Global perspectives for the management of onychomycosis

Efinaconazole 10% solution: a comprehensive review of its use in the treatment of onychomycosis

INTRODUCTION

Onychomycosis is an infection of the nail bed and the nail plate. While oral antifungals are first-line for moderate to severe onychomycosis, topical efinaconazole 10% solution (JUBLIA®; Clenafin®) is effective and safe for mild to moderate severity onychomycosis. It is FDA-approved for patients aged 6 years and above.

AREAS COVERED

This literature review includes pharmacokinetics, microbiology, efficacy, safety, and post-marketing surveillance. It demonstrates consistent safety and efficacy across diverse patient demographics and comorbidities, including pediatric, diabetic and the elderly populations, without systemic side effects or drug interactions.

EXPERT OPINION

Efinaconazole 10% solution is an important addition to the armamentarium of therapies available to treat onychomycosis. Certain subgroups respond particularly well: females versus males, children versus adults, early onset onychomycosis (<1-year disease), those with mild onychomycosis (≤25% nail involvement), absence of tinea pedis, and thin nail plates at baseline (<1 mm thickness). Efinaconazole 10% solution is effective in diabetics and has demonstrated efficacy against dermatophytomas. Efinaconazole may be a consideration when terbinafine resistance is a concern, due to its different target of action.

Extended Use of Topical Efinaconazole Remains Safe and Can Provide Continuing Benefits for Dermatophyte Toenail Onychomycosis

INTRODUCTION

Efinaconazole 10% topical solution labeling for onychomycosis describes phase III trials of 12 months of treatment; the slow growth of onychomycotic nails suggests a longer treatment period may increase efficacy. We present here the first evaluation of extended use of efinaconazole 10% topical solution for up to 24 months.

MATERIALS AND METHODS

Enrolled patients (n = 101) had one target great toenail with mild to moderate distal lateral subungual onychomycosis and applied efinaconazole 10% topical solution to all affected toenails once daily for 18 months (EFN18) or 24 months (EFN24). Efficacy and safety were evaluated at each visit by visual review and mycology sampling.

RESULTS

Regarding the target toenail for patients treated for 24 months (EFN24), mycological cure (negative microscopy and culture) was 66.0% at Month 12, increasing to 71.7% at Month 24; effective cure (mycological cure and ≤10% affected nail) was 13.2% at Month 12, rising to 22.6% at Month 24. Mild to moderate application site reactions (symptoms of erythema/scaling) were the only efinaconazole-related reactions, in eight patients (7.9%). No systemic efinaconazole events or drug interactions were found. Patients aged 70 years or more had similar efficacy to younger patients at all time periods and did not show any increased treatment risks. Thinner nails exhibited better clearance versus thicker nails. A higher proportion of patients with Trichophyton mentagrophytes complex infection experienced application site reactions (35.7%), and a higher effective cure was found at Month 24 versus T. rubrum patients.

CONCLUSION

There is a trend of increasing mycological cure and effective cure beyond Month 12 to Month 24, without an increased safety risk. The enrolled population in this trial was significantly older than in the phase III trials, with a greater degree of onychomycosis severity; however, increased age did not appear to reduce the chance of efficacy to Month 24 in this study. Our data suggest that lack of ability to clear nail dystrophy remains a significant problem for patients, rather than any lack of efinaconazole action over long-term treatment periods.

Utility of devices for onychomycosis: a review

Onychomycosis is difficult to treat due to long treatment durations, poor efficacy rates of treatments, high relapse rates, and safety issues when using systemic antifungal agents. Device-based treatments are targeted to specific regions of the nail, have favorable safely profiles, and do not interfere with systemic agents. They may be an effective alternative therapy for onychomycosis especially with increasing reports of squalene epoxidase gene mutations and potential resistance to terbinafine therapy. In this review, we discuss four devices used as antifungal treatments and three devices used as penetration enhancers for topical agents. Lasers, photodynamic therapy, microwaves, and non-thermal plasma have the capacity to inactivate fungal pathogens demonstrated through in vivo studies. Efficacy rates for these devices, however, remain relatively low pointing toward the need to further optimize device or usage parameters. Ultrasound, nail drilling, and iontophoresis aid in improving the permeability of topical agents through the nail and have been investigated as adjunctive therapies. Due to the paucity in clinical data, their efficacy in treating onychomycosis has not yet been established. While the results of clinical studies point toward the potential utility of devices for onychomycosis, further large-scale randomized clinical trials following regulatory guidelines are required to confirm current results.

