Nail digital dermoscopy (onychoscopy) in the diagnosis of onychomycosis

Comparison of dermoscopic characteristics on toenail onychomycosis in psoriatic and non-psoriatic patients: A prospective study

BACKGROUND

Psoriatic patients may experience the coexistence of onychomycosis (OM). However, the evaluation of OM in psoriatics has been hindered by potential clinical differences from OM in non-psoriatics.

OBJECTIVE

To assess and compare dermoscopic features between toenail OM in psoriatic and in non-psoriatic patients.

PATIENTS AND METHODS

Between September 2020 and September 2023, dermoscopy was conducted on 183 affected toenails by OM in psoriatics and 232 affected toenails by OM in non-psoriatics in two centres. The dermoscopic characteristics were compared using the Chi-squared test.

RESULTS

Among toenail OM cases in psoriatic subjects, the most prevalent dermoscopic features included pitting (147/183, 80.33%) and subungual hyperkeratosis (118/183, 64.48%). Conversely, toenail OM in non-psoriatics was characterized by subungual hyperkeratosis (175/232, 75.43%) and nail spikes (139/232, 59.91%). Comparative analysis revealed a significantly higher occurrence of pitting (80.33% vs. 15.96%, p < .001), periungual telangiectasis (22.40% vs. 4.74%, p < .001), oil patches (12.57% vs. 0.43%,p < .001) and transverse grooves (43.72% vs. 28.45%,p < .01) in toenail OM in psoriatics. Furthermore, toenail OM in psoriatics exhibited a significantly lower frequency of yellow structureless area (13.11% vs. 42.67%, p < .001), nail spikes (43.17% vs. 59.91%, p < .01), ruin appearance of sulphur nugget (8.20% vs. 31.03%, p < .001), dotted/blocky haemorrhage (6.01% vs. 20.69%,p < .001) and partial onycholysis (32.79% vs. 46.98%, p < .01).

CONCLUSIONS

Dermoscopic features of toenail OM in psoriatic and non-psoriatic patients exhibit notable differences. OM in psoriatics shows a higher frequency of pitting and periungual telangiectasis, while a lower frequency of yellow structureless areas and nail spikes under dermoscopy.

Line-field confocal optical coherence tomography, a novel non-invasive tool for the diagnosis of onychomycosis

BACKGROUND AND OBJECTIVES

Onychomycosis is common and important to distinguish from other nail diseases. Rapid and accurate diagnosis is necessary for optimal patient treatment and outcome. Non-invasive diagnostic tools have increasing potential for nail diseases including onychomycosis. This study evaluated line-field confocal optical coherence tomography (LC-OCT) as a rapid non-invasive tool for diagnosing onychomycosis as compared to confocal laser scanning microscopy (CLSM), optical coherence tomography (OCT), and conventional methods.

PATIENTS AND METHODS

In this prospective study 86 patients with clinically suspected onychomycosis and 14 controls were examined using LC-OCT, OCT, and CLSM. KOH-preparation, fungal culture, PCR, and histopathology were used as comparative conventional methods.

RESULTS

LC-OCT had the highest sensitivity and negative predictive value of all methods used, closely followed by PCR and OCT. Specificity and positive predictive value of LC-OCT were as high as with CLSM, while OCT scored much lower. The gold standard technique, fungal culture, showed the lowest sensitivity and negative predictive value. Only PCR and culture allowed species differentiation.

CONCLUSIONS

LC-OCT enables quick and non-invasive detection of onychomycosis, with advantages over CLSM and OCT, and similar diagnostic accuracy to PCR but lacking species differentiation. For accurate nail examination, LC-OCT requires well-trained and experienced operators.

Konfokale Line-Field optische Kohärenztomographie, ein innovatives nichtinvasives Instrument zur Diagnose der Onychomykose: Line-field confocal optical coherence tomography, a novel non-invasive tool for the diagnosis of onychomycosis

Hintergrund und Ziele

Onychomykose ist weit verbreitet und sollte von anderen Nagelerkrankungen unterschieden werden. Eine rasche und genaue Diagnostik ist für die optimale Behandlung des Patienten und ein bestmögliches Ergebnis erforderlich. Nichtinvasive Techniken haben ein wachsendes Potenzial bei der Diagnose von Nagelerkrankungen, einschließlich Onychomykose. In dieser Studie wurde die konfokale Line‐Field optische Kohärenztomographie (LC‐OCT) als schnelle nichtinvasive Methode zur Diagnose von Onychomykose im Vergleich zur konfokalen Laserscanmikroskopie (KLM), optischen Kohärenztomographie (OCT) und konventionellen Methoden bewertet.

