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Axler E, Lipner SR. Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes. Infect Drug Resist 2024; 17:819-843. [PMID: 38463386 PMCID: PMC10922011 DOI: 10.2147/idr.s431526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.
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Affiliation(s)
- Eden Axler
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
| | - Shari R Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
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2
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Gupta AK, Talukder M, Carviel JL, Cooper EA, Piguet V. Combatting antifungal resistance: Paradigm shift in the diagnosis and management of onychomycosis and dermatomycosis. J Eur Acad Dermatol Venereol 2023; 37:1706-1717. [PMID: 37210652 DOI: 10.1111/jdv.19217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
Antifungal resistance has become prevalent worldwide. Understanding the factors involved in spread of resistance allows the formulation of strategies to slow resistance development and likewise identify solutions for the treatment of highly recalcitrant fungal infections. To investigate the recent explosion of resistant strains, a literature review was performed focusing on four main areas: mechanisms of resistance to antifungal agents, diagnosis of superficial fungal infections, management, and stewardship. The use of traditional diagnostic tools such as culture, KOH analysis and minimum inhibitory concentration values on treatment were investigated and compared to the newer techniques such as molecular methods including whole genome sequencing, and polymerase chain reaction. The management of terbinafine-resistant strains is discussed. We have emphasized the need for antifungal stewardship including increasing surveillance for resistant infection.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, Ontario, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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3
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Lu LY, Ou JH, Hui RCY, Chuang YH, Fan YC, Sun PL. High Diversity of Fusarium Species in Onychomycosis: Clinical Presentations, Molecular Identification, and Antifungal Susceptibility. J Fungi (Basel) 2023; 9:jof9050534. [PMID: 37233245 DOI: 10.3390/jof9050534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/10/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Fusarium are uncommon but important pathogenic organisms; they cause non-dermatophyte mould (NDM) onychomycosis. Patients typically respond poorly to treatment owing to Fusarium's native resistance to multiple antifungal drugs. However, epidemiological data for Fusarium onychomycosis are lacking in Taiwan. We retrospectively reviewed the data of 84 patients with positive Fusarium nail sample cultures at Chang Gung Memorial Hospital, Linkou Branch between 2014 and 2020. We aimed to investigate the clinical presentations, microscopic and pathological characteristics, antifungal susceptibility, and species diversity of Fusarium in patients with Fusarium onychomycosis. We enrolled 29 patients using the six-parameter criteria for NDM onychomycosis to determine the clinical significance of Fusarium in these patients. All isolates were subjected to species identification by sequences and molecular phylogeny. A total of 47 Fusarium strains belonging to 13 species in four different Fusarium species complexes (with Fusarium keratoplasticum predominating) were isolated from 29 patients. Six types of histopathology findings were specific to Fusarium onychomycosis, which may be useful for differentiating dermatophytes from NDMs. The results of drug susceptibility testing showed high variation among species complexes, and efinaconazole, lanoconazole, and luliconazole showed excellent in vitro activity for the most part. This study's primary limitation was its single-centre retrospective design. Our study showed a high diversity of Fusarium species in diseased nails. Fusarium onychomycosis has clinical and pathological features distinct from those of dermatophyte onychomycosis. Thus, careful diagnosis and proper pathogen identification are essential in the management of NDM onychomycosis caused by Fusarium sp.
