Do fungi play a role in psoriatic nails?

The link between total antioxidant status, total oxidant status, arylesterase activity, and subgingival microbiota in psoriasis patients

BACKGROUND

Studies focusing on the relationship between periodontitis and systemic diseases have suggested a possible association between these two chronic and inflammatory disorders. We aimed to comparatively investigate the salivary oxidative status, biomarker levels, clinical findings, and the microbial load on subgingival biofilm samples in psoriasis patients and controls.

METHODS

Forty participants were allocated into four groups as follows: (1) systemically and periodontally healthy (C group); (2) systemically healthy with periodontitis (P group); (3) psoriasis (Ps) and periodontally healthy (Ps-C group); and (4) Ps with periodontitis (Ps-P group). Subgingival biofilm samples were obtained to detect the periodontopathogenic agents by Real-time PCR (qPCR). The total antioxidant status (TAS) (mmol/l), total oxidant status (TOS) (μmol/l), and arylesterase (ARE) activity (U/L) were analyzed using saliva samples.

RESULTS

The level of TOS and oxidative stress index (OSI) were significantly higher in patients with Ps-P and P compared to controls (P = 0.001, and P ˂ 0.001, respectively). ARE levels were higher in controls compared to Ps and P (P ˂ 0.001). The prevalences of bacteria detected in subgingival biofilm samples were similar between all groups (P > 0.05).

CONCLUSIONS

This study reported that psoriasis may amplify TOS and OSI, and the co-existence of psoriasis and periodontitis may aggravate oxidative stress.

Characterisation of the nail microbiome in psoriatic and nonpsoriatic patients with onychomycosis

BACKGROUND

Onychomycosis (OM) is the most common infectious nail disease, and it occurs frequently in patients with psoriasis. Microbial community shifts have been suggested to play a role in psoriasis and fungal infection occurrence.

OBJECTIVES

To investigate and compare nail microbial community compositions in psoriatic and nonpsoriatic patients with OM.

METHODS

Toenail samples were collected from nonpsoriatic patients with OM, psoriatic patients with nail psoriasis (NP) and OM, patients with only NP and healthy controls. Bacterial and fungal community compositions were analysed by amplicon sequencing of the V3-V4 regions of the 16S rDNA gene and the ITS1 region, respectively.

RESULTS

Psoriatic OM patients had higher bacterial and fungal alpha diversities. Taxonomic analysis revealed a significantly lower relative abundance of Trichophyton rubrum (32.88% vs 82.18%, p < .001) and an increased trend of the abundance of Candida in psoriatic patients with OM than in nonpsoriatic patients. Nonpsoriatic patients with OM had a higher abundance of Staphylococcus than healthy controls (59.66% vs 45.76%, p < .05). Trichophyton, Alternaria and Malassezia could accurately differentiate psoriatic and nonpsoriatic patients with OM, with an area under the curve (AUC) of 0.86. The severity of OM was positively correlated with the relative abundance of Trichophyton rubrum. Further, Trichophyton was positively correlated with Staphylococcus and negatively correlated with Corynebacterium, Anaerococcus, Malassezia and Alternaria.

CONCLUSIONS

The nail microbiome in psoriatic patients with OM has distinct bacterial and fungal signatures, suggesting that different dysbiosis is associated with the pathogenesis of OM in psoriatic and nonpsoriatic patients.

Coexistence of onychomycosis and nail psoriasis and its correlation with systemic treatment

BACKGROUND

Epidemiological studies indicate that onychomycosis may affect up to 79% of psoriatic patients. Onychomycosis in psoriatic patients is more commonly caused by yeasts comparing with non-psoriatic.

OBJECTIVES

Evaluate the prevalence of fungi in nail psoriasis. Evaluate the association between direct mycological examination (DME) and mycological culture, Nail Psoriasis Severity Index (NAPSI) and systemic treatment for psoriasis.

METHODS

Of 133 nails from 20 patients with nail psoriasis were evaluated as follows: 9 patients were using topical treatment and 11 were on systemic treatment. The assessment of psoriasis severity using NAPSI was performed in all psoriatic nails. The presence of fungi was confirmed in DME and culture.

