Fungal foot infection, cellulitis and diabetes: a review

Diabetic Foot and Fungal Infections: Etiology and Management from a Dermatologic Perspective

Diabetes Mellitus (DM) is a significant global concern. Many diabetic patients will experience complications due to angiopathy, neuropathy, and immune dysfunction, namely diabetic foot ulcers (DFU) and diabetic foot infections (DFI), which can result in lower limb amputation and potentially death. The prevalence of common superficial fungal infections, such as tinea pedis and onychomycosis, can directly increase a diabetic patient's risk of developing both DFU and DFI. In this review article, we discuss the etiology of diabetic foot complications as well as considerations for both screening and management. We also discuss the role of the dermatologist within a multidisciplinary care team in prescribing and managing treatments for tinea pedis and onychomycosis infections within this patient population. We believe that reducing the burden of these fungal infections in the context of the diabetic foot will help reduce DFU and DFI complications and their associated morbidity and mortality.

How effective is topical miconazole or amorolfine for mild to moderately severe onychomycosis in primary care: the Onycho Trial - a randomised double-blind placebo-controlled trial

OBJECTIVES

To evaluate the efficacy of topical miconazole or amorolfine compared to placebo for mild to moderately severe onychomycosis.

DESIGN

Randomised, double-blind, placebo-controlled trial, with computer-generated treatment allocation at a 1:1:1 ratio.

SETTING

Primary care, recruitment from February 2020 to August 2022.

PARTICIPANTS

193 patients with suspected mild to moderately severe onychomycosis were recruited via general practices and from the general public, 111 of whom met the study criteria. The mean age of participants was 51 (SD 13.1), 51% were female and onychomycosis was moderately severe (mean OSI 12.1 (SD 8.0)).

INTERVENTIONS

Once-daily miconazole 20 mg/g or once-weekly amorolfine 5% nail lacquer solution was compared with placebo (denatonium benzoate solution).

MAIN OUTCOME MEASURES

Complete, clinical and mycological cure at 6 months. Secondary outcomes were clinical improvement, symptom burden, quality of life, adverse effects, compliance, patient-perceived improvement and treatment acceptability.

RESULTS

Based on intention-to-treat analysis, none of the participants receiving miconazole or amorolfine reached complete cure compared with two in the placebo group (OR not estimable (n.e.), p=0.493 and OR n.e., p=0.240, respectively). There was no evidence of a significant difference between groups regarding clinical cure (OR n.e., p=0.493 and OR 0.47, 95% CI 0.04 to 5.45, p=0.615) while miconazole and amorolfine were less effective than placebo at reaching both mycological cure (OR 0.25, 95% CI 0.06 to 0.98, p=0.037 and OR 0.23, 95% CI 0.06 to 0.92, p=0.029, respectively) and clinical improvement (OR 0.26, 95% CI 0.08 to 0.91, p=0.028 and OR 0.25, 95% CI 0.07 to 0.85, p=0.021, respectively). There was no evidence of a significant difference in disease burden, quality of life, adverse reactions, compliance, patient-perceived improvement or treatment acceptability.

CONCLUSIONS

Topical miconazole and amorolfine were not effective in achieving a complete, clinical or mycological cure of mild to moderately severe onychomycosis, nor did they significantly alleviate the severity or symptom burden. These treatments should, therefore, not be advised as monotherapy to treat onychomycosis.

TRIAL REGISTRATION NUMBER

WHO ICTRP NL8193.

Association between onychomycosis and ulcerative complications in patients with diabetes: a longitudinal cohort study in Dutch general practice

INTRODUCTION

Diabetic foot ulcers are feared complications of diabetes mellitus (DM), requiring extensive treatment and hospital admissions, ultimately leading to amputation and increased mortality. Different factors contribute to the development of foot ulcers and related complications. Onychomycosis, being more prevalent in patients with diabetes, could be an important risk factor for developing ulcers and related infections. However, the association between onychomycosis and diabetic complications has not been well studied in primary care.

RESEARCH DESIGN AND METHODS

To determine the impact of onychomycosis on ulcer development and related complications in patients with diabetes in primary care, a longitudinal cohort study was carried out using routine care data from the Extramural Leiden University Medical Center Academic Network. Survival analyses were performed through Cox proportional hazards models with time-dependent covariates.