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Affiliation(s)
- Lai-Ying Lu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Department of Dermatology and Aesthetic Medicine Center, Jen-Ai Hospital, Taichung 412224, Taiwan
| | - Jie-Hao Ou
- Department of Plant Pathology, National Chung Hsing University, Taichung 402202, Taiwan
| | - Rosaline Chung-Yee Hui
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
| | - Ya-Hui Chuang
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
| | - Yun-Chen Fan
- Department of Plant Pathology, National Chung Hsing University, Taichung 402202, Taiwan
| | - Pei-Lun Sun
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Research Laboratory of Medical Mycology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33323, Taiwan
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4
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Pospischil I, Reinhardt C, Bontems O, Salamin K, Fratti M, Blanchard G, Chang YT, Wagner H, Hermann P, Monod M, Hoetzenecker W, Guenova E. Identification of Dermatophyte and Non-Dermatophyte Agents in Onychomycosis by PCR and DNA Sequencing—A Retrospective Comparison of Diagnostic Tools. J Fungi (Basel) 2022; 8:jof8101019. [PMID: 36294584 PMCID: PMC9605175 DOI: 10.3390/jof8101019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 12/02/2022] Open
Abstract
Rapid and reliable fungal identification is crucial to delineate infectious diseases, and to establish appropriate treatment for onychomycosis. Compared to conventional diagnostic methods, molecular techniques are faster and feature higher accuracy in fungal identification. However, in current clinical practice, molecular mycology is not widely available, and its practical applicability is still under discussion. This study summarizes the results of 16,094 consecutive nail specimens with clinical suspicion of onychomycosis. We performed PCR/sequencing on all primary nail specimens for which conventional mycological diagnostics remained inconclusive. In specimens with a positive direct microscopy but negative or contaminated culture, molecular mycology proved superior and specified a fungal agent in 65% (587/898). In 75% (443/587), the identified pathogen was a dermatophyte. Positive cultures for dermatophytes, yeasts and non-dermatophyte molds (NDMs) were concordant with primary-specimen-DNA PCR/sequencing in 83% (10/12), 34% (22/65) and 45% (76/169), respectively. Among NDMs, agreement was high for Fusarium spp. (32/40; 80%), but low for Penicillium spp. (5/25; 20%) and Alternaria spp. (1/20; 5%). This study underlines the improvement in diagnostic yield by fungal primary-specimen-DNA PCR/sequencing in the event of a negative or contaminated culture, as well as its significance for the diagnosis of dermatophyte and non-dermatophyte onychomycosis. Molecular mycology methods like PCR and DNA sequencing should complement conventional diagnostics in cases of equivocal findings, suspected NDM onychomycosis or treatment-resistant nail pathologies.
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Affiliation(s)
- Isabella Pospischil
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
- Correspondence: (I.P.); (W.H.); (E.G.)
| | - Charlotte Reinhardt
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Olympia Bontems
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Karine Salamin
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Marina Fratti
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Gabriela Blanchard
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Yun-Tsan Chang
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Helga Wagner
- Center for Clinical Studies (CCS Linz), Johannes Kepler University Linz, 4020 Linz, Austria
- Institute of Applied Statistics, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Philipp Hermann
- Center for Clinical Studies (CCS Linz), Johannes Kepler University Linz, 4020 Linz, Austria
| | - Michel Monod
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
| | - Wolfram Hoetzenecker
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
- Correspondence: (I.P.); (W.H.); (E.G.)
| | - Emmanuella Guenova
- Department of Dermatology, Lausanne University Hospital (CHUV) and the Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland
- Department of Dermatology, University Hospital Zurich and the University of Zurich, 8091 Zurich, Switzerland
- Department of Dermatology, Hospital 12 de Octubre, Medical School, University Complutense, 28040 Madrid, Spain
- Correspondence: (I.P.); (W.H.); (E.G.)
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5
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Uemura EVG, Barbosa MDS, Simionatto S, Al-Harrasi A, Al-Hatmi AMS, Rossato L. Onychomycosis Caused by Fusarium Species. J Fungi (Basel) 2022; 8:jof8040360. [PMID: 35448591 PMCID: PMC9027400 DOI: 10.3390/jof8040360] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023] Open
Abstract
Onychomycosis is a nail fungal infection that produces nail discolouration, thickness, and separation from the nail bed. The species of the Fusarium genus that cause onychomycosis are emerging and the number of cases has increased throughout the years. Microscopic examination, as well as cultures, are required for the accurate diagnosis of onychomycosis. The goal of treatment is to eliminate the organism that causes the disease and restore the nail’s normal appearance. Here, we provide an overview of the onychomycosis cases that have been reported in literature over the last 24 years, which have been caused by the Fusarium species. We performed a review on the onychomycosis cases caused by the Fusarium species from January 1997 to January 2021. Patients aged between 40 and 49 years made up 30.23% of the cases. The most common aetiologic species was Fusarium solani species complex (FSSC), which accounted for 44.11% of the cases, followed by F. fujikuroi species complex (FFSC), which accounted for 17.64%; 14.70% of the cases were due to F. dimerum species complex (FDSC) and 14.70% of the cases were due F. oxysporum species complex (FOSC). Europe accounted for 29.06% of the cases caused by FOSC, whereas Africa accounted for 46.67% of the cases due to FSSC. The clinical presentation of onychomycosis due to Fusarium spp. is commonly the distal–lateral pattern of onychomycosis. Identification of the infectious agent in onychomycosis cases due to Fusarium is crucial in deciding the proper treatment. Although antifungal susceptibility tests have only been performed in a few cases, susceptibility testing can help with patient management.