Fungal Skin Disease Classification Using the Convolutional Neural Network

Skin is the outer cover of our body, which protects vital organs from harm. This important body part is often affected by a series of infections caused by fungus, bacteria, viruses, allergies, and dust. Millions of people suffer from skin diseases. It is one of the common causes of infection in sub-Saharan Africa. Skin disease can also be the cause of stigma and discrimination. Early and accurate diagnosis of skin disease can be vital for effective treatment. Laser and photonics-based technologies are used for the diagnosis of skin disease. These technologies are expensive and not affordable, especially for resource-limited countries like Ethiopia. Hence, image-based methods can be effective in reducing cost and time. There are previous studies on image-based diagnosis for skin disease. However, there are few scientific studies on tinea pedis and tinea corporis. In this study, the convolution neural network (CNN) has been used to classify fungal skin disease. The classification was carried out on the four most common fungal skin diseases: tinea pedis, tinea capitis, tinea corporis, and tinea unguium. The dataset consisted of a total of 407 fungal skin lesions collected from Dr. Gerbi Medium Clinic, Jimma, Ethiopia. Normalization of image size, conversion of RGB to grayscale, and balancing the intensity of the image have been carried out. Images were normalized to three sizes: 120 × 120, 150 × 150, and 224 × 224. Then, augmentation was applied. The developed model classified the four common fungal skin diseases with 93.3% accuracy. Comparisons were made with similar CNN architectures: MobileNetV2 and ResNet 50, and the proposed model was superior to both. This study may be an important addition to the very limited work on the detection of fungal skin disease. It can be used to build an automated image-based screening system for dermatology at an initial stage.

Treatment of nail clippings with ethyl alcohol improves the efficacy of Raman spectroscopy in the diagnosis of Trichophyton rubrum onychomycosis

The purpose of this work was to enhance the diagnostic accuracy of nail Raman spectroscopy for fungal nail infections, specifically onychomycosis caused by Trichophyton rubrum. The study assessed the different ethyl alcohol retention rates between control and infected nails after soaking nail clippings in ethanolic solutions and drying. Results revealed that ethyl alcohol completely evaporated from infected nail samples, while significant amounts were still present in control samples. Principal component analysis (PCA) was applied to discriminate control from infected nails and showed superior group separation when nails were treated with ethyl alcohol. PCA loadings plot attributed the efficient classification to the ν_s (CCO) Raman vibrational mode of ethyl alcohol. As Raman spectroscopy can detect minute concentration changes of ethyl alcohol in nails and the deterioration caused by onychomycosis accelerates its evaporation, a simple and rapid method for detecting T. rubrum onychomycosis is proposed.

Evaluation of Thermography as a Diagnostic Technique in Asymptomatic or Incipient Onychomycosis

Onychomycosis is usually diagnosed symptomatically due to the very clear signs caused by the fungus on the nail surface and structure, although the growth of the infecting agent must also be verified by culture in an enriched medium. This procedure is normally lengthy (four weeks), and samples can be contaminated, delaying the prescription of appropriate and effective treatment. Only one previous study has addressed the possibility of using thermography as a diagnostic method for onychomycosis in older people (31-70 years). The present study confirms this use but in individuals aged 18-31 years with incipient mycosis and no pathological signs. Using an FLIR E60 BX camera in a study with 214 samples, we found that men had more onychomycosis than women. We observed a relation between the presence of infection and nail temperature, with a higher temperature in yeast infections (+1 °C) and a lower temperature in dermatophyte infections (-2 °C). A higher temperature by almost 1 °C was also observed in older participants. Thermography can be viewed as a new diagnostic method in asymptomatic or incipient onychomycosis, providing the thermographic camera is sufficiently sensitive and the appropriate procedure is followed, although fungal culture is always necessary to confirm recovery after treatment.