Patienten und Methodik

In dieser prospektiven Studie wurden 86 Patienten mit klinischem Verdacht auf Onychomykose und 14 Kontrollen mittels LC‐OCT, OCT und KLM untersucht. KOH‐Präparation, Pilzkultur, PCR und Histopathologie wurden als vergleichende konventionelle Methoden eingesetzt.

Ergebnisse

LC‐OCT hatte die höchste Sensitivität und den höchsten negativen Vorhersagewert aller verwendeten Methoden, dicht gefolgt von PCR und OCT. Die Spezifität und der positive Vorhersagewert der LC‐OCT waren genauso hoch wie bei der KLM, während OCT deutlich schlechter abschnitt. Das Goldstandardverfahren Pilzkultur zeigte die geringste Sensitivität und den niedrigsten negativen Vorhersagewert. Nur PCR und Kultur ermöglichten eine Differenzierung der Pilzspezies.

Schlussfolgerungen

LC‐OCT ermöglicht eine schnelle und nichtinvasive Diagnostik von Onychomykose, mit Vorteilen gegenüber KLM und OCT und ähnlicher diagnostischer Genauigkeit wie die PCR, aber ohne Differenzierung der Pilzarten. Für eine genaue Nageluntersuchung erfordert die LC‐OCT gut geschulte und erfahrene Anwender.

Novel Discoveries and Clinical Advancements for Treating Onychomycosis: A Mechanistic Insight

Onychomycosis continues to be the most challenging disease condition for pharmaceutical scientists to develop an effective drug delivery system. Treatment challenges lie in incomplete cure and high relapse rate. Present compilation provides cumulative information on pathophysiology, diagnostic techniques, and conventional treatment strategies to manage onychomycosis. Novel technologies developed for successful delivery of antifungal molecules are also discussed in brief. Multidirectional information offered by this article also unlocks the panoramic view of leading patented technologies and clinical trials. The obtained clinical landscape recommends the use of advanced technology driven approaches, as a promising way-out for treatment of onychomycosis. Collectively, present review warrants the application of novel technologies for the successful management of onychomycosis. This review will assist readers to envision a better understanding about the technologies available for combating onychomycosis. We also trust that these contributions address and certainly will encourage the design and development of nanocarriers-based delivery vehicles for effective management of onychomycosis.

Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study

BACKGROUND

Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible.

OBJECTIVES

The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway.

PATIENTS AND METHODS

We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae).

RESULTS

Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis.

CONCLUSIONS

Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Q-switched Nd:YAG laser versus itraconazole pulse therapy in treatment of onychomycosis: A clinical dermoscopic and mycologic study

BACKGROUND

Onychomycosis (OM) represents about 50% of nail disorders. Oral antifungals have proven efficacy in the treatment of onychomycosis but their associated side effects limit their use. Accordingly, there is an increased need for a safe and effective therapy to induce clearance and improve the esthetic appearance of diseased nails.

OBJECTIVE

The current study is an attempt to evaluate and compare the efficacy of Q-Switched Nd:YAG (1064 nm) laser as monotherapy versus pulse itraconazole in the clearance of onychomycosis.

METHODS

In this prospective study, 40 onychomycosis patients were equally divided into two groups: Groups I (laser group) and II (Itraconazole group). Patients of Group I are treated with six biweekly sessions of Q-Switched Nd:YAG (1064 nm) laser. Patients of Group II are treated with itraconazole pulse therapy. The assessment of clearance was rated using the "Onychomycosis Severity Index (OSI)", photographs, dermoscopy, and mycology. All 40 patients were followed up for 3 months after the end of treatment.

RESULTS

Group I's clinical improvement response was a marked improvement in 19 cases and moderate improvement in one case (OSI before treatment was 24.5 and after was 0). A dermoscopic cure occurred in 19 cases. Mycological cure was obtained in 19 cases. Group II's clinical improvement response was marked in 15 and moderate in 5 (OSI before treatment was 24 and after was 0). Dermoscopic cure occurred in 15 cases. Mycological cure was obtained in 15 cases. There were no adverse effects. The clinical response, the dermoscopic cure, and the mycological cure were equal in both groups, with no significant difference found between them.