RESULTS

DME showed the presence of fungal elements in 45 nails (33.83%) with a predominance of blastoconidia (95.5%) No septate hyphae were seen. Mycological culture was positive in 36 (27.06%) samples. Among them, Candida grew in 31 (86.1%): Candida parapsilosis in 15 (48.38%), Candida spp in 14 (45.16%). No growth of dermatophytes was observed. Patients with systemic treatment showed a higher frequency of positive test (DME and culture) for fungi when compared to topic treatment (p:.006). There was a positive correlation between NAPSI, mycological culture and systemic treatment (p:.0063); the risk was four times higher (OR:4.0).

LIMITATION OF THE STUDY

Sample size.

CONCLUSION

These results are consistent with some previous reports, Candida was the fungus with higher frequency on the psoriatic nails, however, the role of these fungi is controversial (contamination x colonisation x infection). The fact that the immunosuppressive treatment increases the chance of fungal infection leads us to a greater attention to this patient profile, to prevent the intensification of nail psoriasis (Köbner phenomenon).

Effect of Different Nail Penetration Enhancers in Solid Lipid Nanoparticles Containing Terbinafine Hydrochloride for Treatment of Onychomycosis

Onychomycosis is considered a stubborn nail fungal infection that does not respond to conventional topical antifungal treatments. This study aimed to develop and characterize novel solid lipid nanoparticles (SLNs) formulae containing terbinafine HCl (TFH) and loaded with different nail penetration enhancers (nPEs). Three (nPEs) N-acetyl-L-cysteine, thioglycolic acid, and thiourea were used. Characterization of the prepared formulae was done regarding particle size, zeta potential, polydispersity index (PDI), entrapment efficiency (EE%), physical stability, in vitro release study, infrared (FT-IR), and their morphological structures. The selected formulae and the marketed cream Lamifen® were compared in terms of their antifungal activity against Trichophyton rubrum as well as their nail hydration and their drug uptake by the nail clippers. Thiourea was the nPE of choice; formulae (N2 and N8), with thiourea, were considered the optimum TFH SLNs containing nPEs. They were selected for their optimum particle size of 426.3 ± 10.18 and 450.8 ± 11.45 nm as well as their highest EE% of 89.76 ± 1.25 and 90.35 ± 1.33, respectively. The in vitro microbiological screening of the antifungal activity of these two formulae showed significantly larger zones of inhibition in comparison with the marketed product. The ex vivo screening of the drug uptake of the two selected formulae was significantly higher than that of the marketed product. The nPE formulae present a very promising option as they showed optimum physicochemical characterization with high antifungal activity and high drug uptake as well as good nail hydration effect.

Comparative study between the effect of topical tazarotene 0.1 gel alone vs its combination with tioconazole nail paint in treatment of onychomycosis

Onychomycosis (OM) is a chronic fungal infection of the nail caused by dermatophytes, yeasts, and nondermatophytes. Tioconazole is one of the topical antifungal belonging to imidazole derivatives. Tazarotene is a synthetic retinoid, with immunomodulating properties and anti-inflammatory activity. To evaluate the efficacy of tazarotene 0.1% gel alone in comparison with its combination with tioconazole nail paint in the treatment of onychomycosis. Forty patients presented with onychomycosis, subjected to a full history taking, clinical examination, and nail examination, which includes a clinical, dermoscopic, assessment of severity by using Onychomycosis Severity Index (OSI), KOH examination, and fungal culture. There was a statistically significant increase in the response of treatment in patients treated by a combination of tazarotene and tioconazole compared to tazarotene alone through (decrease in OSI, dermoscopic features, and mycological clearance). Tazarotene had antifungal activity specially against Aspergillus niger while its combination with tioconazole gave better results and can be used as an adjuvant to the standard systemic or topical antifungal treatment for OM.