Promising onychomycosis treatment with hypericin-mediated photodynamic therapy: case reports

BACKGROUND

Onychomycosis (OM) is a common nail plate disorder caused by dermatophyte molds, yeasts, and non-dermatophyte molds, which use keratin in the nail plate as an energy source. OM is characterized by dyschromia, increased nail thickness, subungual hyperkeratosis, and onychodystrophy, and is typically treated with conventional antifungals despite frequent reports of toxicity, fungal resistance, and OM recurrence. Photodynamic therapy (PDT) with hypericin (Hyp) as a photosensitizer (PS) stands out as a promising therapeutic modality. When excited by a specific wavelength of light and in the presence of oxygen, to lead to photochemical and photobiological reactions on the selected targets.

METHODS

OM diagnosis was made in three suspected cases, and the causative agents were identified by classical and molecular methods, and confirmed by attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR). Susceptibility of planktonic cells of the clinical isolates to conventional antifungals and PDT-Hyp was evaluated, and photoacoustic spectroscopy (PAS) of Hyp permeation in nail fragments ex vivo was analyzed. Furthermore, the patients opted to undergo PDT-Hyp treatment and were subsequently followed up. The protocol was approved by the human ethics committee (CAAE, number 14107419.4.0000.0104).

RESULTS

The etiological agents of OM in patients ID 01 and ID 02 belonged to the Fusarium solani species complex, being identified as Fusarium keratoplasticum (CMRP 5514) and Fusarium solani (CMRP 5515), respectively. For patient ID 03, the OM agent was identified as Trichophyton rubrum (CMRP 5516). PDT-Hyp demonstrated a fungicidal effect in vitro, with reductions of ≥3 log₁₀ (p<0.0051 and p<0.0001), and the PAS analyses indicated that Hyp could completely permeate through both healthy and OM-affected nails. After four sessions of PDT-Hyp, mycological cure was observed in all three cases, and after seventh months, clinical cure was confirmed. PDT-Hyp showed satisfactory results in terms of efficacy and safety, and thus can be considered a promising therapy for the clinical treatment of OM.

Efficacy of Bovine Nail Membranes as In Vitro Model for Onychomycosis Infected by Trichophyton Species

Onychomycosis is a fungal infection caused by different etiologic agents, including dermatophytes that specifically colonize keratin-rich substrates. The aim of this work was to investigate mechanical modifications of bovine membranes (used as an in vitro nail model) placed in contact with Trichophyton species. Trichophyton strains were isolated from toenails specimens. The procedure was set up by spreading T. rubrum,T. interdigitale, and T. mentagrophytes strains on Petri dishes with minimal and rich media; after that, bovine membranes were placed in the center. After 27 days, T. interdigitale and T. mentagrophytes significantly reduced the thickness of the colonized membranes, whereas two T. rubrum strains showed the highest degradation limited to the small colonized area. These results were confirmed by SEM images of the colonization profile on membranes. Mechanical analyses performed on membranes were used as an innovative method to evaluate the thickness and structural integrity of membranes variation following fungal colonization. In conclusion, mechanical analyses of substrate may be used as a procedure for the development of a new onychomycosis diagnosis test in order to develop personalized and strain-specific treatment.

