Patients at risk of onychomycosis - risk factor identification and active prevention

Global prevalence of onychomycosis in general and special populations: An updated perspective

BACKGROUND

Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge.

OBJECTIVE

To provide an updated estimate on the prevalence of toenail onychomycosis.

METHODS

We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients.

RESULTS

A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture.

CONCLUSION

Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.

Clinical Diagnosis and Laboratory Testing of Abnormal Appearing Toenails: A Retrospective Assessment of Confirmatory Testing for Onychomycosis in the United States, 2022-2023

Onychomycosis is an under-recognized healthcare burden. Despite the risk of misdiagnosis, confirmatory laboratory testing is under-utilized. Histopathologic examination with polymerase chain reaction (PCR) is currently the most effective diagnostic method; it offers direct detection and identification of a fungal invasion. In this retrospective cohort study, we assessed confirmatory testing results, with matching clinical diagnoses, in 96,293 nail specimens submitted during a 9-month period from 2022 to 2023. Toenail specimens were examined using fungal culture, histopathology and/or PCR. Clinical diagnoses were identified using the International Classification of Diseases 10th Revision codes. For clinically diagnosed onychomycosis patients, the overall positivity rate was 59.4%; a similar positivity rate (59.5%) was found in patients with clinically diagnosed non-fungal nail dystrophy. Performing a histopathologic examination with PCR was more likely to provide pathogen identification results than using fungal culture. Male patients had a higher rate of onychomycosis overall; however, female patients had more non-dermatophyte mold onychomycosis caused by Aspergillus. Clinically diagnosed onychomycosis patients with a co-diagnosis of tinea pedis were more likely to test positive for onychomycosis by PCR (odds ratio [OR]: 4.2; 95% confidence interval [CI]: 2.7-6.4), histopathology (OR: 2.5; 95% CI: 2.0-3.1) and fungal culture (OR: 3.2; 95% CI: 1.5-6.6). Our results support the use of confirmatory laboratory testing when there is a clinical diagnosis of onychomycosis.

Therapeutic treatment strategies for the management of onychomycosis: a patent perspective

INTRODUCTION

Onychomycosis, a multifactorial fungal infection of the nails, shows a global prevalence of about 5.5% and is responsible for 50% of all nail infections. To develop effective management strategies, it is necessary to understand the etiology, pathophysiology, and risk factors of onychomycosis. Oral route of drug delivery is one of the routes utilized to deliver anti-fungal agents, but, has its own limitations like longer duration of treatment, increased adverse effects, and potential for drug interaction. The ungual route has received greater attention due to its localized, non- invasive action and improved patient compliance.

AREAS COVERED

This review comprehensively discusses conventional onychomycosis therapies and patented novel drug delivery systems for the management of onychomycosis including chemical permeation enhancers, non-particulate drug delivery systems, penetration enhancing devices etc., Databases such as PubMed, ResearchGate, and Google Patents were searched by using the keywords onychomycosis and trans-ungual drug delivery.

EXPERT OPINION

Enormous research has been conducted and is still ongoing to find the best possible novel drug delivery system for onychomycosis management. Approaches like incorporation of herbal constituents in nano-formulations, inkjet printing, laser devices, iontophoretic techniques, etc. can be employed to make safe and effective drug delivery systems which are regulatory compliant.

Risk factors of dermatophytosis among Korean adults

Dermatophytosis includes all fungal infections caused by dermatophytes in humans. Some risk factors for the development of subtypes of dermatophytosis have been studied; however, large-scale epidemiologic studies on risk factors for total dermatophytosis are scarce. We investigated the risk factors of dermatophytosis using a nationwide study. Total 4,532,655 subjects with dermatophytosis aged between 20 and 40 years were examined using data from the Korean National Health Insurance Service from 2009 to 2018. Women showed a lower risk of development of dermatophytosis compared to men [hazard ratio (HR) 0.848; 95% confidence interval (CI) 0.843–0.853]. Subjects with elevated waist circumference (HR 1.057; 95% CI 1.048–1.065), heavy drinking (HR 1.053; 95% CI 1044–1.061), engaging in mild-to-heavy exercise (HR 1.071; 95% CI 1.064–1.077) had a higher risk of dermatophytosis. In addition, subjects with body mass index (BMI) of more than 30 kg/m² exhibited a higher risk of dermatophytosis (HR 1.36; 95% CI 1.342–1.378) compared to those with BMIs in the range of 18.5–23 kg/m². In this study, the risk of developing dermatophytosis significantly increased in individuals with elevated waist circumference or high BMI. Lifestyle modifications, including weight management, are suggested to be important in preventing dermatophytosis.