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Affiliation(s)
- Eduardo Vinicius Grego Uemura
- Faculdade de Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados 79862-000, MS, Brazil; (E.V.G.U.); (M.d.S.B.); (S.S.)
| | - Marcelo dos Santos Barbosa
- Faculdade de Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados 79862-000, MS, Brazil; (E.V.G.U.); (M.d.S.B.); (S.S.)
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados 79862-000, MS, Brazil
| | - Simone Simionatto
- Faculdade de Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados 79862-000, MS, Brazil; (E.V.G.U.); (M.d.S.B.); (S.S.)
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa 616, Oman; (A.A.-H.); (A.M.S.A.-H.)
| | - Abdullah M. S. Al-Hatmi
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa 616, Oman; (A.A.-H.); (A.M.S.A.-H.)
- Centre of Expertise in Mycology, Radboud University Medical Centre/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
| | - Luana Rossato
- Faculdade de Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados 79862-000, MS, Brazil; (E.V.G.U.); (M.d.S.B.); (S.S.)
- Correspondence: ; Tel.: +55-11-971224947
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6
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Assessment of the properties of terbinafine hydrochloride and the search route for antifungal agents. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2021.132225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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Gupta AK, Talukder M, Venkataraman M. Review of the alternative therapies for onychomycosis and superficial fungal infections: posaconazole, fosravuconazole, voriconazole, oteseconazole. Int J Dermatol 2021; 61:1431-1441. [PMID: 34882787 DOI: 10.1111/ijd.15999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 12/16/2022]
Abstract
Terbinafine and itraconazole are the most commonly used oral antifungals to treat onychomycosis and superficial dermatomycoses. Recently, poor response to oral terbinafine has been reported. We have summarized the most appropriate dosing regimens of posaconazole, fosravuconazole, voriconazole, and oteseconazole (VT-1161) to treat onychomycosis and superficial fungal infections. A structured search on PubMed and Google Scholar was conducted. Additionally, the bibliographies of selected articles were searched to identify relevant records. The number of records identified from the searches was 463, with 50 articles meeting the inclusion criteria for review. None of the new azoles are US FDA approved for onychomycosis treatment; however, an increasing number of studies have evaluated these agents. The efficacies (complete cure and mycologic cure) of the antifungal agents for dermatophyte great toenail onychomycosis treatment are terbinafine 250 mg/day × 12 weeks (Phase III trial) (38%, 70%), itraconazole 200 mg/day × 12 weeks (Phase III trial) (14%, 54%), posaconazole 200 mg/day × 24 weeks (Phase IIB) (54.1%, 70.3%), fosravuconazole 100 mg/day ravuconazole equivalent × 12 weeks (Phase III) (59.4%, 82.0%), and oteseconazole 300 mg/day loading dose × 2 weeks (Phase II), followed by 300 mg/week × 10 weeks (maintenance dose) (45%, 70%). Guidelines for monitoring are also presented.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Mediprobe Research Inc, London, Ontario, Canada
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8
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Skin Appendage Disord 2021; 7:351-358. [PMID: 34604322 DOI: 10.1159/000516112] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022] Open
Abstract
There is an increase in the incidence of onychomycosis, especially in at-risk populations. Onychomycosis is difficult to treat, as the efficacy of most antifungal agents is relatively low. Nondermatophyte molds (NDMs) and mixed infection (dermatophyte plus NDM) onychomycosis are contributing to growing antifungal resistance, as they are often underestimated and ignored due to incorrect diagnosis. There is a need for a paradigm shift in the management of onychomycosis to a patient-centered, holistic approach with an emphasis on laboratory diagnosis prior to initiating treatment, which enables the rational choice of the antifungal agent. Additionally, in the case of resistant infections, antifungal susceptibility testing is recommended. Strategies for effective management of onychomycosis include disinfection of fungal reservoirs in shoes and socks and prophylaxis posttreatment using topical antifungal agents. These measures may reduce the recurrence of onychomycosis and improve long-term clinical success.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Mediprobe Research Inc., London, Ontario, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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9