Novel and Investigational Treatments for Onychomycosis

Onychomycosis is a common nail disease caused by fungi. The primary pathogens are dermatophytes; however, yeasts, non-dermatophyte moulds, and mixed fungal populations may also contribute to the development of a recalcitrant condition, usually accompanied by difficulties in everyday life and severe emotional stress. Treatment failure and relapse of the infection are the most frequent problems, though new issues have become the new challenges in the therapeutic approach to onychomycosis. Resistance to antifungals, an increasing number of comorbidities, and polydrug use among the ageing population are imperatives that impose a shift to safer drugs. Topical antifungals are considered less toxic and minimally interact with other drugs. The development of new topical drugs for onychomycosis is driven by the unmet need for effective agents with prolonged post-treatment disease-free time and a lack of systemic impact on the patients’ health. Efinaconazole, Tavaborole, and Luliconazole have been added to physicians’ weaponry during the last decade, though launched on the market of a limited number of countries. The pipeline is either developing new products (e.g., ME-1111 and NP213) with an appealing combination of pharmacokinetic, efficacy, and safety properties or reformulating old, well-known drugs (Terbinafine and Amphotericin B) by using new excipients as penetration enhancers.

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.

Relevant insights into onychomycosis' pathogenesis related to the effectiveness topical treatment

Onychomycosis (OM) is a fungal infection, responsible for about 50% of nail diseases. OM has been attributed to the ability of fungi to naturally organize themselves into biofilms on nail surfaces. However, little is known about the exact role of the biofilm in the etiopathogenesis of OM, as well as its influence in the permeation of a topical treatment. The objectives of this study were to review the literature for topical OM treatments in clinical trials, assess the efficiency of these treatments, and discuss factors that could affect the success of these treatments. First, a systematic search of articles published in the MEDLINE database (PubMed) between January 2010 and December 2019 was conducted, focusing on drugs under clinical trials for the topical treatment of OM. Of the publications selected, it was clear that none of them had considered the fungi organized in biofilm. Therefore, we reflected on some important variables involved in OM, such as the nail structure and the mechanism of fungal invasion. Some methods, such as histopathologic analysis and spectroscopy techniques, were found to be effective in the detection of nail biofilm, and could be used in future drug permeation studies. This review allowed us to conclude that novel antifungals for the topical treatment of OM must consider the drug to permeate through biofilm. Natural products, such as propolis, seem strong candidates in this respect.

Meta-analysis of the antifungal activities of three essential oils as alternative therapies in dermatophytosis infections

Aims

This work examines the available scientific evidence about the efficiency of essential oils (EO) as an alternative therapy to traditional treatment of fungal infections, including onychomycosis, assessing the effect of the three EO most frequently studied for their antifungal activity (thyme, cinnamon and tea tree EO) against three causative agents of fungal diseases in humans: Trichophyton rubrum, Trichophyton mentagrophytes complex and Candida albicans.

Methods and Results

The PRISMA statement protocol was followed to conduct a bibliographical search and 54 articles that met all the inclusion criteria were retrieved. Differences were observed in the MIC and MFC values depending on the micro‐organism strain and the EO used. The lowest MIC were observed with Cinnamomum zeylanicum EO (0.013–1120 μl ml⁻¹) against the three micro‐organisms. For MFC, the lowest value was found for Thymus vulgaris EO (4.2 μl ml⁻¹) against Trichophyton rubrum.

Conclusions

The antifungal effects of EO could be a very promising solution to overcome the therapeutic shortcomings of antimycotic medication. More experiments are needed to examine the properties of these oils to devise effective and nonaggressive therapies for treatment of dermatophytosis.

Significance and Impact of Study

The results indicate that EO remain good candidates for future treatments and could provide a solution for failed medications and/or adverse reactions to current pharmacological treatments.

What can GP data tell us about the treatment of onychomycosis in the UK?

Background

Treatment of onychomycosis is challenging, and there is much literature on optimal treatment strategies. In contrast, information on how onychomycosis is actually treated in primary care is scarce. Information on practice is important as it can reveal much, such as, to what extent national guidelines are followed and which population groups seek/receive treatment or do not do so.

Objectives

To describe the pattern of onychomycosis treatment in primary care in the UK, by patient's gender and age.

Methods

A population‐based retrospective cross‐sectional study was conducted. The Health Improvement Network (THIN) database was used to calculate incidence rates of onychomycosis in the years 2001–2017. The prescription of oral and topical anti‐fungal drugs to patients with onychomycosis was reviewed.