CONCLUSION

Q-Switched Nd:YAG (1064 nm) laser can be used as an effective and safe modality in the clearance of nail onychomycosis, particularly in patients who have a contraindication to or refuse the use of oral antifungals.

Dermoscopy of Onychomycosis: A Systematic Review

INTRODUCTION

Onychomycosis represents a global burden accounting for about 50% of nail consultations. Several studies have tried to assess the dermoscopic features of onychomycosis. With the multiplication of papers, several "new" dermoscopic signs keep being added leading to some inconsistency in onychoscopic terminology.

OBJECTIVE

This study aimed to summarize the existing literature on the dermoscopic features of onychomycosis and propose a unified onychoscopic terminology.

METHODS

The literature search was performed using PubMed and Scopus databases up to October 30, 2021 to identify eligible contributions. In total, 33 records (2111 patients) were included.

RESULTS

The main dermoscopic signs of onychomycosis are "ruin appearance", "longitudinal striae" and "spikes" on the proximal margin of onycholytic areas, with a specificity of 99.38%, 83.78%, and 85.64% respectively. The "aurora borealis" sign had the highest sensitivity and specificity.

CONCLUSIONS

The current review provides a framework for issues related to the onychoscopic terminology of onychomycosis and is intended to serve as an aid for students, teachers, and researchers. We proposed a unifying terminology to describe dermoscopic signs of onychomycosis. Dermoscopic signs of onychomycosis show good specificity and are useful in distinguishing nail psoriasis, trauma, and onychomycosis. It helps differentiate fungal melanonychia from nail melanoma, nevi, and melanocytic activation.

Fractional CO2 laser - assisted methylene blue photodynamic therapy is a potential alternative therapy for onychomycosis in the era of antifungal resistance

BACKGROUND

Treatment of onychomycosis is challenging by virtue of the impact of nail disfigurement, the location of the fungi within the nail and reported antifungal resistance worldwide. Light-based technologies are promising primary or adjunctive therapeutic modalities. We aimed to compare the efficacy of photodynamic therapy and fractional CO2 laser monotherapy either alone or in combination for onychomycosis.

PATIENTS AND METHODS

This prospective randomized comparative study was conducted on 51 onychomycosis patients divided into three groups. In group A, patients were treated using 6 photodynamic therapy sessions using methylene blue and IPL (560 to 700 nm, fluence 12 J/cm2). Group B patients were treated using 6 bimonthly fractional CO2 laser sessions (10,600 nm, 1.600 mj energy and 0.6 mm density) and group C patients were treated using 6 combined fractional CO2 laser and photodynamic therapy sessions. Patients were evaluated mycologically, dermoscopically and clinically by calculation of proximal nail diameter percentage at baseline, monthly, at the end of treatment and after a 6-month follow-up period post-treatment.

RESULTS

Candida was the most commonly isolated organismin in 64.7%, 70.6% and 70.6% of the pateints in groups A, B and C, respectively. The dermoscopic findings in the total dystrophic onychomycosis was subungual hyperkeratosis in 6 patients (100%), longitudinal streaks and striae in 1 patient (16.7%). In dorsolateral subungual onychomycosis, jagged proximal edge in 31 patients (70.5%), and pigmentation in 30 patients (68.2%) were noted. In proximal subungual onychomycosis irregular matt patches were seen in 1 patient (100%). Proximal nail diameter percentage showed statistically significant improvement after treatment and 6 months follow up in the 3 studied groups. Mean increase of proximal nail diameter after treatment was highest in group C (52.94 ± 20.24), followed by group B (43.82 ± 21.03) and least in group A (35.29 ± 17.0). This difference was statistically significant (p = 0.044). Reported side effects were mild-moderate pain, discoloration and paronychia.

CONCLUSION

We conclude that fractional CO2 laser and photodynamic monotherapy, and their combination achieve high success rates, good patient satisfaction and safety profile. Fractional CO2-assisted photodynamic therapy is associated with the highest improvement over either fractional CO2 or photodynamic therapy alone.