Management of nail psoriasis by topical drug delivery: a pharmaceutical perspective

The management of nail psoriasis is an arduous task owing to the disease manifestations and anatomical structure of the nail plate. Although various treatment therapies are available for nail psoriasis, topical therapy is contemplated as one of the most favorable options as systemic therapies are accompanied by numerous side effects that result in patient incompliance. The topical formulations including creams, gels, ointments, and nail lacquers have been used as delivery systems for various antipsoriatic drugs. Among these, nail lacquers emerge to be promising and patient friendly formulations. However, the major defiance with topical delivery is inefficacious penetration of drug through impenetrable keratinized nail plate to reach the target sites: nail matrix and nail bed. Therefore, in order to obtain effectual drug delivery systems that can retain/remain on the nail plate for a prolonged period of time and deliver the drug across it, systematic approaches like quality by design (QbD) need to be followed so that the desired quality can be "built in" the system rather than to rely solely on retrograde evaluation. Furthermore, more advances in research are still required to develop a validated animal model so as to determine the efficacy of the formulation and to establish a mathematical model that can help in predicting the desirable attributes of the formulation and permeation of various molecules through the nail plate.

Psoriatic onychodystrophy: clinical manifestations (part 1)

Psoriatic onychodystrophy is quite common in patients with psoriasis. Changes in psoriatic nails have a wide range of clinical manifestations, including symptoms of damage of the nail bed and/or nail matrix. The article presents information about clinical and pathological manifestations of psoriatic onychodystrophy, the mechanisms of formation of pathological changes. The existence of the relationship between the change of nail plates in patients with psoriasis and the development of psoriatic arthritis is explained, the prognostic value of individual symptoms is analyzed. The diagnostic criteria for the histological diagnosis of psoriatic onychodystrophy are described. The information about the occurrence of each symptom in patients with psoriasis with dystrophic nail changes is given.

Case Report: Successful Treatment of Chromoblastomycosis Caused by Fonsecaea monophora in a Patient with Psoriasis Using Itraconazole and Acitretin

Chromoblastomycosis is a worldwide chronic subcutaneous infection caused by dematiaceous fungi and clinically characterized by verrucous lesions. Herein, we report a rare case of chromoblastomycosis caused by Fonsecaea monophora in a 60-year-old male carpenter with a 40-year history of psoriasis from Shandong in northern China. A fungal infection coexisting with psoriasis presents a management dilemma. Our patient responded well to combined itraconazole and acitretin therapy and the lesions resolved completely after 1 month of treatment.

Etiology of Onychomycosis in Patients in Turkey

BACKGROUND

Onychomycosis is a chronic nail infection caused by dermatophytes, Candida, nondermatophyte molds, and Trichosporon. The purpose of this study was to identify the underlying pathogen in patients with onychomycosis in our region.

METHODS

A retrospective analysis of 225 cases with onychomycosis, diagnosed over a 27-month period at the Department of Dermatoveneorology, Bezmialem Vakif University, Istanbul, Turkey, and confirmed with culture, was performed.

RESULTS

Patient age ranged from 2 to 87 years (mean ± SD, 41.59 ± 17.61), and female patients were more commonly affected (120 cases, 53.3%) than male patients. Lateral and distal subungual onychomycosis was detected in 180 cases (80%). Etiologic agents were as follows: Trichophyton rubrum, 77 cases (34.2%); Trichophyton mentagrophytes, 30 cases (13.3%), Candida albicans, 28 cases (12.4%); Candida parapsilosis, 25 cases (11.1%); Acremonium species, one case (0.4%); Aspergillus species, two cases (0.9%); Fusarium species, four cases (1.3%); and Trichosporon species, three cases (1.3%).

CONCLUSIONS

The most frequent isolated etiologic agents were T rubrum for toenails and C albicans for fingernails.

The prevalence and etiological factors of onychomycosis in psoriatic patients

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

Oral Candida colonization and plaque type psoriasis: Is there any relationship?

AIM

The potential role of superantigens derived from microbial agents could be considered in the pathogenesis of psoriasis, but the association between Candida albicans and psoriasis severity is still controversial. The present study was designed to compare the prevalence of oral candidiasis in a group of psoriatic patients and healthy patients, and its correlation with psoriasis severity.

METHODS

Seventy psoriatic patients with no history of systemic treatment and 70 closely-matched control patients underwent oral examination. Scraping of oral mucosa to detect Candida species was done using a sterile cytobrush.