Results

THIN data showed an onychomycosis incidence rate of about 50 per 100,000. More males than females (52% vs. 48%), and more people aged 50–59 years had received treatment for onychomycosis. Oral terbinafine was the most commonly prescribed drug, followed by topical amorolfine, although terbinafine was used more commonly by men and amorolfine by women. Patients with onychomycosis were also prescribed other antifungals, including itraconazole, griseofulvin, tioconazole, ketoconazole shampoo, fluconazole and clotrimazole. A greater proportion of women, compared to men, were prescribed fluconazole.

Conclusions

Onychomycosis treatment in primary care in the UK is broadly in concordance with national guidelines.

Automatic skin disease diagnosis using deep learning from clinical image and patient information

Background

Skin diseases are the fourth most common cause of human illness which results in enormous non-fatal burden in daily life activities. They are caused by chemical, physical and biological factors. Visual assessment in combination with clinical information is the common diagnostic procedure for diseases. However, these procedures are manual, time-consuming, and require experience and excellent visual perception.

Objectives

In this study, an automated system is proposed for the diagnosis of five common skin diseases by using data from clinical images and patient information using deep learning pre-trained mobilenet-v2 model.

Methods

Clinical images were acquired using different smartphone cameras and patient's information were collected during patient registration. Different data preprocessing and augmentation techniques were applied to boost the performance of the model prior to training.

Results

A multiclass classification accuracy of 97.5%, sensitivity of 97.7% and precision of 97.7% has been achieved using the proposed technique for the common five skin disease. The results demonstrate that, the developed system provides excellent diagnosis performance for the five skin diseases.

Conclusion

The system has been designed as a smartphone application and it has the potential to be used as a decision support system in low resource settings, where both the expert dermatologist and the means are limited.

Deep learning-based diagnosis models for onychomycosis in dermoscopy

BACKGROUND

Onychomycosis is a common disease. Emerging noninvasive, real-time techniques such as dermoscopy and deep convolutional neural networks have been proposed for the diagnosis of onychomycosis. However, deep learning application in dermoscopic image hasn't been reported.

OBJECTIVES

To explore the establishment of deep learning-based diagnostic models for onychomycosis in dermoscopy to improve the diagnostic efficiency and accuracy.

METHODS

We evaluated the dermoscopic patterns of onychomycosis diagnosed at Sun Yat-sen Memorial Hospital, Guangzhou, China from May 2019 to February 2021 and included nail psoriasis and traumatic onychodystrophy as control groups. Based on the dermoscopic images and the characteristic dermoscopic patterns of onychomycosis, we gain the faster region-based convolutional neural networks to distinguish between nail disorder and normal nail, onychomycosis and non-mycological nail disorder (nail psoriasis and traumatic onychodystrophy). The diagnostic performance is compared between deep learning-based diagnosis models and dermatologists.

RESULTS

All of 1155 dermoscopic images were collected, including onychomycosis (603 images), nail psoriasis (221 images), traumatic onychodystrophy (104 images) and normal cases (227 images). Statistical analyses revealed subungual keratosis, distal irregular termination, longitudinal striae, jagged edge, marble-like turbid area, and cone-shaped keratosis were of high specificity (>82%) for onychomycosis diagnosis. The deep learning-based diagnosis models (ensemble model) showed test accuracy /specificity/ sensitivity /Youden index of (95.7%/98.8%/82.1%/0.809), (87.5%/93.0%/78.5%/0.715) for nail disorder and onychomycosis. The diagnostic performance for onychomycosis using ensemble model was superior to 54 dermatologists.

CONCLUSIONS

Our study demonstrated onychomycosis had distinctive dermoscopic patterns, compared with nail psoriasis and traumatic onychodystrophy. The deep learning-based diagnosis models showed a diagnostic accuracy of onychomycosis, superior to dermatologists.