RESULTS

Data from 48 212 patients with a mean age of 58 at diagnosis of DM, predominantly type 2 (87.8%), were analysed over a median follow-up of 10.3 years. 5.7% of patients developed an ulcer. Onychomycosis significantly increased the risk of ulcer development (HR 1.37, 95% CI 1.13 to 1.66), not affected by antimycotic treatment, nor after adjusting for confounders (HR 1.23, 95% CI 1.01 to 1.49). The same was found for surgical interventions (HR 1.54, 95% CI 1.35 to 1.75) and skin infections (HR 1.48, CI 95% 1.28 to 1.72), again not affected by treatment and significant after adjusting for confounders (HR 1.32, 95% CI 1.16 to 1.51 and HR 1.27, 95% CI 1.10 to 1.48, respectively).

CONCLUSIONS

Onychomycosis significantly increased the risk of ulcer development in patients with DM in primary care, independently of other risk factors. In addition, onychomycosis increased the risk of surgeries and infectious complications. These results underscore the importance of giving sufficient attention to onychomycosis in primary care and corresponding guidelines. Early identification of onychomycosis during screening and routine care provides a good opportunity for timely recognition of increased ulcer risk.

Severe drug eruption from oral terbinafine for mild onychomycosis-A case report from family practice and literature review: "Just an innocent little pill?"

Onychomycosis is the most prevalent nail disease and is frequently encountered in clinical practice. Despite having multiple therapeutic options, of which systemic antifungals are the most effective, treatment is not always mandatory in all patients. Especially when considering systemic treatment, the risk of adverse reactions may outweigh the potential benefits of treatment. In this case report, we present a clinical case of a 49-year-old male patient with a blank past medical history who experienced a severe drug eruption from terbinafine prescribed for mild onychomycosis that required discontinuation of terbinafine, additional evaluation, and treatment of this adverse reaction.

Fabrication of gelatin coated polycaprolactone nanofiber scaffolds co-loaded with luliconazole and naringenin for treatment of Candida infected diabetic wounds

The current study focuses on the development of gelatin-coated polycaprolactone (PCL) nanofibers co-loaded with luliconazole and naringenin for accelerated healing of infected diabetic wounds. Inherently, PCL nanofibers have excellent biocompatibility and biodegradation profiles but lack bioadhesion characteristics, which limits their use as dressing materials. So, coating them with a biocompatible and hydrophilic material like gelatin can improve bioadhesion. The preparation of nanofibers was done with the electrospinning technique. The solid state characterization and in-vitro performance assessment of nanofibers indicate the formation of uniformly interconnected nanofibers of 200-400 nm in diameter with smooth surface topography, excellent drug entrapment, and a surface pH of 5.6-6.8. The antifungal study showed that the nanofiber matrix exhibits excellent biofilm inhibition activity against several strains of Candida. Further, in-vivo assessment of nanofiber performance on C. albicans infected wounds in diabetic rats indicated accelerated wound healing efficacy in comparison to gauge-treated groups. Additionally, a higher blood flow and rapid re-epithelialization of wound tissue in the treatment group corroborated with the results obtained in the wound closure study. Overall, the developed dual-drug-loaded electrospun nanofiber mats have good compatibility, surface properties, and excellent wound healing potential, which can provide an extra edge in the management of complex diabetic wounds.

Prevalence and Factors Associated With Tinea Pedis Among Diabetic Patients in Saudi Arabia: A Descriptive Cross-Sectional Study

BACKGROUND

It has been estimated that 30% of diabetic people experience dermatological problems. Fungal infections are the most frequent cause of these lesions. While tinea infections in non-diabetic individuals rarely cause symptoms, in diabetes patients, they can create fistulas and entry sites that can result in catastrophic bacterial infections.

AIM

This research paper aims to evaluate the prevalence and factors associated with tinea pedis among diabetic patients in Saudi Arabia.

METHODS

The research paper incorporated a cross-sectional study approach with the involvement of a questionnaire-based response aimed at all Saudi inhabitants with diabetes mellitus (DM) who conceded to be part of the study. This research was carried out from March 22, 2023, to May 22, 2023, spanning for three months. The participants who satisfied our requirements provided data using computerized Google Forms for data collection; no nominative information disseminated via social media platforms was visible. The three components of the questionnaire address diabetic information, tinea pedis infections, and foot care.

RESULTS

A total of 295 people with diabetes case were involved in the study. Among them, 149 (50.5%) were males, and their ages stretched from 16 to above 60 years, with a mean age of 49.5 ± 12.9 years old. A total of 194 (65.8%) of the study patients had type II DM. Of 134 (45.4%) were diagnosed with diabetes for more than 10 years. Exact 152 (52%) of the study diabetic patients were diagnosed with tinea pedis. Only patients' BMI showed a significant association with having tinea pedis as 47 of overweight diabetics were diagnosed with tinea pedis versus 47 of obese patients and only five patients of others who were underweight (p=0.049).