Candida guilliermondii Onychomycosis Involving Fingernails in a Breast Cancer Patient under Docetaxel Chemotherapy

Onychomycosis has been shown to have a higher incidence in cancer patients. Nail toxicity is a quite common side effect of anticancer agents. Taxotere© is a chemotherapeutic known to cause great incidence of nail change and has a role in subungual suppuration. We report on a 52-year-old woman with breast cancer admitted in our institution for onycholysis. Because of the stage and histology of breast cancer, neoadjuvant chemotherapy was initiated. The patient received 8 cycles of Taxotere and Adriamycin (AT), and she underwent a modified radical mastectomy. Three months later, the patient developed evidence of onycholysis, involving all the fingernails. We observed the following changes in nails of all the digits in both hands: onycholysis, dystrophy, oedema, and exudate. Nail scraping and purulent discharge were collected and cultured on Sabouraud medium. Physical features of the colonies and biochemical tests (Auxacolor©) revealed Candida guilliermondii as the sole etiologic agent of onychomycosis. This case details an onycholysis in a breast cancer case successfully managed solely with amorolfine lacquer. This clinical and mycological presentation should alert the clinician to the possibility of onychomycosis induced by docetaxel chemotherapy.

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.

Safety of current therapies for onychomycosis

INTRODUCTION

Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality.

AREAS COVERED

This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding.

EXPERT OPINION

Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.

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.

Continuous terbinafine and pulse itraconazole for the treatment of non-dermatophyte mold toenail onychomycosis

INTRODUCTION

Although dermatophytes are considered the predominant causative organisms in onychomycosis, non-dermatophyte mold (NDM) infections may be more prevalent than originally thought and may be more difficult to treat. There are limited data of oral antifungal efficacy in treating NDM onychomycosis.

METHOD

A retrospective chart review (2009-2016) was conducted in patients receiving continuous oral terbinafine or pulse itraconazole for toenail onychomycosis due to NDMs. Mycology results and percent nail affected were recorded with patient characteristics including demographics and concurrent diseases. Complete, clinical, and mycological cure were tabulated.

RESULTS

Data from 176 patients were collected. Mycological and complete cure rates for terbinafine (69.8% and 17%) and itraconazole (67.5% and 22%) were not significantly different from each other. Regardless of oral treatment, age (p = .013), baseline severity (p = .016), and presence of atherosclerosis (p = .040) or hyperlipidemia (p = .033) decreased the likelihood of mycological cure, while age decreased the likelihood of complete cure (p = .001).

CONCLUSION

Continuous terbinafine and pulse itraconazole were similar in efficacy for curing NDM onychomycosis. Age was the most consistent prognostic factor affecting likelihood of cure, with factors that may influence drug reaching the site of infection also decreasing likelihood of mycological cure.

Onychomycosis with greenish-black discolorations and recurrent onycholysis caused by Candida parapsilosis

Candida parapsilosis (C. parapsilosis) has become a common pathogen, especially in immunocompromised hosts. Here, we present an immunocompetent adult with greenish-black discoloration of the right first finger nail in combination with recurrent onycholysis. C. parapsilosis was isolated from the right first finger nail and was confirmed by morphological characteristics as well as by DNA molecular analysis. Patient was successfully treated with oral itraconazole in a regimen of 5 cycles of 200 mg twice daily for one week, followed by an interruption of treatment for 3 weeks. To our knowledge, this is the first report of C. parapsilosis-induced onychomycosis with recurrent onycholysis.