Antifungal Polymeric Materials and Nanocomposites

Rising global populations due to medicinal advancements increases the patient population susceptible to superficial and severe fungal infections. Fungi often implicated in these diseases includes the dermatophytes (Microsporum spp., Epidermophtyon spp., Trichophyton spp.) as well as species of the Candida spp., Aspergillosis spp. and Cryptococcus spp. genera. In addition, increasing global populations leads to increasing agricultural demands. Thus, fungal infections of preharvested crops and stored food by plant pathogens such as Magnaporthe oryzae and Fusarium oxysporum can have detrimental socioeconomic effects due to food insecurity. Current antifungal strategies are based mainly on small molecule antifungal drugs. However, these drugs are limited by poor solubility and bioavailability. Furthermore, antifungal resistance against these drugs are on the rise. Thus, antimicrobial polymers offer an alternative antifungal strategy. Antifungal polymers are characterised by cationic and hydrophobic regions where the cationic regions have been shown to interact with microbial phospholipids and membranes. These polymers can be synthetic or natural and demonstrate distinct antifungal mechanisms ranging from fungal cell membrane permeabilisation, cell membrane depolarisation or cell entry. Although the relative importance of such mechanisms is difficult to decipher. Due to the chemical properties of these polymers, they can be combined with other antimicrobial compounds including existing antifungal drugs, charcoals, lipids and metal ions to elicit synergistic effects. In some cases, antifungal polymers and nanocomposites show better antifungal effects or reduced toxicity compared to the widely used small molecule antifungal drugs. This review provides an overview of antimicrobial polymers and nanocomposites with antifungal activity and the current understanding of their antifungal mechanisms.

A multicentre, randomised, parallel-group, double-blind, vehicle-controlled and open label versus amorolfine 5% study, to evaluate the efficacy and safety of terbinafine 10% nail lacquer in the treatment of onychomycosis

BACKGROUND

Onychomycosis is a difficult-to-treat fungal nail infection whose treatment can involve systemic or topical antifungal approaches.

OBJECTIVES

To assess the efficacy and safety of terbinafine 10% nail lacquer in distal lateral subungual onychomycosis (DLSO).

PATIENTS/METHODS

Patients with mild-to-moderate DLSO were randomised (3:3:1) to receive double-blind topical terbinafine 10% (n = 406) or its vehicle (n = 410) administered once daily for 4 weeks and then once weekly for 44 weeks, or open-label topical amorolfine 5% (n = 137) for 48 weeks, with a 12-week follow-up period. The primary efficacy endpoint, complete cure rate at Week 60, was a composite of negative potassium hydroxide (KOH) microscopy, negative culture for dermatophytes and no residual clinical involvement of the target big toenail.

RESULTS

Complete cure rates at Week 60 in the terbinafine, vehicle and amorolfine groups were 5.67%, 2.20% and 2.92%, respectively (odds ratio (OR) vs vehicle = 2.68; 95% confidence intervals (CI): 1.22-5.86; p = .0138). Statistically significant differences in responder (negative KOH and negative culture and ≤10% residual clinical involvement) and mycological cure rates (negative KOH and negative culture) at Week 60 were obtained between terbinafine and vehicle. Terbinafine was well-tolerated with no systemic adverse reactions identified; the most common topical adverse reactions were erythema and skin irritation.

CONCLUSIONS

Terbinafine 10% nail lacquer was an effective treatment for mild-to-moderate onychomycosis improving both clinical and mycological criteria compared with vehicle. Furthermore, there may be some benefits compared to the currently available topical agent, amorolfine 5%. Treatment was well-tolerated and safe.

Hand-foot syndrome and nail disorders secondary to treatment with paclitaxel: Is there a relationship with the presence of fungi?

INTRODUCTION

This study aimed to evaluate the frequency of nail disorders and the presence of fungi on the nails of the hands and feet of patients with hand-foot syndrome secondary to treatment with paclitaxel.

METHODS

Prospective study, carried out from October 2018 to December 2019, which included 81 patients undergoing treatment for breast cancer using paclitaxel and had signs and or symptoms of hand-foot syndrome with or without nail disorders. The data were collected through interviews guided by a structured questionnaire, information from medical records and reports of mycological exams.

