causes itching with inflammation. In terms of pruritus by fungal infection, however, tinea has not been investigated sufficiently to date.

AIM

To evaluate itch caused by Trichophyton infection and the effect of antifungal agents on the infection, by measuring scratch behaviour and profiles of inflammatory cytokines and chemokines.

METHODS

We used a previously established mouse model of contact hypersensitivity induced by trichophytin, a crude extract from Trichophyton mentagrophytes. Scratching behaviour was recorded using a counting device that measured an electric current induced in a coil by movement of magnets that had been inserted into the hind paws of each animal. We investigated expression of various genes in lesional skin of mice and in normal human epidermal keratinocytes. We also investigated the antipruritic effects of the corticosteroid dexamethasone (DEX) and three antifungal agents: ketoconazole (KCZ), terbinafine (TBF) and liranaftate (LNF).

RESULTS

Biphasic peaks of scratching were observed at 1 h and at 6-7 h during an observation period of 14 h after trichophytin induction. For lesional skin, RNA was extracted 24 h after trichophytin challenge, and increased expression was seen in the genes for interleukin (IL)-17A, interferon-γ, tumour necrosis factor (TNF)-α, macrophage inflammatory protein (MIP)-2 and Dectin-1, whereas there was no obvious change in the genes for IL-31 and prostaglandin (PG)E2. Furthermore, KCZ inhibited histidine decarboxylase (HDC) expression in vitro and in vivo, and inhibited scratching in the very early phase. LNF inhibited expression of thymic stromal lymphopoietin (TSLP) and IL-8 in vitro, and TSLP, TNF-α, IL-1α and MIP2 in vivo, and also scratching in the early phase. TBF did not induce any significant alterations in either gene expression or scratching. DEX suppressed expression of all the chemical mediators except HDC in vitro and in vivo, and inhibited scratching.

CONCLUSION

Antifungals can inhibit itching induced by fungal infection through different mechanisms.

The prevalence and etiological factors of onychomycosis in psoriatic patients

Introduction

The role of a number of inherited, acquired and environmental factors has been identified to increase the risk of onychomycosis. The literature data on psoriasis as a risk factor are contradictory. The potential relationship between these pathologies is very important as it influences the patient management.

Aim

To evaluate the frequency of onychomycosis and etiological factors in patients with psoriasis compared to controls.

Material and methods

The studied group (n = 2427) included 2325 patients with nail abnormalities raising a clinical suspicion of nail onychomycosis (with no history of psoriasis) and 102 psoriatic inpatients. The control group included 100 patients with clinically normal nails. The assessment of psoriasis severity using Nail Psoriasis Severity Index (NAPSI) and Psoriasis Area and Severity Index (PASI) was performed in all psoriatic patients. The presence of fungi was confirmed in direct microscopy and culture.

Results

A significantly higher incidence of onychomycosis was observed in psoriatic patients as well as in non-psoriatic patients with clinically abnormal nails compared to controls. The prevalence of onychomycosis did not differ significantly between psoriatic patients and non-psoriatic patients with nail alterations. The characteristics of isolated fungi differed significantly between psoriatic and non-psoriatic patients. NAPSI ≥ 40 and receiving systemic treatment increased the risk of onychomycosis in psoriatic patients.

Conclusions

The presented study showed a relatively high prevalence of onychomycosis in patients with psoriasis, what confirms the accuracy of performing screening mycological examination in this group. Further studies are warranted to evaluate the role of specific risk factors, explain the differences observed in previous studies and to determine optimal patient management.

Influence of custom foot orthoses on venous status: A quasi-experimental study

BACKGROUND

Customized foot orthoses (CFO) have been widely accepted to reduce the frequency of foot problems and postural disorders. The purpose of the research was to compare the influence of CFO utilization on the venous status among healthy females and males.

METHODS

This was a quasi-experimental study (NCT03329430), which included 20 healthy subjects that completed all the stages of the process. The subjects showed an age mean of 20.00 ± 1.62 years and were recruited in a foot and ankle specialist center. Self-reported data were medical records and venous function which were evaluated by plethysmography with or without utilization of CFO.

RESULTS

A sample of 40 feet was studied, showing statistically significant differences between venous filling time (P < 0.001) and in the ejection fraction (P < 0.001) with CFO utilization versus without use of CFO.

CONCLUSIONS

Healthy people who utilize CFO evidenced an increased venous return in the feet.