Diagnostic accuracy of dermoscopy for onychomycosis: A systematic review

Background

Dermoscopy is a non-invasive adjuvant diagnostic tool that allows clinicians to visualize microscopic features of cutaneous disorders. Recent studies have demonstrated that dermoscopy can be used to diagnose onychomycosis. We performed this systematic review to identify the characteristic dermoscopic features of onychomycosis and understand their diagnostic utility.

Methods

We searched the Medline, Embase, Scopus, and Cochrane databases from conception until May 2021. Studies on the dermoscopic features of onychomycosis were screened. The exclusion criteria were as follows: fewer than 5 cases of onychomycosis, review articles, and studies including onychomycosis cases that were not mycologically verified. Studies on fungal melanonychia were analyzed separately. We adhered to the MOOSE guidelines. Independent data extraction was performed. Data were pooled using a random effects model to account for study heterogeneity. The primary outcome was the diagnostic accuracy of the dermoscopic features of onychomycosis. This was determined by pooling the sensitivity and specificity values of the dermoscopic features identified during the systematic review using the DerSimonian-Laird method. Meta-DiSc version 1.4 and Review Manager 5.4.1 were used to calculate these values.

Results

We analyzed 19 articles on 1693 cases of onychomycosis and 5 articles on 148 cases of fungal melanonychia. Commonly reported dermoscopic features of onychomycosis were spikes or spiked pattern (509, 30.1%), jagged or spiked edges or jagged edge with spikes (188, 11.1%), jagged proximal edge (175, 10.3%), subungual hyperkeratosis (131, 7.7%), ruins appearance, aspect or pattern (573, 33.8%), and longitudinal striae (929, 54.9%). Commonly reported features of fungal melanonychia included multicolor (101, 68.2%), non-longitudinal homogenous pigmentation (75, 50.7%) and longitudinal white or yellow streaks (52, 31.5%).

Conclusion

This study highlights the commonly identified dermoscopic features of onychomycosis. Recognizing such characteristic dermoscopic features of onychomycosis can assist clinicians diagnose onychomycosis by the bedside.

Updated Perspectives on the Diagnosis and Management of Onychomycosis

Onychomycosis is the most common nail disease encountered in clinical practice and can cause pain, difficulty with ambulation, and psycho-social problems. A thorough history and physical examination, including dermoscopy, should be performed for each patient presenting with nail findings suggestive of onychomycosis. Several approaches are available for definitive diagnostic testing, including potassium hydroxide and microscopy, fungal culture, histopathology, polymerase chain reaction, or a combination of techniques. Confirmatory testing should be performed for each patient prior to initiating any antifungal therapies. There are several different therapeutic options available, including oral and topical medications as well as device-based treatments. Oral antifungals are generally recommended for moderate to severe onychomycosis and have higher cure rates, while topical antifungals are recommended for mild to moderate disease and have more favorable safety profiles. Oral terbinafine, itraconazole, and griseofulvin and topical ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the Food and Drug Administration for treatment of onychomycosis in the United States and amorolfine 5% nail lacquer is approved in Europe. Laser treatment is approved in the United States for temporary increases in clear nail, but clinical results are suboptimal. Oral fluconazole is not approved in the United States for onychomycosis treatment, but is frequently used off-label with good efficacy. Several novel oral, topical, and over-the-counter therapies are currently under investigation. Physicians should consider the disease severity, infecting pathogen, medication safety, efficacy and cost, and patient age, comorbidities, medication history, and likelihood of compliance when determining management plans. Onychomycosis is a chronic disease with high recurrence rates and patients should be counseled on an appropriate plan to minimize recurrence risk following effective antifungal therapy.

Clinical Clues to Differentiate between Dermatophyte Onychomycosis (DP-OM) and Dermatophytoma-Like Traumatic Onychodystrophy (DP-TO)

Background

Dermatophytoma is a recalcitrant condition of onychomycosis (OM). It presents as a white- or yellow-colored fungal mass that appears linear/triangular or round on a nail plate. Traumatic onychodystrophy (TO) can present with dermatophytoma-like lesions. Typically, OM and TO are not clinically distinguishable. Mycological testing is the gold standard for differentiating these disorders.

Objectives

This study is aimed at differentiating between the clinical and dermoscopic factors related to dermatophytoma onychomycosis (DP-OM) and dermatophytoma-like traumatic onychodystrophy (DP-TO).