Pharmacy Technicians and Improving Onychomycosis Treatment Outcomes

Objective: To provide an overview of onychomycosis and current treatments and to identify opportunities for pharmacy technicians to improve treatment outcomes. Data Sources: A MEDLINE/PubMed search (1966 to October 2018) was performed using search terms designed to identify English-language articles on onychomycosis diagnosis, treatment, and prevention, as well as articles on the impact of pharmacy technicians on onychomycosis outcomes and the use of pharmacy technicians to improve treatment adherence. Study Selection and Data Extraction: Review articles and clinical studies describing onychomycosis, risk factors, treatment efficacy, and prevention of recurrent infections were included. Data Synthesis: Although no articles on the impact of pharmacy technicians in the treatment of onychomycosis were found, the importance of treatment adherence on positive outcomes highlights a potential role of pharmacy technicians. Pharmacy technicians can identify patients with potential onychomycosis based on questions about over-the-counter products and refer patients to the pharmacist for counseling on treatment. Pharmacy technicians can also reinforce treatment adherence at refill visits. Conclusions: Pharmacy technicians can have a positive impact on onychomycosis treatment outcomes by addressing barriers to successful treatment and promoting treatment adherence.

The Impact of Onychomycosis on Quality of Life: A Systematic Review of the Available Literature

Purpose

Onychomycosis is a nail disorder that is increasing in prevalence worldwide. The psychological and social limitations caused by onychomycosis can potentially undermine the work and social lives of those experiencing these negative effects. This review aimed to evaluate the randomized controlled trials (RCTs) available in the current literature on the impact onychomycosis has on quality of life (QoL).

Methods

A systematic review was performed using the databases PubMed, PsycINFO, Scopus, ClinicalTrials.gov, and Cochrane Library on July 18, 2017. Only RCTs with clinical effects described in English were included for review.

Results

Ten RCTs reported QoL outcomes for patients suffering from onychomycosis. Treatment satisfaction was statistically significant from baseline to end of treatment in 100.0% (4/4) measures which reported on satisfaction with treatment; mental health was also significant in 100.0% (3/3), symptoms index rating in 100.0% (2/2), symptom frequency in 75.0% (3/4), overall problems in 75.0% (3/4), functional activities in 75.0% (6/8), appearance problems in 66.7% (2/3), symptom distress in 57.1% (4/7), and stigma in 40.0% (2/5). The OnyCOE-t^TM and the NailQoL were the most used common outcome measures to describe QoL.

Conclusion

The study sanctions that onychomycosis physically and psychologically distresses patients' lives. Further research should include validated outcome measures to more effectively treat onychomycosis.

Prevalence, Etiology, and Risk Factors of Tinea Pedis and Tinea Unguium in Tunisia

Background

Foot mycoses are a frequent disease that represents a public health problem worldwide.

Objectives

This study aims to evaluate the epidemiology of foot mycoses among Tunisian patients, in order to determine the fungal etiological agents and to identify possible risk factors.

Patients and Methods

A prospective study of three hundred and ninety-two patients was undertaken during one year (2013-2014). All subjects were asked to collect demographic data related to the risk factors of foot mycoses. A complete mycological diagnosis was carried out on all patients.

Results

A total of 485 samples were collected; tinea pedis and tinea unguium were confirmed in 88.2% of cases. Dermatophytes were isolated in 70.5% and the most frequent pathogen was Trichophyton rubrum (98.1%), followed by yeasts (17.7%) commonly Candida parapsilosis. Non-dermatophyte molds (NDMs) were observed in 8.02% cases and Fusarium sp. was the frequent genus (29.1%). The main predisposing factors of fungal foot infections were practicing ritual washing (56.6%) and frequentation of communal showers (50.5%).

Conclusion

This is a recent survey of foot mycoses in Tunisia. Epidemiological studies can be useful to eradicate these infections and to provide further measures of hygiene and education.

Novel investigational therapies for onychomycosis: an update

INTRODUCTION

Onychomycosis is an infection of the nail plate that is prevalent among the ageing population. Onychomycosis is difficult to treat with low initial cure rates, high rates of relapse, and reinfection. Present treatment options include oral and topical therapies, with oral therapies yielding better results. However, there has been a greater emphasis on the development of topical antifungal therapies as they have fewer side effects and drug interactions.