RESULTS

The average age of women was 54.7 ± 7.4 years. Nail disorders occurred in 69 patients (85.2%), and of these, 43 (62.3%) were positive for fungi. The fungi were yeasts (n = 38; 69%), dermatophytes (n = 15; 27.2%) and non-dermatophyte filamentous fungi (n = 8; 14.5%).

CONCLUSIONS

Nail disorders were the most frequent manifestations in patients with hand-foot syndrome treated with paclitaxel and occurred in 85.2% of them. It was evidenced that fungi are present on the nails of these patients and can occur in up to 65.28%. The most prevalent fungi were Candida and Trichophyton. The nail lesion was associated with the type of treatment protocol used by the patient. The results of the study point to the need to select safe management alternatives for patients, so they can prevent nail lesions and prevent the proliferation of fungi, consequently reducing negative life impact during treatment.

Dermatophytic onychia: Effectiveness of rapid immunochromatographic diagnostic testing directly on samples compared to culture

BACKGROUND

Until now, definite diagnosis of dermatophytic onychia has been made by taking a nail sample and placing it in culture. The result is usually obtained only after 2 to 3weeks. More recently, diagnosis within a few minutes after sampling has become possible thanks to an immunochromatography technique developed in Japan and now available in France: the Diafactory Tinea Unguium® test strip (Biosynex, France).

METHODS

Over a 12-month period, 80nail samples from 80patients giving rise to a positive fungal culture were included in the study. For each patient, part of the removed nail was stored at room temperature and an immunochromatographic test was retrospectively performed according to the supplier's instructions. A small fragment of nail (≥ 1mg) was mixed with a few drops of reagent in a tube for 1min and the test strip was then placed in the tube with the result being visible to the naked eye (control strip, positivity strip) after incubation for a few minutes.

RESULTS

Compared with the culture method used for 51 isolated dermatophytes (42 Trichophyton rubrum, 9 Trichophyton interdigitale), the sensitivity of the rapid test was 96.07% (49/51). For the 29other fungal cultures (10Fusarium sp., 3Scytalidium sp., 3Scopulariopsis brevicaulis,3Aspergillus sp., 1Alternaria sp., 3Candida albicans, 1Candida parapsilosis, 1Trichosporons sp., 1Rhodotorula sp., and 3Corynebacterium sp.), the specificity was 75.86% (22/29). False positives were mainly due to the genera Fusarium and Scopulariopsis (6 of 7false positives), which were the likely cause of onychomycosis.

DISCUSSION

This rapid test could be useful in limiting excessive clinical diagnosis of dermatophyte onychomycosis. The rapid test has several advantages: ease of application, speed of results, and good performance, which, together, could improve diagnostic certainty during the actual consultation, thus limiting prolonged unnecessary prescriptions of antifungal treatments, while waiting for the laboratory culture results (3weeks for a negative result).

A Paradigm Shift in the Treatment and Management of Onychomycosis

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.

Diagnosis of Onychomycosis: From Conventional Techniques and Dermoscopy to Artificial Intelligence

Onychomycosis is a common fungal nail infection. Accurate diagnosis is critical as onychomycosis is transmissible between humans and impacts patients' quality of life. Combining clinical examination with mycological testing ensures accurate diagnosis. Conventional diagnostic techniques, including potassium hydroxide testing, fungal culture and histopathology of nail clippings, detect fungal species within nails. New diagnostic tools have been developed recently which either improve detection of onychomycosis clinically, including dermoscopy, reflectance confocal microscopy and artificial intelligence, or mycologically, such as molecular assays. Dermoscopy is cost-effective and non-invasive, allowing clinicians to discern microscopic features of onychomycosis and fungal melanonychia. Reflectance confocal microscopy enables clinicians to observe bright filamentous septate hyphae at near histologic resolution by the bedside. Artificial intelligence may prompt patients to seek further assessment for nails that are suspicious for onychomycosis. This review evaluates the current landscape of diagnostic techniques for onychomycosis.

Nondermatophyte mould onychomycosis

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.

Onychomycosis: An Updated Review

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.