CONCLUSION

This research concluded that almost 50% of patients with diabetes were suffering from obesity and were earlier diagnosed with tinea pedis and poor glycemic control irrespective of reported good diabetic foot care.

Toe Web Infections, the Microbiome, and Toe Web Psoriasis: A Review

OBJECTIVE

To present the toe web space as an anatomically, physiologically, and pathologically unique part of the human body; characterize toe web infections and discuss why they occur; and highlight toe web psoriasis as an uncommon condition that providers should consider if toe web intertrigo does not respond to treatment.

DATA SOURCE

This review encompassed many years of clinical observation and photographs; medical textbooks; and a literature search of MEDLINE, PubMed, and Google Scholar.

STUDY SELECTION

Primary research keywords included intertrigo, toe web intertrigo, toe web infection, tinea pedis, microbiome, skin microbiome, toe web microbiome, ecology, psoriasis, psoriasis microbiome, intertriginous psoriasis, and Wood's lamp. More than 190 journal articles met the search criteria.

DATA EXTRACTION

The authors sought data relating to what makes for a healthy toe web space and what makes for disease. They extracted and collated relevant information to compare and contrast among sources.

DATA SYNTHESIS

After understanding the normal toe web space and the microorganisms that normally reside there, the authors investigated why infections occur, how they should be treated, what complications may result, and what other diseases occur in the toe web area.

CONCLUSIONS

This review of toe web infection illustrates the effect of the microbiome and reports a rare form of psoriasis that is usually misdiagnosed as athlete's foot. The toe web space is a unique part of the human body that can be affected by a variety of both common and unusual conditions.

Foot Problems and Their Associations with Toe Grip Strength and Walking Speed in Community-Dwelling Older Individuals Using Day Services: A Cross-Sectional Study

Foot disorders in older individuals compromise balance and contribute to postural and gait instabilities, causing a decrease in the activities of daily living and quality of life. In this cross-sectional study, we analyzed the foot-related data of 160 frail older participants who attended day service centers in A prefecture in Japan to determine the prevalence of foot problems and their associations with toe grip strength and walking speed in frail older people. Multiple regression analysis was used to identify foot-related variables that correlated with toe grip strength and walking speed. The prevalence rates of skin dryness (Support level 88.2%, Care level 85.2% for men; Support level 84.9%, Care level 93% for women) and suspected and existing fungal infections in nails (Support level 94.1%, Care level 92.6% for men; Support level 98.1%, Care level 95.2% for women) were high in both sexes regardless of the level of care required. Furthermore, in both sexes, the prevalence rates of toe and arch deformities were significantly increased in the people who required care. Regression analysis revealed that some right-sided foot-related problems were significantly associated with right toe grip strength and walking speed. The decrease in toe grip strength was significantly associated with walking speed. Our study provides evidence that some specific conditions were associated with toe grip force and walking speed. This finding can contribute to future strategies to protect foot health in community-dwelling older individuals.

Loop-mediated isothermal amplification-microfluidic chip for the detection of Trichophyton infection

Trichophyton is the most pathogenic type of fungal skin infection. It often invades and grows in a keratin-rich matrix, and lesions include human skin, hair, and fingernails (toenails). We designed LAMP primers for Trichophyton and developed a LAMP-Microfluidic chip detection system for Trichophyton. This system detects six common species of Trichophyton in the genus Trichophyton, including Trichophyton rubrum, Trichophyton mentagrophyte, Trichophyton violaceum, Trichophyton tonsurans, Trichophyton verrucosum, and Trichophyton schoenleinii. The specificity reached 100%, and the sensitivity could reach about 1 × 10² copies/μl. The entire detection process can be completed within 60 min and does not cross-react with other dermatophytes. The established LAMP-Microfluidic chip detection system has the advantages of simple operation, high specificity, and high sensitivity, and has the potential for clinical application.

Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?

Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.

A Comparative Study on the Phenotypic Versus Molecular Identification of Clinical Dermatophytes

Dermatophytosis is the superficial infection of keratinized tissue like skin, hair, and nails, in humans and animals, by a group of closely related fungi known as dermatophytes. Phenotypic identification of dermatophytes, especially through classical methods can be difficult and uncertain at times, especially when differentiating species with overlapping characteristics. Alternative identification methods based on amplification and sequence analysis of the highly polymorphic internal transcribed spacer (ITS) sequences flanking the 5.8S ribosomal RNA gene has proven to be quite sensitive and reliable. The objective of our study was to compare the phenotypic and the ITS sequencing-based methods for the identification of clinically isolated dermatophyte specimens from Puducherry, India. A total of 13 clinical samples from 39 suspected cases were found positive for dermatophytes using KOH/DMSO preparations. Specimens were subsequently cultured in Sabouraud dextrose agar (SDA) supplemented with chloramphenicol, gentamicin, and cycloheximide. Dermatophytes were identified based on culture characteristics and microscopic examination in lactophenol cotton blue preparations. ITS sequencing was additionally performed after PCR amplification for species identification. Identification based on phenotype through microscopy and culture methods confirmed infections with Trichophyton mentagrophytes (n = 11), T. rubrum (n = 1), and Microsporum gypseum (n = 1). The strains were confirmed by ITS sequencing without any discrepancy with phenotypic identification. Identification of common dermatophytes based on phenotypic characteristics may be used as a reliable method of diagnosis where sophisticated methods like ITS sequencing and PCR are unavailable.