Abnormal skin in toe webs is a marker for abnormal glucose metabolism. A cross-sectional survey among 1,849 adults in Finland

Diabetes is undiagnosed disease and easy screening tools for it are warranted. Because foot complications are usual in diabetes, we aimed to test hypothesis that skin abnormalities are found already from patients who are not aware of having diabetes, by studying the possible association between unhealthy toe web skin and abnormal glucose metabolism. 1,849 cases without previously diagnosed diabetes participated to the 46-year follow-up study of the Northern Finland Birth Cohort. A skin investigation was performed for all, and abnormal skin findings in toe web spaces were taken as explanatory variables. Abnormal glucose tolerance was the main outcome and it was tested with an oral glucose tolerance test (OGTT), glycosylated haemoglobin fraction (HbA_1c) Values are numbers (percentages) of sub and fasting blood glucose. The participants who had any abnormal skin findings in toe webs were associated with 2.5-fold (OR 2.5, 95% CI 1.3–4.9) and 6-fold (OR 6.2, 1.4–27.6) increased risk of having previously undiagnosed diabetes detected by a 2-hour OGTT and HbA_1c, respectively. The predictive power of toe web findings was comparable with FINDRISC score. Abnormal skin findings in the toe webs show increased risk of occult diabetes, and may, thus serve as an additional sign of undiagnosed diabetes.

Epidemiology of Dermatophytoses in Crete, Greece

Dermatophytoses are among the most frequently diagnosed skin infections worldwide. However, the distribution of pathogenic species and the predominating anatomical sites of infection vary with geographical location and change over time. The aim of this study was to determine the epidemiological and aetiological factors of dermatophytoses in Crete, Greece over the last 5-year period (2011-2015) and their incidence in relation to the gender and the age of the patients. We compared our findings with those previously reported from the same area and from other parts of the world. A total of 2,910 clinical specimens (skin scrapings, nail clippings, and hair specimens) obtained from 2,751 patients with signs of dermatomycoses were examined using direct microscopy and culture. Overall, 294 specimens (10.1%) were proved mycologically positive for dermatophytes. The age of the patients ranged from 2 to 86 years (mean age, 37 years). Tinea corporis was the predominant clinical type of infection, followed by tinea unguium, tinea pedis, tinea capitis, tinea faciei, tinea cruris and tinea manuum. Among dermatophytes, eight species were isolated: Microsporum canis (35.8%), Trichophyton rubrum (35.1%), Trichophyton mentagrophytes (23.3%), Epidermophyton floccosum (2.5%), Microsporum gypseum (1.8%), Trichophyton violaceum (0.7%), Trichophyton verrucosum (0.4%), and Trichophyton tonsurans (0.4%). In our area, the most common dermatophyte was M. canis followed by T. rubrum. Increased migration, mass tourism, and climate changes will contribute to further changes in the epidemiology of dermatophytoses in our area. Continuing studies are necessary for determining the new epidemiological trends and to implement the appropriate control measures.

Foot health of nurses-A cross-sectional study

AIM

To analyze the level of nurses' foot health and its associations with work well-being.

METHODS

A descriptive, cross-sectional study design was applied to a random sample of Finnish nurses (n = 411). The data were collected between May 18 and June 21, 2015 using a self-administered Foot Health Assessment Instrument and analyzed using descriptive statistics and parametric tests.

RESULTS

Nurses had a variety of foot problems. Dry skin, foot pain, and corns or calluses were the most prevalent foot problems. Long-term diseases, the need for a physician's appointment due to foot problems, and decreased working ability were all associated with foot health. This finding was also supported by multivariate analysis.

CONCLUSIONS

Foot problems are common among nurses and are associated with individual and work-related factors. Prevention of foot problems in nurses should be prioritized to promote their working ability and predisposing factors identified as potential intervention targets.

Antidermatophytic Activity of the Fruticose Lichen Usnea orientalis

In the present study, the new biological sources in the form of lichen Usnea orientalis Motyka was screened for its antidermatophytic potential. Six species of dermatophytes were chosen on the basis of their prevalence for antidermatophytic assays, and the Clinical Laboratory Standard Institute (CLSI)-recommended broth microdilution procedure was used to detect the efficacy of extract against dermatophytes. Thin layer chromatography of lichen extracts reveals the presence of two secondary metabolites viz. salazinic acid and usnic acid. U. orientalis extract exhibited promising antidermatophytic activity against all tested pathogens. Amongst all tested pathogens, Epidermophyton floccosum exhibited most susceptibility towards extract, whereas Trichophyton mentagrophytes exhibited the least susceptibility. Topical application of U. orientalis extract might be helpful in the cure of dermal infections.