AREAS COVERED

This review summarizes new and reformulated drugs. Results from in vitro studies to Phase III clinical trials are discussed. Novel drugs include: the oral azole VT-1161, the topical azole efinaconazole, the benzoxaborole tavaborole, reformulations of terbinafine P-3058 and LI-P, novel inhibitor of succinate dehydrogenase ME1111, and off-label use of tazarotene. Enhanced permeation of the morpholine amorolfine through the nail plate is also discussed using ultraviolet (UV) curable gels, and a fractional CO2 laser.

EXPERT OPINION

Novel topical antifungals and the reformulation of current antifungals have demonstrated marked improvement in nail penetration. Current research has an emphasis on topical therapies due to their minimized risk for adverse effects and higher patient demand. Nevertheless, few topical agents have surfaced in the past few years and the investigation of efficacious combination therapies may become more important.

Onychomycosis: Practical Approaches to Minimize Relapse and Recurrence

INTRODUCTION

Toenail onychomycosis is a common disease in which treatment options are limited and treatment failures and disease recurrence are frequently encountered. It usually requires many months of treatment, and recurrence may occur in more than half of the patients within 1 year or more after the infection has been eradicated. Data on long-term treatment, follow-up and recurrence are limited.

OBJECTIVE

Our objective is to interpret these data and recommend practical approaches that should minimize recurrence based on our clinical experience.

RESULTS

Several factors have been suggested to play a role in the high incidence of recurrence, but only the extent of nail involvement and co-existing diabetes mellitus have been shown to have a significant impact.

CONCLUSION

The use of topical antifungals to prevent recurrences after complete cure was achieved has been suggested by various workers and used successfully in our practice. However, it has never been validated through clinical studies. Topical prophylaxis once weekly or twice monthly would seem appropriate in those patients most at risk. Prompt treatment of tinea pedis is essential, as is ensuring family members are free from disease. Patient education and pharmacologic intervention are equally important, and there are a number of simple strategies patients can employ. Managing onychomycosis is a significant long-term commitment for any patient, and minimizing recurrence is critical to meet their expectations.

Improving Cure Rates in Onychomycosis

Background:

Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management.

Objective:

To identify ways to improve cure rates for onychomycosis.

Method:

The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates.

Results and Conclusion:

To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.

Onychomycosis and Onychomatricoma

Nail dermoscopy is helpful in the differential diagnosis of nail disorders including onychomycosis and pigmented and nonpigmented nail tumors. We report two cases of onychomatricoma with concurrent onychomycosis of the same digit. In both cases, dermoscopy of the nail plate exhibited features of onychomatricoma, whereas dermoscopy of the distal free edge revealed features of onychomycosis. It is not uncommon for patients with onychomatricoma to develop coexisting onychomycosis, as channels created by the tumor render the nail plate susceptible to invasion by fungi.

Causative Agents of Onychomycosis: A 7-Year Study

BACKGROUND

Onychomycosis is principally caused by dermatophyte species, but nondermatophyte molds and yeasts have also been involved, causing different clinical manifestations. The aim of this investigation is to determine the clinicomycological and epidemiological profile of the etiologic agents of onychomycosis.

METHODS

The study population included 9,785 suspected cases of onychomycosis referred to the Medical Mycology Reference Laboratory in Isfahan, Iran, during 2007-2014. Nail clipping was collected in sterile Petri dishes for direct microscopic examination and culture. Clinical isolates were identified by using phenotypic tests and molecular techniques.

RESULTS

Of total 9,785 cases with clinical suspicion of onychomycosis comprised in the present study, 1,284 patients (13.1%) were positive by direct microscopy. Age range of patients was between 1 and 82 years. Housewives were the commonest infected population. Candida albicans was the most prevalent species isolated from patients in this study (34.9%) followed by Trichophyton interdigitale (11.7%) and Aspergillus flavus (9.1%).

CONCLUSION

The pattern of causative agents and clinical signs of onychomycosis is altering region to region, so repeated epidemiological surveys of onychomycosis seems to be fundamental. The present study provides novel and appropriate epidemiologic data of onychomycosis for the better prevention and treatment of this fungal infection.