Platyphylloside, a potential inhibitor from epicarp of B.aegyptiaca against CYP450 protein in T.rubrum – In vitro and in silico approaches

Trichophyton rubrum is one of the major disease causing pathogens in human; mainly it causes tinea pedis, tinea cruris and tinea corporis. Cytochrome P450 which considered to be an important protein that can impact ergosterol biosynthesis pathway. B. aegyptiaca is rich source of secondary metabolites with tremendous medicinal values and it has sweet pulp, leaves with spine, strong seed and oily kernel. The epicarp of the fruit was taken for this study to inhibit T. rubrum using in vitro and in silico techniques. The epicarp portion was extracted using various solvents and water. The anti-dermatophytic activity on T. rubrum of these extracts was assessed utilizing poison plate technique with 5 individual concentrations. The fractioned chloroform extract of epicarp had fully inhibited the growth of T. rubrum at 3 mg/ml. Further, the chloroform extract was subjected to LC-MS analysis, in total, 40 compounds were elucidated. Then, the derived compounds were included for predicting ADMETox properties using Qikprop module. From the analysis 40 compounds were identified to be eligible for docking process. Then the desirable compounds, drug Ketoconazole were subjected to docking analysis using Glide module of Schrödinger. It shows that Platyphylloside has better docking result than other compounds and drug Ketoconazole. Further, MD simulation was carried out for Ketoconazole-Cyp450 and Platyphylloside-CYP450 complexes using Desmond, Schrödinger. MD simulation study also confirmed that the Platyphylloside-CYP450 complex more stable. This study suggests that Platyphylloside may act as potential inhibitor and it could be further subjected to experimental analysis to inhibit the T. rubrum growth.

Superficial mycoses, a matter of concern: Global and Indian scenario-an updated analysis

Superficial mycoses of skin, nails and hair are among the common fungal infections. They are caused by dermatophytes, non-dermatophyte moulds, yeasts and yeast-like fungi. Such fungal infections are widespread all over the world and are predominant in tropical as well as subtropical regions. Environmental factors, such as warm, humid and pitiable hygienic conditions, are conducive for their growth and proliferation. Although it does not cause mortality, it is known to be associated with excessive morbidity which may be psychological or physical. This affects the quality of life of the infected individuals which leads to a negative impact on their occupational, emotional and social status. Such infections are increasing on a global scale and, therefore, are of serious concern worldwide. This review article covers the global and Indian scenario of superficial mycoses taking into account the historical background, aetiological agents, prevalence, cultural and environmental factors, risk factors, pathogenesis and hygienic practices for the prevention of superficial mycoses.

Effects of Nurse and Care Worker-led Foot-Care Program on Older People's Foot Conditions: Before and After Intervention Study

INTRODUCTION

An increasing number of older people with frailty in Japan use geriatric day care centers. Older people who have been certified as requiring long-term care attend centers during the day and receive nursing care help with bathing, excretion, meals, and functional training services. Many older people have foot problems with need foot care by nurses and care workers (NCWs) at geriatric day care centers.

OBJECTIVE

This study explored the effects of NCWs' foot-care programs on the foot conditions of older people attending daytime services.

METHODS

A before-after intervention study was conducted at geriatric day care centers for older people, where the foot-care program was presented by NCWs for two months. The foot conditions of 23 clients (8 men, 15 women, mean age = 78.6 years, standard deviation = 9.2) were assessed before and after the program. Changes in foot condition and clients' perceptions after the study were analyzed through descriptive statistics, McNemar, and paired t-tests.

RESULTS

Although dramatic changes in foot conditions were not observed, some conditions were improved or maintained. Changes were observed in mean dry skin scores (p < .01; right foot: 1.6→1.1, left foot: 1.6→1.1), skin lesions and long nails (skin lesions R: 0.2→0.1; long nail R: 1.4→1.0, L: 1.1→0.8), and edema (R: 43.5%→39.1%, L: 52.2%→47.8%). Further, clients started perceiving that foot health is important and discussed their feet with staff more often.