Methods

A retrospective study was conducted of patients with dermatophytoma-like nail lesions who visited the Siriraj Nail Clinic between January 2010 and July 2020. The diagnosis of DP-OM was made by direct microscopy, fungal cultures, and histopathology of nail clippings.

Results

A total of 36 nails were included in the study. Thirteen nails were DP-OM, and 23 nails were DP-TO. The demographic data and risk factors for the 2 groups were not significantly different. Dermatophytoma lesions were found on the lateral side of nails in 12 cases of DP-OM (92.3%) and 11 cases of DP-TO (47.8%; P = 0.008). DP-OM was associated with longitudinal striae adjacent to dermatophytoma (69.2% vs. 30.4%; P = 0.024), sulfur-nugget-like subungual debris (23.1% vs. 0%; P = 0.040), and scale on the ipsilateral foot (69.2% vs. 8.7%; P < 0.001). DP-TO was associated with a homogenous, whitish discoloration (47.8% vs. 7.7%; P = 0.014) and a sharp edge of the onycholytic area (43.5% vs. 0%; P = 0.005).

Conclusions

The lateral location of dermatophytoma, adjacent striae, sulfur-nugget-like debris, and scale on the ipsilateral foot were significantly associated with DP-OM. Dermoscopic examination (dorsal and hyponychium views) and foot examination are beneficial for distinguishing between DP-OM and DP-TO.

A descriptive study of onychoscopic features in various subtypes of onychomycosis

Background

The diagnosis of onychomycosis is usually clinical and is confirmed by 40% KOH examination. A diagnostic dilemma occurs when KOH examination is negative despite strong clinical suspicion. Dermoscopic evaluation of the nail is referred to as onychoscopy. We attempted to assess the dermoscopic findings in Onychomycosis positive with KOH examination.

Methods

A cross sectional study was conducted in a tertiary care center including 122 patients with clinical suspicion of onychomycosis with KOH positivity. After assessment of risk factors and gross nail examination, onychoscopic examination was done to identify the presence of the specific features.

Results

Primary findings of onychoscopic examination were 'spiked pattern' in 80.3% subjects, of which 95 were distal lateral subungual onychomycosis (DLSO), 8 of total dystrophic onychomycosis (TDO). True leukonychia was seen in the single patient of proximal subungual onychomycosis (PSO) and pseudoleukonychia in the single patient of white superficial onychomycosis (WSO). Distal irregular termination was observed in 23% of subjects - 8 from DLSO and in all 20 patients of TDO. 'Ruin appearance' was observed in all 20 patients of TDO, 56 patients with DLSO and not seen in other types of onychomycosis (OM). Presence of spiked pattern, Longitudinal striae, Distal irregular termination and Ruin appearance were found to be statistically significant (p < 0.001).

Conclusion

In suspected onychomycosis, specific onychoscopic findings such as Spiked pattern, Longitudinal striae, Ruin appearance and Distal irregular termination can be used as supporting evidence for diagnosing onychomycosis clinically and initiating antifungal therapy if mycological testing is unavailable or negative.

Dermatophytomas: Clinical Overview and Treatment

Dermatophytomas are characterized as a hyperkeratotic fungal mass in the subungual space, showing as dense white or yellow, typically in longitudinal streaks or patches. Masses can be visualized by traditional microscopy or histology. Newer technologies such as dermoscopy and optical coherence tomography also provide visual features for dermatophytoma diagnosis. The density of fungal mass, and lack of adherence to the nail structures, as well as possible biofilm development, may play a role in the reduction in drug penetration and subsequent lack of efficacy with traditional oral therapies such as terbinafine and itraconazole. A combination of drug treatment with mechanical or chemical debridement/avulsion has been recommended to increase efficacy. The topical antifungal solutions such as tavaborole, efinaconazole, and luliconazole may reach the dermatophytoma by both the transungual and subungual routes, due to low affinity for keratin and low surface tension. Current data indicates these topicals may provide efficacy for dermatophytoma treatment without debridement/avulsion. Similarly, fosravuconazole (F-RVCZ) has an improved pharmacological profile versus ravuconazole and may be an improved treatment option versus traditional oral therapies. The availability of improved treatments for dermatophytomas is crucial, as resistance to traditional therapies is on the increase.