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Abstract
BACKGROUND AND OBJECTIVE With the widespread use of antifungals to treat superficial mycoses, reports of antifungal resistance are increasing. Antifungal resistance is becoming a public health challenge and needs to be addressed in parallel with antibacterial and antiviral resistance. METHODS We review the growing resistance of fungal pathogens such as Trichophyton species and the emergence of novel pathogens, including multidrug-resistant strains in superficial mycoses. We also discuss the importance of laboratory diagnosis and antifungal susceptibility testing (AFST) in the management of recalcitrant infections. RESULTS AND CONCLUSION Antifungal resistance can occur naturally or develop over time when fungi are exposed to antifungals. The frequency of terbinafine-resistant Trichophyton isolates is increasing. Opportunistic pathogens such as Aspergillus and Candida species have developed resistance to classic azoles such as itraconazole and fluconazole, and the newer azoles such as posaconazole and voriconazole. Although uncommon, topical antifungals such as efinaconazole and tavaborole have shown to induce resistance in Trichophyton rubrum. The emergence of multidrug-resistant Trichophyton mentagrophytes/interdigitale, Candida auris, and Aspergillus species causing severe infections is highly concerning. Routine AFST should be considered to determine the most effective treatment, especially if there is failure to therapy. Combination treatment of oral and topical antifungals may be a consideration for managing recalcitrant infections.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, Division of Dermatology, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
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10
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Gupta AK, Summerbell RC, Venkataraman M, Quinlan EM. Nondermatophyte mould onychomycosis. J Eur Acad Dermatol Venereol 2021; 35:1628-1641. [PMID: 33763903 DOI: 10.1111/jdv.17240] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/09/2021] [Indexed: 01/21/2023]
Abstract
Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.
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Affiliation(s)
- A K Gupta
- Mediprobe Research Inc., London, ON, Canada.,Department of Dermatology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - R C Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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11
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Leung AKC, Lam JM, Leong KF, Hon KL, Barankin B, Leung AAM, Wong AHC. Onychomycosis: An Updated Review. ACTA ACUST UNITED AC 2020; 14:32-45. [PMID: 31738146 PMCID: PMC7509699 DOI: 10.2174/1872213x13666191026090713] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 12/19/2022]
Abstract
Background: Onychomycosis is a common fungal infection of the nail. Objective: The study aimed to provide an update on the evaluation, diagnosis, and treatment of onychomycosis. Methods: A PubMed search was completed in Clinical Queries using the key term “onychomycosis”. The search was conducted in May 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. The search was restricted to English literature. Patents were searched using the key term “onychomycosis” in www.freepatentsonline.com. Results: Onychomycosis is a fungal infection of the nail unit. Approximately 90% of toenail and 75% of fingernail onychomycosis are caused by dermatophytes, notably Trichophyton mentagrophytes and Trichophyton rubrum. Clinical manifestations include discoloration of the nail, subungual hyperkeratosis, onycholysis, and onychauxis. The diagnosis can be confirmed by direct microscopic examination with a potassium hydroxide wet-mount preparation, histopathologic examination of the trimmed affected nail plate with a periodic-acid-Schiff stain, fungal culture, or polymerase chain reaction assays. Laboratory confirmation of onychomycosis before beginning a treatment regimen should be considered. Currently, oral terbinafine is the treatment of choice, followed by oral itraconazole. In general, topical monotherapy can be considered for mild to moderate onychomycosis and is a therapeutic option when oral antifungal agents are contraindicated or cannot be tolerated. Recent patents related to the management of onychomycosis are also discussed. Conclusion: Oral antifungal therapies are effective, but significant adverse effects limit their use.Although topical antifungal therapies have minimal adverse events, they are less effective than oral antifungal therapies, due to poor nail penetration. Therefore, there is a need for exploring more effective and/or alternative treatment modalities for the treatment of onychomycosis which are safer and more effective.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Shatin, Hong Kong