CONCLUSION

The NCWs' foot-care program was effective in maintaining and improving foot health in older people and positively affected their perception of foot care.

Noninvasive Assessment of Mycotic Nail Tissue Using an Ultraviolet Fluorescence Excitation Imaging System

BACKGROUND AND OBJECTIVES

Mycological diagnosis of onychomycosis is based on direct microscopy using external fluorophores to visualize fungal tissue in nail samples and agar culture. Ultraviolet fluorescence excitation imaging (u-FEI) has shown potential in monitoring biological processes by exploiting variations in autofluorescence. This study aimed at assessing the potential of a handheld u-FEI system as a practical screening tool for fungal nail infections.

STUDY DESIGN/MATERIALS AND METHODS

Ninety samples from 29 patients with microscopy-confirmed fungal infection and 10 control samples from healthy participants were collected (n = 100). Using a prototype u-FEI system (single bandpass 25 mm filter with a central pass wavelength of 340 nm and a bandwidth of 12 nm, 295 nm excitation flash, resolution of 640 × 480), images of all samples were acquired under standardized conditions. Average and maximum fluorescence intensity image values in arbitrary units (AU) of manually delineated regions of interests were quantitated and statistically assessed for significant differences between healthy and mycotic samples.

RESULTS

UV-images clearly depicted all 100 nail samples, with a visibly stronger signal in infected samples. Statistically significant differences (P < 0.05) in signal intensity between mycotic samples and healthy controls were observed for maximum and average fluorescence values. Mean fluorescence values of onychomycotic samples showed 23.9% higher maximum (mycotic: 34.9 AU [standard deviation [SD] 4.7]; healthy: 28.2 AU [SD 1.9]) and 10.2% higher average (mycotic: 27.6 AU [SD 2.0]; healthy: 25.0 AU [SD 0.7]) signal intensity values. Receiver operating characteristic curves demonstrated excellent discriminatory ability (area under the curve > 0.9). Analysis of fluorescence measurements of the reference standard demonstrated very low variation (coefficient of variation = 0.62%) CONCLUSION: Quantitation of u-FEI intensities enables differentiation between healthy and mycotic nail samples, constituting a potential point-of-care tool for cost-effective screening for onychomycosis at a primary care level. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Optical coherence tomography of onychomycosis: proposed terminology and a suggestion of practical usage

Onychomycosis is the most common cause of nail changes accounting for about half of all nail diseases. It is important to diagnose the fungal pathogen to prescribe adequate treatment, but as genus- and species-specific diagnostic tests can be time consuming and expensive, it is crucial to obtain representative tissue during nail scrapings. Optical coherence tomography (OCT) is a non-invasive imaging tool enabling real-time imaging of skin and tissue. Pilot studies using OCT have described morphological characteristics of onychomycosis, though diagnostic criteria of onychomycosis and other nail diseases are lacking. The aim of this study is to investigate the applicability of OCT to detect and localize fungal elements in nails with clinical signs of onychomycosis. OCT scans and nail scrapings were performed on all participants and only confirmed cases of onychomycosis were included in the data analysis. All scans were analyzed, and a set of morphological criteria based on known literature and deviations from healthy nail morphology were suggested. The suggested morphological features were: hyperreflective lines divided into sharply and diffusely demarcated; hyperreflective dots divided into singular and clustered patterns; irregular surface, divided into mild, moderate and severe degree; dark bands and disturbed architecture. The suggested OCT morphology is a refinement of previous studies, and though OCT cannot replace genus- or species-specific identification, it could be a useful assistance tool to increase diagnostic sensitivity of nail scrapings and laboratory tests as well as for monitoring treatment response.

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial

Importance

Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost.

Objective

To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis.

Design, Setting, and Participants

This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups.

Interventions

Dermatology consultation within 24 hours of hospitalization.

Main Outcomes and Measures

Length of hospital stay and duration of intravenous antibiotic treatment.

Results

Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines.

Conclusions and Relevance

Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment.

Trial Registration

clinicaltrials.gov Identifier: NCT01706913.

Patients' understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care

BACKGROUND

Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately one-third of cases. The only proven strategy to reduce the risk of recurrence is long-term, low-dose antibiotics. Given current concerns about antibiotic resistance and the pressure to reduce antibiotic prescribing, other prevention strategies are needed.

OBJECTIVES

To explore patients' views about cellulitis and different ways of preventing recurrent episodes.

METHODS

Adults aged ≥ 18 years with a history of first-episode or recurrent cellulitis were invited through primary care, hospitals and advertising to complete a survey, take part in an interview or both.