RESULTS

Candida was detected in the oral cavity of 20% of patients with psoriasis and 2.8% of control cases (P = .002), but none had clinical features of oral candidiasis. Candida albicans was the only species isolated from the oral cavity of both groups. No correlation was found between sex, age, phototherapy, and presence of oral candidiasis. There was a positive correlation between psoriasis severity and colony count (P < .001).

CONCLUSIONS

The prevalence of oral candidiasis is higher in psoriatic patients and is associated with disease severity. It is not exactly clear whether oral candidiasis can aggravate psoriasis or if psoriasis can predispose patients to oral candidiasis.

New insight into the pathogenesis of nail psoriasis and overview of treatment strategies

Psoriasis is a chronic inflammatory disease affecting up to 3% of the general population. The prevalence of nail involvement in psoriasis patients varies between 15% and 79%. While the nails represent a small portion of the body surface area, psoriasis in these areas can have a disproportionate influence on a patient’s physical and psychosocial activities. Differential diagnosis between an onychomycosis and a psoriatic nail could be challenging; nevertheless, coexistence of onychomycosis and nail psoriasis also occurs and both are common disorders in the general population. Nail psoriasis can be difficult to treat. Treatment of nail psoriasis should consider the body surface area of skin disease, psoriatic arthritis, severity of nail disease, and the impairment in the quality of life. All patients should be tested for onychomycosis before starting a therapy. This recommendation is underlined by the fact that nail psoriasis is mostly treated by immunosuppressive drugs, like steroids, methotrexate, or biologics, which may aggravate mycotic nail infections. Conventional systemic therapy, such as use of steroids, cyclosporine, methotrexate, and retinoid in the long term, can cause organ toxicities. Currently, use of apremilast and tofacitinib favors an early healing of nail psoriasis because they act directly on the pathogenic targets, distressing the inflammatory signals associated with the initiation and maintenance of the disease activity, and as with several conventional synthetic disease modifying antirheumatic drugs, they are characterized by the convenience of oral administration. The number of treatment options has increased considerably in recent years; however, given the heterogeneity of the disease, the therapy should be personalized to individual cases.

Role of HLA-DR Alleles to Increase Genetic Susceptibility to Onychomycosis in Nail Psoriasis

BACKGROUND

Patients with nail psoriasis have an increased risk of onychomycosis. Previous studies suggest it may be due to structural changes of the nails. However, a genetic predisposition seems to be also at play.

OBJECTIVE

To determine a genetic susceptibility for onychomycosis in nails with changes of psoriasis.

METHODS

This is a prospective case-control study of patients with suggestive changes of nail psoriasis with onychomycosis (cases) and without onychomycosis (controls) confirmed by mycological tests. HLA typing was performed in all of them by sequence-specific primers.

RESULTS

Twenty-five patients and 20 controls with a mean age of 50 years (range 37-72 years) were studied. HLA-DRB1*08 was found in 12 cases (48%) and only 3 controls (15%) [p < 0.033, odds ratio (OR) = 3.8, 95% confidence interval (CI): 0.9-19]. HLA-DR1 was found in 9 cases (36%) and only 1 control (5%) (p < 0.023, OR = 8.5, 95% CI: 1-188).

CONCLUSION

HLA-DR*08 and HLA-DR*01 probably increase the susceptibility to fungal infection in psoriasis-affected nails, but larger studies are required to confirm this observation.

Psoronychomycosis: A New Term for an Old Problem

Occasionally, psoriatic nail changes are seen in psoriatic patients. The prevalence of psoriasis of the nails has been reported to range from 15% to 79%. Even with effective systemic treatment for psoriasis, the nails may not improve, and these nails are considered nonresponsive psoriatic nails. Psoriatic nails are rarely investigated, and it is assumed that the nail changes are simply attributed to psoriasis because of their clinical similarity. Even patients with nails unresponsive to systemic treatment, or psoriasis treated topically or with phototherapy, onychomycosis is often forgotten, and patients may be left with both onychomycosis and psoriasis or onychomycosis alone. A retrospective chart review of 361 patients was carried out. The investigators report the prevalence of psoriasis and onychomycosis as less than 1%. A new term, "psoronychomycosis," is suggested to denote the rare combination of psoriasis and onychomycosis.

Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features

BACKGROUND

Psoriasis is a disease of worldwide distribution with a prevalence of 1 to 3%. Nail psoriasis is estimated in 50% of patients with psoriasis, and in the presence of joint involvement, it can reach 80%.

OBJECTIVE

To study the nail changes - and their clinical implications - presented by patients with psoriasis vulgaris under surveillance in a university hospital from the south of Brazil.

METHODS

his cross-sectional study evaluated 65 adult patients from January 2012 to March 2013. Cutaneous severity was assessed according to the Psoriasis Area and Severity Index (PASI). The Nail Psoriasis Severity Index (NAPSI) was used to evaluate patient's nails. The diagnosis of psoriatic arthritis was established according to the Classification Criteria for Psoriatic Arthritis (CASPAR).

RESULTS

The prevalence of NP was 46.1%. These patients had a median [interquartilic range (IQR)] NAPSI of 1 (0-15). A total of 63.3% of patients reported aesthetic discomfort or functional impairment related to their nails. Onycholysis was the most common feature (80%). When compared with patients without nail involvement, patients with NP had lower mean age at psoriasis onset [21 (18-41) vs. 43 (30-56) years, p=0,001]; longer disease duration [15.5 (10-24) vs. 6 (2-12) years, p=0.001]; higher PASI [9.2 (5-17) vs. 3.7 (2-10), p=0.044], higher frequency of psoriatic arthritis (43.3 vs. 3.7, p = 0.002) and more often reported family history of psoriasis (40% vs. 7.4%, p = 0.011).

CONCLUSION

Onycholysis was the most frequent finding and most patients feel uncomfortable with the psoriatic nail changes that they experience.

Nail psoriasis: a review of the literature

Nails are considered epidermal appendages, and as such, are commonly affected in patients with psoriasis, 80% of whom are likely to develop nail psoriasis as a result of their condition. Two patterns of nail disorders have been shown to be caused by psoriasis. Nail matrix involvement can result in features such as leukonychia, pitting (punctures or cupuliform depressions), red spots in the lunula and crumbling. Nail bed involvement, on the other hand, can cause onycholysis, salmon or oil-drop patches, subungual hyperkeratosis and splinter hemorrhages. Nail disease causes aesthetic and functional impairment, and is indicative of more severe forms of psoriasis as well as of joint involvement. The treatment for nail psoriasis involves behavioral interventions, topical medications, or systemic therapy in case of extensive skin or joint involvement. This article presents a review of the main features of nail psoriasis, its clinical presentation, diagnostic and assessment methods, clinical repercussions, and of its available treatment options.

The prevalence of onychomycosis in psoriatic patients: a systematic review

We systematically reviewed all available literature concerning the prevalence of onychomycosis in patients with nail psoriasis and the distribution of pathogens causing onychomycosis in this specific group of patients. Databases searched were Pubmed, EMBASE and the Cochrane Controlled Clinical Trial Register. All studies reporting on the prevalence of onychomycosis in nail psoriasis were obtained, and quality assessment was determined by the STrengthening the Reporting of OBservational studies in Epidemiology checklist. Literature search revealed 720 studies, of which 10 studies met the inclusion criteria. The major limitation of the review was the heterogeneity of the included studies, which prevented the possibility to conduct a meta analysis. However, the average prevalence of 18.0% of onychomycosis in psoriatic patients seems to be increased when compared with control groups and literature on healthy population, even though the ultimate evidence remains lacking. As in the literature hypothesized shift in causative agents from dermatophytes to yeasts and/or moulds could not be confirmed. The clinical consequence of the relatively high prevalence of onychomycosis in psoriasis may be a general advice to rule out onychomycosis or concomitant onychomycosis in these patients with (suspected) nail psoriasis. This advice is stressed by the relative simplicity of treating the contribution of onychomycosis in the nail dystrophy but also the fact that nail psoriasis mostly is treated by immunosuppressive drugs, like steroids, methotrexate or biologics which may aggravate mycotic nail infections.