| | | | - Amy A M Leung
- Department of Family Medicine, The University of Alberta, Edmonton, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
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12
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Al-Hatmi AMS, Bonifaz A, Ranque S, Sybren de Hoog G, Verweij PE, Meis JF. Current antifungal treatment of fusariosis. Int J Antimicrob Agents 2017; 51:326-332. [PMID: 28705676 DOI: 10.1016/j.ijantimicag.2017.06.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/28/2017] [Accepted: 06/24/2017] [Indexed: 12/12/2022]
Abstract
Fungi of the genus Fusarium are well known as major plant pathogens and soil inhabitants, but also cause a broad spectrum of human infections. Fusariosis is the second most common mould infection after aspergillosis, and keratitis is the most encountered implantation infection in immunocompetent individuals. Natamycin is active against Fusarium species both in vitro and in vivo, and is used along with voriconazole as the mainstay of treatment for Fusarium keratitis. Onychomycosis is treated with terbinafine, voriconazole and sometimes itraconazole. Cure is possible despite high in vitro minimum inhibitory concentrations (MICs). Recently, disseminated infections have increased dramatically, mainly affecting severely immunocompromised patients. The remarkable intrinsic resistance of Fusarium species to most antifungal agents results in high mortality rates in this patient population. Recovery of neutropenia is essential for patient survival and treatment should include voriconazole or amphotericin B as first-line and posaconazole as salvage therapy.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Directorate General of Health Services, Ministry of Health, Ibri Hospital, Ibri, Oman; Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Alexandro Bonifaz
- Hospital General de México, 'Dr. Eduardo Liceaga', Mexico City, Mexico
| | - Stephane Ranque
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands; Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil; Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Samerpitak K, Gloyna K, Gerrits van den Ende AHG, de Hoog GS. A novel species of the oligotrophic genus Ochroconis colonizing indoor wet cells. MYCOSCIENCE 2017. [DOI: 10.1016/j.myc.2017.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Reduced Multidrug Susceptibility Profile Is a Common Feature of Opportunistic Fusarium Species: Fusarium Multi-Drug Resistant Pattern. J Fungi (Basel) 2017; 3:jof3020018. [PMID: 29371536 PMCID: PMC5715927 DOI: 10.3390/jof3020018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 03/27/2017] [Accepted: 04/07/2017] [Indexed: 01/26/2023] Open
Abstract
The resistance among various opportunistic Fusarium species to different antifungal agents has emerged as a cause of public health problems worldwide. Considering the significance of multi-drug resistant (MDR), this paper emphasizes the problems associated with MDR and the need to understand its clinical significance to combat microbial infections. The search platform PubMed/MEDLINE and a review of 32 cases revealed a common multidrug-resistant profile exists, and clinically relevant members of Fusarium are intrinsically resistant to most currently used antifungals. Dissemination occurs in patients with prolonged neutropenia, immune deficiency, and especially hematological malignancies. Amphotericin B displayed the lowest minimum inhibitory concentrarions (MICs) followed by voriconazole, and posaconazole. Itraconazole and fluconazole showed high MIC values, displaying in vitro resistance. Echinocandins showed the highest MIC values. Seven out of ten (70%) patients with neutropenia died, including those with fungemia that progressed to skin lesions. Clinical Fusarium isolates displayed a common MDR profile and high MIC values for the most available antifungal agents with species- and strain-specific differences in antifungal susceptibility. Species identification of Fusarium infections is important. While the use of natamycin resulted in a favorable outcome in keratitis, AmB and VRC are the most used agents for the treatment of fusariosis in clinical settings.
