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Haneke E. Onychomycosis in Foot and Toe Malformations. J Fungi (Basel) 2024; 10:399. [PMID: 38921385 PMCID: PMC11204549 DOI: 10.3390/jof10060399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.
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Affiliation(s)
- Eckart Haneke
- Schlippehof 5, 79110 Freiburg, Germany;
- Department of Dermatology, Inselspital, University of Berne, 3010 Bern, Switzerland
- Private Dermatology Practice Dermaticum, 79098 Freiburg, Germany
- Centro de Dermatología Epidermis, Instituto CUF, Senhora da Hora, 8050 Matosinhos, Grande Porto, Portugal
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2
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Punchihewa N, Orchard D. Combination oral antifungal therapy for paediatric fungal infection: An option to improve efficacy and overcome clinical resistance. Australas J Dermatol 2024; 65:59-62. [PMID: 37927148 DOI: 10.1111/ajd.14186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/21/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
There is increasing evidence of clinically resistant cutaneous fungal infections. The use of combination oral antifungals is described in adults but not in paediatric patients. We present seven paediatric cases of clinically resistant fungal infections treated successfully with combination oral antifungal therapy after inadequate response to a single agent.
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Affiliation(s)
- Nisal Punchihewa
- Department of Medicine, Eastern Health, Melbourne, Victoria, Australia
| | - David Orchard
- Royal Children's Hospital, Melbourne, Victoria, Australia
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Vestergaard-Jensen S, Mansouri A, Jensen LH, Jemec GBE, Saunte DML. Systematic review of the prevalence of onychomycosis in children. Pediatr Dermatol 2022; 39:855-865. [PMID: 36130720 PMCID: PMC10087489 DOI: 10.1111/pde.15100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
Onychomycosis is one of the most common nail diseases in adults but is described as infrequent in children. Data are, however, scattered and diverse. Studies have nevertheless suggested that the prevalence of onychomycosis is increasing in children lately and the aim of this review was therefore to examine this problem. Two authors individually searched PubMed, Embase, and Cochrane Library for articles on epidemiology and prevalence of onychomycosis in children. The literature search was conducted in accordance per PRISMA guidelines. In total 1042 articles were identified of which 23 were eligible for inclusion. One of the articles presented two studies and a total of 24 studies were therefore included. Seventeen studies presented data of the prevalence of onychomycosis in children in the general population and seven studies among children visiting a dermatological and pediatric department or clinic. The prevalence ranged from 0% to 7.66% with an overall discrete increase of 0.66% during the period 1972 to 2014 in population studies (not statistically significant). This review supports a trend towards an increased prevalence of onychomycosis in children, albeit based on a paucity of studies. The data suggests an increasing prevalence of onychomycosis with age, and co-infection with tinea pedis (reported in 25% of the studies). The most common pathogen reported was Trichophyton rubrum and onychomycosis was more prevalent in toenails compared to fingernails. The general characteristics of onychomycosis in children are thus similar to those described in adults.
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Affiliation(s)
| | - Abdullah Mansouri
- Department of Pediatrics, Zealand University Hospital, Roskilde, Denmark
| | | | - Gregor B E Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Marie L Saunte
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
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Falotico JM, Lipner SR. Updated Perspectives on the Diagnosis and Management of Onychomycosis. Clin Cosmet Investig Dermatol 2022; 15:1933-1957. [PMID: 36133401 PMCID: PMC9484770 DOI: 10.2147/ccid.s362635] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/08/2022] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- Julianne M Falotico
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Shari R Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY, USA
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Abstract
Onychomycosis is a fungal nail infection that causes nail discoloration, nail plate thickening, and onycholysis. Efinaconazole 10% topical solution is an FDA-approved treatment for onychomycosis patients aged 6 years and above. The drug functions as an antifungal by disrupting ergosterol synthesis in the fungal cell membrane. It exhibits higher in vitro activity against dermatophytes than other available antifungals such as ciclopirox and itraconazole, and the activity is comparable to amorolfine and terbinafine. Efinaconazole also provides enhanced nail penetration compared with other topical antifungals due to low surface tension, poor water solubility, and low keratin affinity. The pharmacokinetic studies suggest that the efinaconazole topical delivery to the nail bed is not markedly affected by the presence of disease. There is a subset of onychomycosis patients who are more likely to respond to efinaconazole 10% solution: female patients, those with lower BMI, mild onychomycosis, a short disease duration, no infected non-target toenails (large toenail disease only), and when concomitant tinea pedis is treated. Experts recommend efinaconazole 10% topical solution as the first line for mild-to-moderate onychomycosis, pediatric onychomycosis, those with liver or kidney disease, and as maintenance therapy to prevent relapse. The side effects of topical efinaconazole are minimal: most commonly ingrown toenails, dermatitis, vesicles, and pain at the application site. Altogether, phase I and phase III clinical trials, and post-hoc analyses indicate that efinaconazole 10% topical solution is a safe and effective treatment for adult and pediatric onychomycosis, with a satisfactory mycological and clinical cure.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada.