RESULTS

Thirty interviews were conducted between August 2016 and July 2017. Two hundred and forty surveys were completed (response rate 17%). Triangulation of quantitative and qualitative data showed that people who have had cellulitis have wide-ranging beliefs about what can cause cellulitis and are often unaware of risk of recurrence or potential strategies to prevent recurrence. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were more popular potential strategies than the use of compression stockings or long-term antibiotics. Participants expressed caution about long-term oral antibiotics, particularly those who had experienced only one episode of cellulitis.

CONCLUSIONS

People who have had cellulitis are keen to know about possible ways to prevent further episodes. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were generally viewed to be more acceptable, feasible strategies than compression or antibiotics, but further research is needed to explore uptake and effectiveness in practice.

A neglected causative agent in diabetic foot infection: a retrospective evaluation of 13 patients with fungal etiology

Background/aim

Clinicians often neglect fungal infections and do not routinely investigate deep tissue from the wound for fungal culture and sensitivity due to insufficient information in the literature. In this study, we aimed to evaluate fungal etiology of invasive fungal diabetic foot which is rarely reported in the literature.

Materials and methods

The patients who were unresponsive to antibiotic therapy and those with positive fungal in bone or deep tissue culture were enrolled in the study. Detailed hospital records were retrieved for demographics and clinical features.

Results

A total of 13 patients who were diagnosed with invasive fungal diabetic foot (ten females, three males, mean age 59.8 ± 9 years) were included. All of the patients had type-2 diabetes mellitus. Eleven (84.6%) patients had mixed infection. The most common cause of fungal infections of diabetic foot ulcers was the Candida species. Ten (76.9%) patients underwent amputation, two (15.4%) patients refused amputation, and one patient died before surgery.

Conclusion

Invasive fungal infections may also be a causative pathogen in deep tissue infections. Therefore, fungal pathogens should be considered in patients unresponsive to long-term antibiotic therapy. Early detection of fungal infections in high-risk individuals is critical for the prevention of severe consequences such as foot amputation.

Candida sp. Infections in Patients with Diabetes Mellitus

Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.

Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India)

Background

Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. Current treatment recommendations appear to lose their relevance in the current clinical scenario. The objective of the current consensus was to provide an experience-driven approach regarding the diagnosis and management of tinea corporis, cruris and pedis.

Methods

Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi process consisting of two workshops and five rounds of questionnaires, elaborating definitions, diagnosis and management. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. More than 75% of concordance in response was set to reach the consensus.

Result

KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was recommended for naïve and recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine and itraconazole should be the preferred systemic drugs. Minimum duration of treatment should be 2–4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea management was strongly discouraged.

Conclusion

This consensus guideline will help to standardise care, provide guidance on the management, and assist in clinical decision-making for healthcare professionals.

Sphingobacterium spiritivorum bacteremia due to cellulitis in an elderly man with chronic obstructive pulmonary disease and congestive heart failure: a case report

Background

Sphingobacterium spiritivorum is a glucose non-fermenting Gram-negative rod, formerly classified as one of the Flavobacterium species. It is characterized by a large number of cellular membrane sphingophospholipids. Sphingobacterium species are ubiquitous and isolated from natural environments, such as soil and water. However, they rarely cause infections in humans. Only a limited number of cases have been reported in elderly and immunocompromised patients with underlying diseases and predisposing factors.

Case presentation

An 80-year-old Japanese man with chronic obstructive pulmonary disease and congestive heart failure visited the Kariya Toyota General Hospital, Aichi, Japan with the chief complaint of fever accompanied by chills and left leg pain. At initial presentation, he was distressed and dyspneic. He was febrile (38.8 °C), and his left foot was swollen with reddening and tenderness. We diagnosed him as having cellulitis, and he was hospitalized for antibiotic therapy. Initially, he was treated with intravenously administered cefazolin, but after the isolation of a glucose non-fermenting Gram-negative rod from blood cultures, we decided to switch cefazolin to intravenously administered meropenem on day 4, considering the antibiotic resistance of the causative organism. The causative organism was identified as S. spiritivorum on day 6. His condition gradually stabilized after admission. Meropenem was switched to orally administered levofloxacin on day 12. He was discharged on day 16 and treated successfully without any complications.

Conclusions

Although S. spiritivorum is rare, with limited cases isolated from cellulitis, it should be considered as a causative organism in elderly and immunocompromised patients with cellulitis. Blood cultures are the key to correct diagnosis and appropriate treatment.