Isolation, Identification, and In Vitro Antifungal Susceptibility Testing of Dermatophytes from Clinical Samples at Sohag University Hospital in Egypt

Aim

The objective of this study was to isolate, identify, and explore the in-vitro antifungal susceptibility pattern of dermatophytes isolated from clinically suspected cases of dermatophytosis (tinea infections) attending the Dermatology Outpatient Clinic.

Methods

This study was conducted at Sohag University Hospital from December 2014 to December 2015. Clinical samples (e.g., skin scrapings and hair stumps) were collected under aseptic precautions. The identification of dermatophytes was performed through microscopic examination using 10% potassium hydroxide (KOH) with 40% dimethyl sulphoxide (DMSO) mounts and culture on Sabouraud dextrose agar (SDA) and on Dermasel agar base media, both supplemented with chloramphenicol and cycloheximide. All dermatophytes isolates were subjected to antifungal susceptibility testing using the agar-based disk diffusion (ABDD) method against Clotrimazole, Miconazole, Fluconazole, and Griseofulvin. Data were analyzed via SPSS 16, using Chi square and a screening test (cross-tabulation method).

Results

A total of 110 patients of dermatophytosis were studied. The patients were clinically diagnosed and mycologically confirmed as having tinea capitis (49), tinea corporis (30), tinea pedis (16), tinea cruris (9), or tinea barbae (6). The dermatophytes isolates belonged to 4 species: Microsporum canis 58 (52.7%), Microsporum gypseum 23 (20.9%), Trichophyton mentagrophytes 18 (16.4%), and Microsporum audouinii 11 (10%). The most effective antifungal drugs tested were Clotrimazole, followed by Miconazole (95.5% and 84.5% of isolates were susceptible, respectively).

Conclusion

Every patient with a tinea infection should be properly studied for a mycological examination and should be treated accordingly. Dermasel agar is more useful as an identification medium in the isolation of dermatophytes. The ABDD method appears to be a simple, cost-effective, and promising method for the evaluation of antifungal susceptibility of dermatophytes.

Prevalence and Epidemiology of Onychomycosis

The prevalence of onychomycosis has been estimated at approximately 6.48% (95% confidence interval 6.09–6.88%) within the Canadian population. Dermatophytes are the most commonly cultured organisms, appearing in approximately 75 to 91% of nails with fungal involvement, with Trichophyton rubrum and Tricophyton mentagrophytes most commonly isolated. However, Candida spp and nondermatophyte molds are also sometimes cultured. The most common presentation is distal and lateral subungual onychomycosis (DLSO), which can involve 75% of patients with pedal onychomycosis. The distribution of DLSO, superficial white onychomycosis, and proximal subungual onychomycosis (PSO) has been reported to be 360:59:1 in patients with mycologic confirmation of onychomycosis; however, some reported that the incidence of PSO is slightly higher in immunocompromised individuals. Age, gender, family history, and the presence of tinea pedis are all elements associated with a nail fungal infection. In addition, many conditions, including diabetes mellitus, immune disorders, and vascular disease, have been associated with the presence of onychomycosis. When choosing the best treatment regimen for individuals with onychomycosis, it is very important to consider all of the factors involved, including the infecting species, the presentation of the disease, the level of disease progression, and its predisposing factors.

An explorative investigation of functional differences in plantar center of pressure of four foot types using sample entropy method

In the study of biomechanics of different foot types, temporal or spatial parameters derived from plantar pressure are often used. However, there is no comparative study of complexity and regularity of the center of pressure (CoP) during the stance phase among pes valgus, pes cavus, hallux valgus and normal foot. We aim to analyze whether CoP sample entropy characteristics differ among these four foot types. In our experiment participated 40 subjects with normal feet, 40 with pes cavus, 19 with pes valgus and 36 with hallux valgus. A Footscan^® system was used to collect CoP data. We used sample entropy to quantify several parameters of the investigated four foot types. These are the displacement in medial–lateral (M/L) and anterior–posterior (A/P) directions, as well as the vertical ground reaction force of CoP during the stance phase. To fully examine the potential of the sample entropy method for quantification of CoP components, we provide results for two cases: calculating the sample entropy of normalized CoP components, as well as calculating it using the raw data of CoP components. We also explored what are the optimal values of parameters m (the matching length) and r (the tolerance range) when calculating the sample entropy of CoP data obtained during the stance phases. According to statistical results, some factors significantly influenced the sample entropy of CoP components. The sample entropies of non-normalized A/P values for the left foot, as well as for the right foot, were different between the normal foot and pes valgus, and between the normal foot and hallux valgus. The sample entropy of normalized M/L displacement of the right foot was different between the normal foot and pes cavus. The measured variable for A/P and M/L displacements could serve for the study of foot function.