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Mesbah Talukder
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
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Löser CR, Nenoff P, Mainusch O, Dippel E, Balakirski G. Häufige Nagelerkrankungen: Diagnostik und Therapie. J Dtsch Dermatol Ges 2021; 19:1761-1776. [PMID: 34894183 DOI: 10.1111/ddg.14627_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/05/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Christoph R Löser
- Hautklinik, Hauttumorzentrum, Klinikum Ludwigshafen GmbH, Ludwigshafen
| | - Pietro Nenoff
- Labor für medizinische Mikrobiologie, Rötha/OT Mölbis
| | | | - Edgar Dippel
- Hautklinik, Hauttumorzentrum, Klinikum Ludwigshafen GmbH, Ludwigshafen
| | - Galina Balakirski
- Zentrum für Dermatologie, Allergologie und Dermatochirurgie, HELIOS Universitätsklinikum Wuppertal, Universität Witten/Herdecke, Wuppertal
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Löser CR, Nenoff P, Mainusch O, Dippel E, Balakirski G. Common diseases of the nail: Diagnosis and therapy. J Dtsch Dermatol Ges 2021; 19:1761-1775. [PMID: 34862725 DOI: 10.1111/ddg.14627] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/05/2021] [Indexed: 11/27/2022]
Abstract
This review focuses on nail changes that do not belong to the group of benign or malignant nail tumors. These common afflictions of the nail include structural changes in and under the nail plate as well as inflammation around and in the nail bed. They include onychomycoses, nail psoriasis, onychodystrophies, subungual hematoma, paronychia, ingrown nails and pincer nails. Due to the peculiar anatomy and physiological growth conditions of the nail, the pathology does not necessarily stem from the site of the clinical problem and calls for careful inspection and interpretation.
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Affiliation(s)
- Christoph R Löser
- Department for Skin Diseases and Skin Tumors, Klinikum Ludwigshafen GmbH, Ludwigshafen
| | - Pietro Nenoff
- Laboratory for Medical Microbiology, Rötha/OT Mölbis
| | | | - Edgar Dippel
- Department for Skin Diseases and Skin Tumors, Klinikum Ludwigshafen GmbH, Ludwigshafen
| | - Galina Balakirski
- Center for Dermatology, Allergology and Dermatosurgery, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal
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Souza AMS, Ribeiro RCA, Pinheiro GKLO, Pinheiro FI, Oliveira WN, Souza LBFC, Silva AL, Amaral-Machado L, Alencar ÉN, Chaves GM, Egito EST. Polishing the Therapy of Onychomycosis Induced by Candida spp.: Amphotericin B-Loaded Nail Lacquer. Pharmaceutics 2021; 13:pharmaceutics13060784. [PMID: 34073997 PMCID: PMC8225016 DOI: 10.3390/pharmaceutics13060784] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022] Open
Abstract
Onychomycosis induced by Candida spp. has several limitations regarding its treatment. Nail lacquers display the potential to overcome these drawbacks by providing therapeutic compliance and increasing local drug bioavailability. Thus, this work aimed to produce a nail lacquer loaded with Amphotericin B (AmB) and evaluate its performance. The AmB-loaded nail lacquer was produced and preliminarily characterized. An AmB quantification method was developed. Stability, drug release, permeability and anti-Candida activity assays were conducted. The analytical method validation met the acceptance criteria. The drug loading efficiency was 100% (0.02 mg/g of total product), whereas the AmB stability was limited to ≅7 days (≅90% remaining). The nail lacquer displayed a drying time of 187 s, non-volatile content of around 20%w/w, water-resistance of approximately 2%w/w of weight loss and satisfactory in vitro adhesion. Moreover, the in vitro antifungal activity against different Candida spp. strains was confirmed. The AmB release and the ex vivo permeability studies revealed that AmB leaves the lacquer and permeates the nail matrix in 47.76 ± 0.07% over 24 h. In conclusion, AmB-loaded nail lacquer shows itself as a promising extemporaneous dosage form with remarkable anti-Candida activity related to onychomycosis.