A preformulation strategy for the selection of penetration enhancers for a transungual formulation

Onychomycosis is associated with the cutaneous fungal infection of the nail and the nail folds (skin surrounding the nail). It is therefore important to target drug delivery into the nail folds along with nail plate and the nail bed. Systematic and strategic selection of the penetration enhancers specific for the skin and the nail is discussed. Twelve penetration enhancers were screened for their ability to improve solubility, in vitro nail penetration, in vitro skin permeation, and in vitro skin penetration of the antifungal drug ciclopirox olamine. In contrast to transdermal drug delivery, the main selection criteria for skin penetration enhancer in topical drug delivery were increased drug accumulation in the epidermis and minimal permeation across the skin. Thiourea improved the solubility and nail penetration of ciclopirox olamine. It also showed enhancement in the transungual diffusion of the drug. Propylene glycol showed a 12-fold increase in solubility and 3-fold increase in epidermal accumulation of ciclopirox olamine, while minimizing the transdermal movement of the drug. Thiourea was the selected nail permeation enhancer and propylene glycol was the selected skin penetration enhancer of ciclopirox olamine. A combination of the selected enhancers was also explored for its effect on drug delivery to the nail and nail folds. The enhancer combination reduced the penetration of ciclopirox in the skin and also the permeation through the nail. The proposed preformulation strategy helps to select appropriate enhancers for optimum topical delivery and paves way towards an efficient topical formulation for passive transungual drug delivery.

Onychomycosis in patients of nail psoriasis on biologic therapy: a randomized, prospective open label study comparing Etanercept, Infliximab and Adalimumab

INTRODUCTION AND OBJECTIVE

The association between patients of psoriasis on anti TNF therapy and onychomycosis has not been explored. The aim of this study was to determine the rate of onychomycosis in patients of psoriasis with nail involvement on anti TNF therapy.

MATERIALS AND METHODS

All patients of psoriasis with nail involvement seen between February 2007 - July 2012 were examined. All the patients with negative nail scrapings for fungus were enrolled. Patients found fit for biologics after investigations were randomly divided into 3 groups (Group A: Infliximab, Group B: Etanercept and Group C: Adalimumab). The patients were followed up every 4 weeks for 24 weeks. Repeat nail scrapings were done at week 24. The results were compared with controls.

RESULT

In total, 315 (178 males and 137 females) patients were enrolled. The mean age was 37.5 ± 11.4 years. The results for scraping for fungus at the end of 24 weeks were as follows: 33% (33/100) in patients on Infliximab followed by 15.45% (17/110), 13.33% (14/105) in patients on treatment with Etanercept and Adalimumab respectively as compared to 13.89% (25/180) among controls. Onychomycosis in association with nail psoriasis was more common in males.

CONCLUSION

This study revealed statistically significant association between fungal infections of the nail in patients of psoriasis on treatment with Infliximab.

Oral Candida colonization and candidiasis in patients with psoriasis

OBJECTIVES

The objective of this study was to investigate oral Candida colonization and candidosis in a group of patients with psoriasis and controls.

STUDY DESIGN

A total of 100 patients with psoriasis and matched controls underwent the concentrated oral rinse test for Candida isolation. Candida species were identified by the VITEK 2 Identification System. Categorical variables were evaluated using the χ(2) test. The median Candida count was compared using the Mann-Whitney U test.

RESULTS

Oral candidiasis was diagnosed in 3% of the patients with psoriasis. The Candida count and prevalence were significantly higher in the patients with psoriasis compared with controls (69% vs 44%, P < .001), but with no relationship to the severity or treatment of psoriasis. Oral Candida was significantly higher in late-onset (at age ≥30 years) compared with early-onset psoriasis (at age <30 years).

CONCLUSIONS

Patients with psoriasis have increased oral Candida colonization and candidiasis. Further studies are needed to clarify the predisposing factor(s) for oral Candida in patients with psoriasis.