The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30 000 patients visiting physicians' offices

BACKGROUND

Onychomycosis is difficult to treat and a concern for many patients. Prevalence estimates of onychomycosis in North American clinic samples have been higher than what has been reported for general populations.

OBJECTIVE

A large, multicentre study was conducted to estimate the prevalence of toenail onychomycosis in the Canadian population.

METHODS

Patients were recruited from the offices of three dermatologists and one family physician in Ontario, Canada. Nail samples for mycological testing were obtained from normal and abnormal-looking nails. This sample of 32 193 patients includes our previous published study of 15 000 patients.

RESULTS

Abnormal nails were observed in 4350 patients. Of these, the prevalence of culture-confirmed toenail onychomycosis was estimated to be 6.7% (95% CI, 6.41-6.96%). Following sex and age adjustments for the general population, the estimated prevalence of toenail onychomycosis in Canada was 6.4% (95% CI, 6.12%-6.65%). The distribution of fungal organisms in culture-confirmed onychomycosis was 71.9% dermatophytes, 20.4% non-dermatophyte moulds and 7.6% yeasts. Toenail onychomycosis was four times more prevalent in those over the age of 60 years than below the age of 60 years.

CONCLUSION

The present data highlights that onychomycosis may be a growing medical concern among ageing patients.

Treatment of superficial mycosis of glabrous skin of itraconasole

The treatment of fungal infections of the skin is actual problem of modern dermatology. The goal of the research. The study of the clinical efficacy, tolerance and safety of the use of the systemic antifungal drug itraconazole (Irunin) in treatment of extensive and often recidivic clinical forms of superficial mycosis of glabrous skin. Material and methods. The authors observed 56 patients aged from 18 to 60 with different clinical forms of dermatomycosis (33 - with extensive pytiriasis vesicolor, 13 - with chronic recidivic tinea pedis, 7 - with extensive mycosis of body and large flexures, 3 - with mycosis of different localizations). All patients received monotherapy of itraconazole (Irunin): two capsules (200 mg) once a day for 7 days, then one capsule (100 mg) once a day for 14 days. The duration of the treatment was 21 days. Results. Clinical and mycological recovery was achieved in all number of the cases. Serious unnecessary effects of treatment was not observed. Conclusions. The results of the study have shown high therapeutic efficacy and good tolerability of antifungal drug itraconazole (Irunin) in the systemic treatment of fungal infections of the skin.

Distinct characteristics of Scytalidium dimidiatum and non-dermatophyte onychomycosis as compared with dermatophyte onychomycosis

Studies of demographic data, predisposing factors and clinical manifestations of non-dermatophyte mold (NDM) infection particularly in Scytalidium spp. have been limited. This study aimed to compare these data between dermatophytes (DMP) and NDM onychomycosis with statistical analysis. This was a retrospective chart review of outpatients with onychomycosis in the Nail Clinic of Department of Dermatology between January 2011 and December 2013. A total of 237 patients who had presented with onychomycosis were included. One hundred and eighty patients (75.9%) were infected with DMP: Trichophyton mentagrophytes, 46.8%; and Trichophyton rubrum, 28.3%. Of patients who had NDM onychomycosis, 17.3% were Scytalidium dimidiatum and 6.8% were Fusarium spp. Comparing the DMP and NDM groups, family history of superficial fungal infection was significantly demonstrated in the DMP group. Approximately 50% of patients in both groups had feet infections. However, no patients with NDM onychomycosis had fungal glabrous skin infection at other sites beyond the feet that was statistically different from cases with DMP onychomycosis. In conclusion, The distinct characteristic of patients with NDM onychomycosis was absence of fungal glabrous skin infection in areas other than the feet. This was statistically different from DMP.