The prevalence of Candida onychomycosis in Southeastern Serbia from 2011 to 2015

Despite the increasing of onychomycosis caused by Candida spp., in referent literature, there is still data insufficiency about this nail infection. The objectives of this retrospective study were to determine epidemiological characteristics of Candida onychomycosis, the antifungal susceptibility of isolated species in vitro, and to compare the results of antifungal susceptibility testing with conducted treatment in period from 2011 to the end of March 2015. Out of 761 patients who were underwent clinical and mycological examinations, 137 had Candida species isolated from nails. The dominant species was Candida albicans (C. albicans) (36.59%) followed by C. parapsilosis (23.78%), C. krusei (9.76%), and C. guilliermondii (6.71%). Antifungal susceptibility in vitro testing showed good susceptibility to antimycotics, except C. krusei, which was resistance to fluconazole (FCZ) and isolates of C. tropicalis and C. glabrata which were dose dependent to itraconazole (ITZ) and fluconazole. Evaluation of medical histories determined that combined therapy, which included pulsed systemic regimen of ITZ with topical application of clotrimazole, had better clinical outcomes regarding the proscribed only topical application of clotrimazole. Multidisciplinary approach of dermatologists and mycologists is required in solving the problem of onychomycosis, which is the dominant nail disease.

Prevalence of Candida tropicalis and Candida krusei in onychomycosis in João Pessoa, Paraiba, Brazil from 1999 to 2010

Over time, as the etiology of onychomycosis has developed, yeasts from the genus Candida have emerged as important etiological agents. This study aimed to determine the frequency of yeast caused onychomycosis in Joao Pessoa, Paraíba, Brazil from 1999 to 2010. A retrospective study from January 1999 to December 2010 evaluated the results of onychomycosis positive direct mycological exams (DME) - for yeast and realized in the Hemato(r) Clinical Laboratory. Women were the most affected by onychomycosis which occur preferentially in adults, and the toenails are the favorite yeast targets. The prevalent yeasts were Candida tropicalis and C. krusei.

Descriptive study of onychomycosis in a hospital in São Paulo

Onychomychosis, a nail fungus infection is the most frequent nail ailment, constituting about half of all nail disorders. It can be caused by dermatophytes, non-dermatophytes, yeasts and Prothoteca spp. Methods include 5407 samples of patients with suspected onychomycosis, studied from January 2002 to December 2006, by direct mycological examination and fungi culture. The diagnosis of onychomycosis was confirmed in samples from 3822 direct mycological and/or culture positive. The diagnosis was established by culture for fungi. Among the 1.428 identified agents, the dermatophytes were responsible for 68.6% (N = 980) of cases, followed by yeasts with 27.6% (N = 394), non-dermatophytes fungi with 2.2% (N = 31), Prothoteca spp with 0.1% (N = 2), and associations with 1.5% (N = 22). Females were more affected, with 66% (N = 2527) of cases, and the most affected age group ranged from 31 to 60 years of age (median 47 years). Fungal microbiota is often changed in the world, both quantitatively and qualitatively, and is affected by several environmental factors. Thus, the periodic review of the composition of this microbiota is important to evaluate the epidemiology and thus proportion a better therapeutic response.

Toenail Onychomycosis—A Canadian Approach With a New Transungual Treatment

Background:

Onychomycosis is a difficult-to-treat infection whose current treatment paradigm relies primarily on oral antifungals. The emergence of new topical drugs broadens the therapeutic options and prompts a re-evaluation of the current Canadian treatment strategy.

Objective:

To define a patient-centred Canadian treatment strategy for onychomycosis.

Methods:

An expert panel of doctors who treat onychomycosis was convened. A systematic review of the literature on treatments for onychomycosis was conducted. Based on the results, a survey was designed to determine a consensus treatment system.

Results:

First-line therapy should be selected based on nail plate involvement, with terbinafine for severe onychomycosis (>60% involvement), terbinafine or efinaconazole for moderate onychomycosis (20%-60% involvement), and efinaconazole for mild onychomycosis (<20% involvement). Comorbidities, patient preference and adherence, or nail thickness may result in the use of alternative oral or topical antifungals.