Reappraisal of Conventional Diagnosis for Dermatophytes

Dermatophytoses include a wide variety of diseases involving glabrous skin, nails and hair. These superficial infections are a common cause of consultation in dermatology. In many cases, their diagnosis is not clinically obvious, and mycological analysis therefore is required. Direct microscopic examination of the samples using clearing agents provides a quick response to the clinician and is usually combined with cultures on specific media, which must be used to overcome the growth of contaminating moulds that may hamper the recovery of dermatophytes. Accurate identification of the causative agent (i.e. at the species level), currently based on morphological criteria, is necessary not only to initiate an appropriate treatment but also for setting prophylactic measures. However, conventional methods often lack sensitivity and species identification may require up to 4 weeks if subcultures are needed. Histological analysis, which is considered the "gold standard" for the diagnosis of onychomycoses, is seldom performed, and as direct examination, it does not allow precise identification of the pathogen. Nevertheless, a particular attention to the quality of clinical specimens is warranted. Moreover, the sensitivity of direct examination may be greatly enhanced by the use of fluorochromes such as calcofluor white. Likewise, sensitivity of the cultures could be enhanced by the use of culture media containing antifungal deactivators. With the generalization of molecular identification by gene sequencing or MALDI-TOF mass spectrometry, the contribution of historical biochemical or physiological tests to species identification of atypical isolates is now limited. Nevertheless, despite the recent availability of several PCR-based kits and an extensive literature on molecular methods allowing the detection of fungal DNA or both detection and direct identification of the main dermatophyte species, the biological diagnosis of dermatophytosis in 2016 still relies on both direct examination and cultures of appropriate clinical specimens.

Onychomycosis in patients with chronic leg ulcer and toenail abnormalities

Nails have a limited number of reactive patterns to disease. Accordingly, toenail changes of different etiologies may mimic onychomycosis.

Patient considerations in the management of toe onychomycosis - role of efinaconazole

Onychomycosis is a difficult diagnosis to manage and treatment is sometimes avoided, as this diagnosis is often wrongly perceived as a cosmetic problem. However, onychomycosis has a negative impact on patients' quality of life, affecting social interaction, psychological well-being, and physical activities. Onychomycosis is also a risk factor for patients with diabetes, with proven increased rates of cellulitis, gangrene, and foot ulcers. Treatments are only mild to moderately effective, and rates of relapse and reinfection are high. Oral treatments require laboratory monitoring due to risk of hepatotoxicity and may be contraindicated in some patients due to risk of drug-drug interactions. Topical treatments require prolonged application and are not very effective. Efinaconazole 10% solution is a new topical triazole treatment for mild to moderate distal subungual onychomycosis, with good efficacy and without the need for debridement of nails. In onychomycosis of the toenails, efinaconazole 10% solution is documented to have a statistically significant, positive impact on patient satisfaction and quality of life.

Prevalence and associated factors of comorbid skin diseases in patients with schizophrenia: a clinical survey and national health database study

OBJECTIVES

To examine the epidemiology of and possible risk factors for skin diseases in patients with schizophrenia.

METHODS

All of 337 patients with schizophrenia were recruited from the therapeutic community of a psychiatric hospital and underwent a detailed skin examination. The National Health Insurance Research Database (NHIRD) was used to compare the prevalence of skin diseases between patients with schizophrenia and those without.

RESULTS

In the clinical survey, fungal infection (61.4%) and dermatitis (46.9%) were the most common skin diseases. Clozapine users had a lower risk of fungal infection than those on typical antipsychotics [odds ratio (OR)=0.49, 95% confidence interval (CI)=0.30-0.81]. Obese patients were more likely to have fungal infections than those without (OR=1.93, 95% CI=1.20-3.09), and those with diabetes had an increased risk of bacterial infection than those without (OR=2.0, 95% CI=1.06-3.75). NHIRD revealed that the overall prevalence of skin diseases, including infections, dermatitis, hyperkeratosis, pilosebaceous disease, androgenic alopecia, xerosis and stasis, were higher in patients with schizophrenia than in those without (75.1% vs. 72.6%, P=.01).

CONCLUSIONS

The prevalence of skin diseases is high in patients with schizophrenia, for whom proper skin care is necessary to improve their life quality.

Tinea pedis: the etiology and global epidemiology of a common fungal infection

Tinea pedis, which is a dermatophytic infection of the feet, can involve the interdigital web spaces or the sides of the feet and may be a chronic or recurring condition. The most common etiological agents are anthropophiles, including Trichophyton rubrum sensu stricto, which is the most common, followed by Trichophyton interdigitale and Epidermophyton floccosum. There has been a change in this research arena, necessitating a re-evaluation of our knowledge on the topic from a multidisciplinary perspective. Thus, this review aimed to provide a solid overview of the current status and changing patterns of tinea pedis. The second half of the twentieth century witnessed a global increase in tinea pedis and a clonal spread of one major etiologic agent, T. rubrum. This phenomenon is likely due to increases in urbanization and the use of sports and fitness facilities, the growing prevalence of obesity and the aging population. For optimal patient care and management, the diagnosis of tinea pedis should be verified by microbiological analysis. In this review, we discuss the epidemiology, clinical forms, complications and mycological characteristics of tinea pedis and we highlight the pathogenesis, prevention and control parameters of this infection.