Topical review: skin infections in the foot and ankle patient

There are numerous cutaneous disorders that affect the foot, but of these conditions skin infections have the most significant impact on overall patient morbidity and clinical outcome. Skin infections in foot and ankle patients are common, with often devastating consequences if left unrecognized and untreated in both surgical and nonsurgical cases. There is a diverse array of infectious dermatoses that afflict the foot and ankle patient including tinea pedis, onychomycosis, paronychia, pitted keratolysis, verruca, folliculitis, and erysipelas. Prompt diagnosis, treatment, and surveillance of these common infectious conditions are critical in managing these dermatoses that can potentially progress to form deep abscesses and osteomyelitis. Infections can be managed with a combination of ventilated shoewear and synthetic substances to keep the feet dry, topical and oral antimicrobial agents, and patient education regarding preventative hygiene measures. The purpose of this review is to aid foot and ankle surgeons and other physicians in the diagnosis and treatment of infectious dermatoses affecting the foot.

Nail dystrophy in psoriatic arthritis presenting as nail onychomycosis: a case report

Dystrophic nail changes without a skin lesion is a rare form of psoriasis. We describe a patient that presented with a chronic nail onychomycosis and a destructive thumb interphalangeal joint which was initially considered as onychomycotic joint infection, and was later diagnosed as having dystrophic nail changes in psoriatic arthritis and coexistent onychomycosis. The nail changes were completely normalized after methotrexate treatment.

Onychomycosis in patients with psoriasis--a multicentre study

1-3% of human population is affected by psoriasis. Nail disorders are reported in 10-80% of patients with psoriasis. Nail deformations vary according to their degree of severity but are mainly represented by pitting, Beau's lines, hyperkeratosis, onycholysis, leuconychia or oil drops. Onychomycosis is a fungal infection of the nails, caused by dermatophytes, yeast and moulds. In this study, 228 patients with psoriasis aged between 18 and 72 were examined (48 - from Plovdiv, Bulgaria; 145 - from Pleven, Bulgaria and 35 - from Thessaloniki, Greece); 145 of them were male and 83 of them were female. The examination of the nail material was performed via direct microscopy with 20% KOH and nail samples plated out on Sabouraud agar methodology. The severity of the nail disorders was determined according to the Nail Psoriasis Severity Index (NAPSI). Positive mycological cultures were obtained from 62% of the patients with psoriasis (52%- Plovdiv, Bulgaria; 70%- Pleven, Bulgaria and 43%- Thessaloniki, Greece). In 67% of the cases, the infection was caused by dermatophytes, in 24% by yeast, in 6% by moulds and in 3% by a combination of causes. All patients with psoriasis were identified with high levels of NAPSI, whereas the ones with isolated Candida had even higher levels. Seventeen percentage of the patients have been treated with methotrexate, 6% have been diagnosed with diabetes and 22% have been reported with onychomycosis and tinea pedis within the family. An increased prevalence of onychomycosis among the patients with psoriasis was found. Dystrophic nails in psoriasis patients are more predisposed to fungal infections. The mycological examination of all psoriasis patients with nail deformations is considered obligatory because of the great number of psoriasis patients diagnosed with onychomycosis.

Onychomycosis in psoriatic patients - rationalization of systemic treatment

Nail changes in patients with psoriasis have been reported with varying prevalence. Onychomycosis has been reported in up to 47% of the psoriasis patients. The purpose of this study was to determine the prevalence of nail abnormalities, onychomycosis in psoriasis and response to itraconazole treatment. We evaluated 312 patients suffering from psoriasis for nail changes and onychomycosis. Patients having laboratory confirmation of onychomycosis were treated with three courses of itraconazole (400 mg day(-1) for 1 week). Of 312 patients with psoriasis, 67 (21.5%) patients had nail changes, 23 (34%) of them suffered from onychomycosis. Complete cure (clinical and mycological) was achieved in 30% of the patients with onychomycosis. The response to treatment of onychomycosis with itraconazole in psoriasis patients was found to be lower than in the general population. Considering the low response to onychomycosis systemic therapy in psoriatic patients and the potential side-effects of the treatment, the rationality of this treatment is questionable.