Conclusion:

These guidelines allow healthcare providers and patients to make informed choices about preventing and treating onychomycosis.

Tazarotene as alternative topical treatment for onychomycosis

Background

Distal and lateral onychomycoses are the most frequent forms of onychomycosis, causing subungual hyperkeratosis that usually limits local penetration of antimycotic drugs. Tazarotene exerts anti-inflammatory and immune-modulating activities toward both infective agents and damaged keratinocytes. Given the well-documented efficacy of tazarotene on hyperkeratotic nail psoriasis, we investigated its therapeutic use in onychomycosis.

Patients and methods

We designed a preliminary open clinical trial in patients affected by distal and lateral subungual onychomycosis of the toenails and verified the fungistatic activity of tazarotene in vitro. Fifteen patients were treated with topical tazarotene 0.1% gel once per day for 12 weeks. Mycological cultures and potassium hydroxide stains of nail samples were performed at the beginning and at the end of the study. Treatment was considered effective when clinical healing and negative mycological culture were obtained. Onycholysis, nail bed discoloration, and subungual hyperkeratosis were measured using standardized methodologies and analyzed by means of Mann–Whitney test and analysis of variance. Fungistatic activity of tazarotene was evaluated by disk diffusion assay.

Results

Six patients (40%) reached a mycological cure on target nail samples already after 4 weeks of treatment. Complete clinical healing and negative cultures were reached in all patients at week 12, with a significant improvement of all clinical parameters of the infected nails. Disk diffusion assay after 48 hours of incubation with tazarotene solution showed a central area of inhibition in all examined fungal cultures.

Conclusion

Our results documented a good clinical outcome using topical tazarotene 0.1% gel in distal and lateral subungual onychomycosis and its fungistatic activity of tazarotene in vitro. The majority of patients appeared cured at a 6-month follow-up. The efficacy and safety of tazarotene must be confirmed on a larger number of patients, although already documented in nail psoriasis patients often affected by onychomycosis.

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.

Antifungal therapy for onychomycosis in children

Onychomycosis is a chronic infection of the nail unit, and its prevalence increases with age. Treatment options for children are similar to those for adults and include both oral and topical therapies. Oral agents, such as terbinafine, itraconazole, and fluconazole have been reported to have good efficacy and a low rate of side effects in children. Topical therapies, such as amorolfine and ciclopirox, can also be used as monotherapy or combined with oral agents to treat onychomycosis. Due to their thinner, faster-growing nails, children are more likely to respond to topical monotherapy than adults. There is currently insufficient data comparing emerging medical devices, such as laser therapy, with standard therapeutic options to recommend their use in children.

Psychosocial perception of adults with onychomycosis: a blinded, controlled comparison of 1,017 adult Hong Kong residents with or without onychomycosis

Background

A survey was conducted amongst 1,017 Hong Kong residents ages 18 and over to determine their knowledge of fungal nail infections (onychomycosis) and the psychosocial impact of the disease on the relationships, social lives and careers of sufferers.

Methods

The Fungal Nail Perception Survey was conducted by email and online between May 29th and June 10th, 2013. Participants were shown three photographs of people with and without onychomycosis of the toenails. Respondents were asked ten questions (repeated for each picture) to ascertain their perceptions of the people in the pictures. Questions were related to perceptions around the ability of sufferers and non-sufferers to form relationships with others, social activities of sufferers and non-sufferers, perceptions of the effect of the disease on the potential for career success, and awareness of fungal nail disease and health. The sub-population who themselves suffered from onychomycosis were asked about self-perception as well as their perception of others with onychomycosis.

Results

Compared with non-sufferers, survey respondents perceived those with onychomycosis as less likely to be able to form good relationships. They also indicated that they would be more likely to exclude sufferers than non-sufferers from social activities and that they would be more likely to feel uncomfortable when sitting or standing beside an infected person than beside an uninfected person. Respondents perceived people with onychomycosis to be less able to perform well in their chosen career than with someone without onychomycosis. Interestingly, those respondents who themselves were infected felt socially excluded, upset and embarrassed by their infection.