Methylene blue vs methyl aminolevulinate photodynamic therapy in the treatment of mild-to-moderate toenail onychomycosis: Short- and medium-term effects

Photodynamic therapy (PDT) has emerged as an interesting alternative option for onychomycosis treatment. The impact of a specific photosensitizer (PS) on the final result is an important factor to consider. We conducted a short- and medium-term controlled trial to compare the effectiveness of PDT in the treatment of mild-to-moderate onychomycosis when it is mediated by two different PSs. Twenty patients were randomized to receive nine sessions of PDT distributed over 16 weeks mediated either by methylene blue (MB/PDT group) or methyl aminolevulinate (MAL/PDT group). Onychomycosis severity index (OSI) and nail involvement were checked along the study. Complete cure, treatment success, and clinical improvement were tabulated at 16 and 40-week follow-ups. OSI scores decreased significantly along the study, from 12.1 ± 5.4 to 3.6 ± 3.2 (MB/PDT group) and from 14.8 ± 6.0 to 5.4 ± 4.4 (MAL/PDT group). At 16-week follow-up, only 20% of the patients in the MB/PDT group reached complete cure and none in the group of MAL/PDT. At 40-week follow-up, complete cure rates were 70% and 40% in the MB/PDT group and MAL/PDT group respectively. Both modalities showed good outcomes in treatment of moderate toenail onychomycosis. MB/PDT showed a faster action but with relapse rates slightly higher than MAL/PDT.

Google search trends in onychomycosis: Influences of flip flops and advertising

BACKGROUND

Onychomycosis is a fungal infection of the nail, affecting 5.5% of the population. Individuals affected by this disease experience increased anxiety about this disorder and a decreased quality of life. There are multiple available treatments across the globe, leading people to search online for information on the various therapies.

AIMS

To analyze Google search trends of fungal infection and treatment keywords and the influence of different geographical locations, season, regulatory decisions, and advertisements on these trends.

METHODS

In May, 2020 we used Google Trends to determine the relative interest of various fungal infection and treatment keywords worldwide and in the US, the UK, Canada, and Australia. Notable peaks were investigated for contemporaneous news events.

RESULTS

In general, searches for toenail fungus and associated treatment terms peak during the summer months. Interest in individual treatments peaks when a product is launched, is the subject of an advertising campaign, or becomes more available to the public through approval or reclassification. Yeast infection, thrush, and ringworm terms are consistently searched more often than toenail fungus, jock itch, or foot fungus; all terms are most popular in the summer months, with toenail fungus reaching annual popularity one month prior to jock itch.

DISCUSSION

In general, interest in toenail fungus and treatments is the highest when social anxiety about toenail appearance and the occurrence of fungal infection is the greatest. Curiosity about treatment products increases with their availability and visibility to the public. Combining the power of seasonal interest and advertising generates the greatest search profile for onychomycosis treatments.

A Week of Oral Terbinafine Pulse Regimen Every Three Months to Treat all Dermatophyte Onychomycosis

Terbinafine has proved to treat numerous fungal infections, including onychomycosis, successfully. Due to its liver metabolization and dependency on the cytochrome P450 enzyme complex, undesirable drug interaction are highly probable. Additionally to drug interactions, the treatment is long, rising the chances of the appearance of side effects and abandonment. Pharmacokinetic data suggest that terbinafine maintains a fungicidal effect within the nail up to 30 weeks after its last administration, which has aroused the possibility of a pulse therapy to reduce the side effects while treating onychomycosis. This study's goal was to evaluate the effectiveness of three different oral terbinafine regimens in treating onychomycosis due to dermatophytes. Sixty-three patients with onychomycosis were sorted by convenience in three different groups. Patients from group 1 received the conventional terbinafine dose (250 mg per day for 3 months). Group 2 received a monthly week-long pulse-therapy dose (500 mg per day for 7 days a month, for 4 months) and group 3 received a 500 mg/day dose for 7 days every 3 months, totaling four treatments. There were no statistical differences regarding the effectiveness or side effects between the groups. Conclusion: A quarterly terbinafine pulse regimen can be a possible alternative for treating onychomycosis caused by dermatophytes.