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Al-Hatmi AMS, Normand AC, Ranque S, Piarroux R, de Hoog GS, Meletiadis J, Meis JF. Comparative Evaluation of Etest, EUCAST, and CLSI Methods for Amphotericin B, Voriconazole, and Posaconazole against Clinically Relevant Fusarium Species. Antimicrob Agents Chemother 2017; 61:e01671-16. [PMID: 27795379 PMCID: PMC5192122 DOI: 10.1128/aac.01671-16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/20/2016] [Indexed: 11/20/2022] Open
Abstract
We compared EUCAST and CLSI methods versus Etest for antifungal susceptibility testing of 20 clinically relevant Fusarium species against amphotericin B, posaconazole, and voriconazole. The median Etest amphotericin B and posaconazole MICs were 1 dilution higher than the median EUCAST and the CLSI MICs. The essential agreement (within ±1/±2 dilutions) was 60/90%, 80/95%, and 70/85% between the Etest and EUCAST methods and 80/95%, 75/95%, and 45/100% between the Etest and CLSI methods for amphotericin B, voriconazole, and posaconazole, respectively. The categorical agreement was >85%. Etest can be used for antifungal susceptibility testing of Fusarium species.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands
- Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands
- Directorate General of Health Services, Ministry of Health, Ibri Hospital, Ibri, Oman
| | - Anne-Cécile Normand
- Aix-Marseille University, APHM, CHU Timone, IP-TPT, Parasitology-Mycology, Marseille, France
| | - Stephane Ranque
- Aix-Marseille University, APHM, CHU Timone, IP-TPT, Parasitology-Mycology, Marseille, France
| | - Renaud Piarroux
- Aix-Marseille University, APHM, CHU Timone, IP-TPT, Parasitology-Mycology, Marseille, France
| | - G Sybren de Hoog
- CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands
- Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Al-Hatmi AMS, Van Den Ende AHGG, Stielow JB, Van Diepeningen AD, Seifert KA, McCormick W, Assabgui R, Gräfenhan T, De Hoog GS, Levesque CA. Evaluation of two novel barcodes for species recognition of opportunistic pathogens in Fusarium. Fungal Biol 2015; 120:231-45. [PMID: 26781379 DOI: 10.1016/j.funbio.2015.08.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/28/2015] [Accepted: 08/04/2015] [Indexed: 02/06/2023]
Abstract
The genus Fusarium includes more than 200 species of which 73 have been isolated from human infections. Fusarium species are opportunistic human pathogens with variable aetiology. Species determination is best made with the combined phylogeny of protein-coding genes such as elongation factor (TEF1), RNA polymerase (RPB2) and the partial β-tubulin (BT2) gene. The internal transcribed spacers 1, 2 and 5.8S rRNA gene (ITS) have also been used, however, ITS cannot discriminate several closely related species and has nonorthologous copies in Fusarium. Currently, morphological approaches and tree-building methods are in use to define species and to discover hitherto undescribed species. Aftter a species is defined, DNA barcoding approaches can be used to identify species by the presence or absence of discrete nucleotide characters. We demonstrate the potential of two recently discovered DNA barcode loci, topoisomerase I (TOP1) and phosphoglycerate kinase (PGK), in combination with other routinely used markers such as TEF1, in an analysis of 144 Fusarium strains belonging to 52 species. Our barcoding study using TOP1 and PKG provided concordance of molecular data with TEF1. The currently accepted Fusarium species sampled were well supported in phylogenetic trees of both new markers.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- CBS-KNAW Fungal Biodiversity Centre, P.O. Box 85167, 3508 AD Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, P.O. Box 94248, 1090 GE Amsterdam, The Netherlands; Directorate General of Health Services, Ibri Hospital, Ministry of Health, P.C.: 100, P.O. Box : 393, Ibri, Oman.
| | | | - J Benjamin Stielow
- CBS-KNAW Fungal Biodiversity Centre, P.O. Box 85167, 3508 AD Utrecht, The Netherlands
| | | | - Keith A Seifert
- Biodiversity (Mycology and Microbiology), Agriculture and Agri-Food Canada, 960 Carling Ave, Ottawa, Ontario K1A 0C6, Canada
| | - Wayne McCormick
- Biodiversity (Mycology and Microbiology), Agriculture and Agri-Food Canada, 960 Carling Ave, Ottawa, Ontario K1A 0C6, Canada
| | - Rafik Assabgui
- Biodiversity (Mycology and Microbiology), Agriculture and Agri-Food Canada, 960 Carling Ave, Ottawa, Ontario K1A 0C6, Canada
| | - Tom Gräfenhan
- Biodiversity (Mycology and Microbiology), Agriculture and Agri-Food Canada, 960 Carling Ave, Ottawa, Ontario K1A 0C6, Canada
| | - G Sybren De Hoog
- CBS-KNAW Fungal Biodiversity Centre, P.O. Box 85167, 3508 AD Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, P.O. Box 94248, 1090 GE Amsterdam, The Netherlands; Peking University Health Science Center, Research Center for Medical Mycology, Beijing 100034, PR China; Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang W Rd, Guangzhou, China; Shanghai Institute of Medical Mycology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China; Basic Pathology Department, Federal University of Paraná State, Curitiba 81531-990, Paraná, Brazil; King Abdulaziz University, Jeddah 22254, Saudi Arabia
| | - C André Levesque
- Biodiversity (Mycology and Microbiology), Agriculture and Agri-Food Canada, 960 Carling Ave, Ottawa, Ontario K1A 0C6, Canada
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