A rare case of Cryptococcus luteolus-related tenosynovitis

A 68-year-old male with type II diabetes mellitus presented with a nodule over the metacarpophalangeal joint of his right second finger after being spurred on the hand by a domestic turkey 2 weeks prior to onset of clinical symptoms. He was diagnosed with cryptococcal tenosynovitis caused by Cryptococcus luteolus identified by DNA sequencing. Complete clinical resolution was achieved with synovectomy and debridement followed by 1 year of fluconazole 800 mg daily.

Onychomycosis: modern diagnostic and treatment approaches

The medical term onychomycosis should be understood as chronic infection of the nails caused by a fungus. The most common causative agents are the dermatophytes and Candida species. The less common are certain types of moulds (nondermatophyte moulds or NDMs). In approximately 60-80 % of the cases, onychomycosis is due to dermatophytes. Among dermatophytes, the most often isolated causative pathogen is Trichophyton (T.) rubrum. Other common species are T. interdigitale (formerly T. mentagrophytes), Epidermophyton floccosum, and T. tonsurans. The most significant yeasts causing onychomycosis are Candida albicans and Candida parapsilosis. Predisposing factors for onychomycosis include mainly diseases such as diabetes mellitus, peripheral vascular arterial disease, chronic venous insufficiency, polyneuropathies of diverse etiologies, and immunosuppression, e.g., myeloproliferative diseases (such as lymphoma and paraproteinemia), HIV/AIDS, etc. Other factors facilitating the fungal infection are frequent trauma in professional sportsmen, often accompanied by excessive perspiration. The diagnostic methods that are often applied in different dermatologic departments and ambulatory units are also different. This precludes the creation of a unified diagnostic algorithm that could be used everywhere as a possible standard. In most of the cases, the method of choice depends on the specialist's individual experience. The therapeutic approach depends mostly on the fungal organism identified by the dermatologist or mycologist. This review hereby includes the conventional as well as the newest and most reliable and modern methods used for the identification of the pathogens causing onychomycosis. Moreover, detailed information is suggested, about the choice of therapeutic scheme in case whether dermatophytes, moulds, or yeasts have been identified as causative agents. A thorough discussion of the schemes and duration of the antifungal therapy in certain groups of patients have been included.

[Fungal nail infections--an update: Part 1--Prevalence, epidemiology, predisposing conditions, and differential diagnosis]

Onychomycosis describes a chronic fungal infection of the nails most frequently caused by dermatophytes, primarily Trichophyton rubrum. In addition, yeasts (e. g. Candida parapsilosis), more rarely molds (Scopulariopsis brevicaulis), play a role as causative agents of onychomycosis. However, in every case it has to be decided if these yeasts and molds are contaminants, or if they are growing secondarily on pathological altered nails. The point prevalence of onychomycosis in Germany is 12.4%, as demonstrated within the "Foot-Check-Study", which was a part of the European Achilles project. Although, onychomycosis is rarely diagnosed in children and teens, now an increase of fungal nail infections has been observed in childhood. More and more, diabetes mellitus becomes important as significant disposing factor both for tinea pedis and onychomycosis. By implication, the onychomycosis represents an independent and important predictor for development of diabetic foot syndrome and foot ulcer. When considering onychomycosis, a number of infectious and non-infectious nail changes must be excluded. While psoriasis of the nails does not represent a specific risk factor for onychomycosis, yeasts and molds are increasing isolated from patients with psoriatic nail involvement. In most cases this represents secondary growth of fungi on psoriatic nails. Recently, stigmatization and impairment of quality of life due to the onychomycosis has been proven.

Cellulitis: definition, etiology, and clinical features

Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric antimicrobial recommendations are suggested, including the most recent recommendations from the Infectious Disease Society of America.

The Etiopathogenesis of the Diabetic Foot: An Unrelenting Epidemic

Diabetes mellitus is a metabolic disease that is associated with hyperglycemia affecting various organ systems of the body. One of the most dreaded complications of this disease is the diabetic foot. The diabetic foot is the end result of multiple causal pathways, which include peripheral neuropathy and vascular disease. The problem is compounded by the increased incidence of infection. This article deals with the various pathogenic pathways associated with the development of the diabetic foot.