Conclusions

Onychomycosis may lead to stigmatization and social exclusion. Misconceptions of onychomycosis are high and education about the disease needs to be improved. Early recognition and treatment of the disease is essential to avoid complications and improve treatment outcomes, which would lead to reduced psychosocial impact on those with fungal nail infections.

Sanitization of Contaminated Footwear from Onychomycosis Patients Using Ozone Gas: A Novel Adjunct Therapy for Treating Onychomycosis and Tinea Pedis?

Background:

Ozone gas possesses antimicrobial properties against bacteria, viruses, and yeasts. Previously, we demonstrated the efficacy of ozone in killing ATCC strains of the dermatophyte fungi Trichophyton rubrum and Trichophyton mentagrophytes.

Objective:

To test the efficacy of ozone gas in sanitizing onychomycosis patient footwear contaminated with fungal material as a means of minimizing the risk of reinfection.

Methods:

Swabs of footwear from onychomycosis patients were cultured prior to and after ozone exposure to test the ability of ozone to sanitize these items.

Results:

We identified contamination of footwear from most onychomycosis patients, a potential source of reinfection in these individuals. Furthermore, ozone gas was effective in sanitizing contaminated footwear.

Conclusion:

Ozone gas is effective in sanitizing footwear and represents a novel adjunct therapy to be used in conjunction with antifungal medications and/or devices to better treat onychomycosis and tinea pedis patients in both the short and the long term.

Evaluation of the morphological effects of TDT 067 (terbinafine in Transfersome) and conventional terbinafine on dermatophyte hyphae in vitro and in vivo

TDT 067 is a novel, carrier-based dosage form of terbinafine in Transfersome (1.5%) formulated for topical delivery of terbinafine to the nail, nail bed, and surrounding tissue. We examined the effects of TDT 067 and conventional terbinafine on the morphology of dermatophytes. Trichophyton rubrum hyphae were exposed to TDT 067 or terbinafine (15 mg/ml) and examined under white light, scanning electron microscopy (SEM), and transmission electron microscopy (TEM). Subungual debris from patients treated with TDT 067 in a clinical trial was also examined. Exposure of T. rubrum hyphae to TDT 067 led to rapid and extensive ultrastructural changes. Hyphal distortion was evident as early as 4 h after exposure to TDT 067. After 24 h, there was complete disruption of hyphal structure with few intact hyphae remaining. Exposure to terbinafine resulted in morphological alterations similar to those seen with TDT 067; however, the effects of TDT 067 were more extensive, whereas a portion of hyphae remained intact after 24 h of exposure to terbinafine. Lipid droplets were observed under TEM following 30 min of exposure to TDT 067, which after 24 h had filled the intracellular space. These effects were confirmed in vivo in subungual debris from patients with onychomycosis who received topical treatment with TDT 067. The Transfersome in TDT 067 may potentiate the action of terbinafine by delivering terbinafine more effectively to its site of action inside the fungus. Our in vivo data confirm that TDT 067 can enter fungus in the nail bed of patients with onychomycosis and exert its antifungal effects.

Establishment of a novel model of onychomycosis in rabbits for evaluation of antifungal agents

We developed a novel model of onychomycosis in which we observed fungi in the deep layer of the nail, and we used the model to evaluate the efficacy of two topical antifungal drugs. To establish an experimental, in vivo model of onychomycosis, we applied Trichophyton mentagrophytes TIMM2789 to the nails of the hind limbs of rabbits that underwent steroid treatment. The nails were taken from the rabbits' feet at 0, 2, and 6 weeks after a 2-week infection. The localization of the fungi was evaluated histopathologically. Some fungi were seen to penetrate to the nail bed, and the infection rate in the sample at 0, 2, and 6 weeks after infection was 57, 87, and 93%, respectively. In addition, fungi proliferated and moved proximally into the nail plate in a manner that depended on the duration of infection. Second, using this model we evaluated antifungal efficacy both by the culture recovery method and histopathological examination. Two topical antifungal drugs, 8% ciclopirox nail lacquer and 5% amorolfine nail lacquer, were applied to the nail for 4 weeks in each group. On histopathological examination, two antifungal treatment groups showed no significant difference against the nontreated control group. However, there were a significantly low fungus-positive rate and intensity of the recovery of fungi on culture between antifungal treatment and nontreated control groups. We therefore suggest that we have established an in vivo model of onychomycosis that is useful for the evaluation of the efficacy of antifungal agents.