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Affiliation(s)
- Aleph M. S. Souza
- Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (A.M.S.S.); (L.B.F.C.S.); (G.M.C.)
| | - Renato C. A. Ribeiro
- Graduate Program in Health Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (R.C.A.R.); (W.N.O.); (L.A.-M.)
| | - Gleyse K. L. O. Pinheiro
- Graduate Program in Biotechnology, School of Health, Potiguar University (UnP)–Laureate International Universities, Natal 59056-000, Brazil; (G.K.L.O.P.); (F.I.P.)
| | - Francisco I. Pinheiro
- Graduate Program in Biotechnology, School of Health, Potiguar University (UnP)–Laureate International Universities, Natal 59056-000, Brazil; (G.K.L.O.P.); (F.I.P.)
| | - Wógenes N. Oliveira
- Graduate Program in Health Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (R.C.A.R.); (W.N.O.); (L.A.-M.)
| | - Luanda B. F. C. Souza
- Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (A.M.S.S.); (L.B.F.C.S.); (G.M.C.)
| | - André L. Silva
- Center for Biological Sciences and Health, Federal University of Western Bahia (UFOB), Barreiras 47800-000, Brazil;
| | - Lucas Amaral-Machado
- Graduate Program in Health Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (R.C.A.R.); (W.N.O.); (L.A.-M.)
| | - Éverton N. Alencar
- Graduate Program in Pharmaceutical Nanotechnology, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil;
| | - Guilherme M. Chaves
- Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (A.M.S.S.); (L.B.F.C.S.); (G.M.C.)
- Graduate Program in Health Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (R.C.A.R.); (W.N.O.); (L.A.-M.)
| | - Eryvaldo S. T. Egito
- Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (A.M.S.S.); (L.B.F.C.S.); (G.M.C.)
- Graduate Program in Health Sciences, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil; (R.C.A.R.); (W.N.O.); (L.A.-M.)
- Graduate Program in Pharmaceutical Nanotechnology, Federal University of Rio Grande do Norte (UFRN), Natal 59012-570, Brazil;
- Correspondence: ; Tel.: +55-(84)-3342–9817
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Gupta AK, Venkataraman M, Quinlan EM. Artificial hair implantation for hair restoration. J DERMATOL TREAT 2021; 33:1312-1318. [PMID: 33565339 DOI: 10.1080/09546634.2021.1887442] [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: 10/22/2022]
Abstract
BACKGROUND Androgenetic alopecia (AGA) is the most common cause of hair loss in men and women. Artificial hair implantation is considered an alternative treatment when the donor area is depleted or unsuitable for hair transplantation. The use of artificial hair implants remains controversial, particularly because this practice has been banned by the US FDA. OBJECTIVE To summarize various aspects of artificial hair implantation. METHODS We discuss the history of artificial hair implantation, development of new biocompatible fibers (Biofibre®, Nido Z-type), patient eligibility for this treatment, implantation technique, follow-up, immune response to the implanted fibers, and post-implantation complications. We performed a methodological quality assessment of the clinical studies that investigated artificial hair implantation using the Canadian Institute of Health Economics (IHE) Quality Appraisal Tool for Case Series (Interventional). RESULTS Although the studies evaluating the use of artificial hair fibers appear promising, the methodological quality of most of them was between 'poor' and 'fair', due to lack of randomization, absence of control groups, improper study design, and inappropriate outcome measures. CONCLUSIONS Artificial hair implantation has been received with skepticism among physicians due to the complications reported. Further high-quality research needs to be performed to ascertain the safety and efficacy of artificial hair implantation.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc, London, Canada.,Department of Medicine, Division of Dermatology, University of Toronto School of Medicine, Toronto, Canada
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