Activity of TDT 067 (terbinafine in Transfersome) against agents of onychomycosis, as determined by minimum inhibitory and fungicidal concentrations

TDT 067 is a novel carrier-based dosage form (liquid spray) of 15 mg/ml of terbinafine in Transfersome that has been developed to deliver terbinafine to the nail bed to treat onychomycosis. In this study, we report the in vitro activities of TDT 067 against dermatophytes, compared with those of the Transfersome vehicle, naked terbinafine, and commercially available terbinafine (1%) spray. The MICs of TDT 067 and comparators against 25 clinical strains each of Trichophyton rubrum, T. mentagrophytes, and Epidermophyton floccosum were determined according to the CLSI M38-A2 susceptibility method (2008). Minimum fungicidal concentrations (MFCs) were determined by subculturing visibly clear wells from the MIC microtiter plates. TDT 067 demonstrated potent activity against the dermatophyte strains tested, with an MIC range of 0.00003 to 0.015 μg/ml. Overall, TDT 067 MIC(50) values (defined as the lowest concentrations to inhibit 50% of the strains tested) were 8-fold and 60-fold lower than those of naked terbinafine and terbinafine spray, respectively. The Transfersome vehicle showed minimal inhibitory activity. TDT 067 demonstrated lower MFC values for T. rubrum and E. floccosum than naked terbinafine and terbinafine spray. TDT 067 has more potent antifungal activity against dermatophytes that cause nail infection than conventional terbinafine preparations. The Transfersome vehicle appears to potentiate the antifungal activity of terbinafine. Clinical investigation of TDT 067 for the topical treatment of onychomycosis is warranted.

The prevalence of tinea pedis and tinea manuum in adults in rural areas in Turkey

The aim of this study was to determine the frequency of tinea pedis and manuum (dermatophyte infections of the hands and feet) in adults in rural areas of Turkey, the risk factors and self-administered treatment options. A total of 2,574 people living in a rural area were enrolled in the study. Participants were asked demographic data, hygienic habits in a questionnaire. KOH preparations and culture were performed from suspicious lesions. Medical and alternative therapy methods and former dermatophytosis diagnosis history were taken from the respondents with suspicious lesions. Microbiological samples were taken from 285 (11.1%) participants. Culture was positive in 109 (4.2%) of those. The most common agent was Trichophyton rubrum. The predisposing factors were found as age older than 40, male gender and obesity. Forty-nine (44.9%) of patients had taken a medical therapy, 56 (51.4%) had performed non-medical methods (cologne, Lawsonia inermis-Henna and softener creams). Patient's education about the treatment compliance is important.

Novel, single-dose, topical treatment of tinea pedis using terbinafine: results of a dose-finding clinical trial

Tinea pedis is the most common dermatophytosis requiring topical antifungals for at least 1-4 weeks. To determine the effectiveness of a novel topical single dose formulation of terbinafine (film forming solution-FFS) in the treatment of tinea pedis, 344 outpatients from 43 dermatological centres in France and Bulgaria suffering from tinea pedis with possible extension to soles confirmed by mycological examination (direct and culture) were evaluated for efficacy of terbinafine 1%, 5%, 10% FFS in a randomised double blind vehicle controlled parallel group dose finding study. Evaluations were carried out at baseline, 1 and 6 weeks after a single application of FFS. Effective treatment rate based on negative mycology (direct and culture) and minimal signs and symptoms (two or less with only mild recorded) was measured at week 6. Effective treatment rates at week 6 with terbinafine 1%, 5% and 10% FFS were 66%, 70%, 61% compared with 18% with placebo. All three active preparations were shown to be significantly superior to placebo (P < 0.001). Terbinafine 1% and 5% FFS were shown to be non-inferior to terbinafine 10% FFS. Terbinafine 1% FFS is an effective, safe dose for the treatment of tinea pedis. This novel product represents a significant advance with the enhanced compliance and convenience that it offers.