Tinea Gladiatorum: Epidemiology, Clinical Aspects, and Management

Tinea gladiatorum (TG) is a fungal skin infection that occurs among wrestlers and other contact sport athletes with a varied prevalence rate. The most common causative factor responsible as well for local outbreaks of the infection is an anthropophilic dermatophyte species—Trichophyton tonsurans (T. tonsurans). The purpose of this study was to gather current data about TG, including epidemiology, possible diagnosing methods, clinical features, treatment approaches, and potential prevention techniques. We also performed a systematic review of studies describing TG incidence. The prevalence of the disease varied from 2.4% up to 100%. That wide range of variability forces medical practitioners to update knowledge about TG and points to the fact that it still may be a diagnostic and therapeutic challenge. Spreading awareness among athletes and trainers is one of the most important preventive steps.

Diagnosing Onychomycosis: What’s New?

An overview of the long-established methods of diagnosing onychomycosis (potassium hydroxide testing, fungal culture, and histopathological examination) is provided followed by an outline of other diagnostic methods currently in use or under development. These methods generally use one of two diagnostic techniques: visual identification of infection (fungal elements or onychomycosis signs) or organism identification (typing of fungal genus/species). Visual diagnosis (dermoscopy, optical coherence tomography, confocal microscopy, UV fluorescence excitation) provides clinical evidence of infection, but may be limited by lack of organism information when treatment decisions are needed. The organism identification methods (lateral flow techniques, polymerase chain reaction, MALDI-TOF mass spectroscopy and Raman spectroscopy) seek to provide faster and more reliable identification than standard fungal culture methods. Additionally, artificial intelligence methods are being applied to assist with visual identification, with good success. Despite being considered the ‘gold standard’ for diagnosis, clinicians are generally well aware that the established methods have many limitations for diagnosis. The new techniques seek to augment established methods, but also have advantages and disadvantages relative to their diagnostic use. It remains to be seen which of the newer methods will become more widely used for diagnosis of onychomycosis. Clinicians need to be aware of the limitations of diagnostic utility calculations as well, and look beyond the numbers to assess which techniques will provide the best options for patient assessment and management.

Assessment of the Clinical Diagnosis of Onychomycosis by Dermoscopy

Background

As a common clinical superficial fungal infection, the diagnosis of onychomycosis relies on clinical features, traditional KOH direct microscopy and fungal culture. In recent years, dermoscopy has been widely used in the diagnosis and treatment of infectious diseases and has provided new options for the diagnosis of onychomycosis.

Objective

To evaluate the value of dermoscopy in the clinical diagnosis of onychomycosis and to explore the relationship between each clinical subtype and the dermoscopic pattern.

Methods

A retrospective study of 114 cases of clinically suspected onychomycosis was conducted to compare the differences between dermoscopy and fungal pathogenic examination (microscopy and culture) in the diagnostic sensitivity of onychomycosis and to analyze the relationship between nine common dermoscopic modalities and clinical subtypes of onychomycosis.

Results

Among the 114 proposed patients, 87 nails with positive fluorescent staining microscopy and/or positive fungal cultures were diagnosed as onychomycosis. The sensitivity and specificity of dermatoscopy, using the mycological findings as a reference, were 86.21 and 33.33%, respectively. The incidence of common dermatoscopic patterns in the 87 nails with confirmed onychomycosis was as follows: white flocculation in 76 cases (87.35%), longitudinal nail pattern in 72 cases (82.76%), jagged changes in the distal nail plate in 69 cases (79.31%) and yellow staining in 46 cases (52.87%), these four patterns were more commonly seen in the distal lateral subungual onychomycosis and total dystrophic onychomycosis, but there was no statistical difference in the positive dermatoscopic pattern between these two types (P > 0.05).

Conclusion

Dermoscopy can be an important aid in the diagnosis of onychomycosis, especially when fungal microscopy or culture is not appropriate, but this method is still not a substitute for fungal microscopy and culture.

Onychomycosis: Recommendations for Diagnosis, Assessment of Treatment Efficacy, and Specialist Referral. The CONSONANCE Consensus Project

Introduction

Onychomycosis is the most common nail disorder in adults, with high recurrence and relapse rates. Its diagnosis may be difficult by non-experts because the clinical signs may overlap with other dermatoses. The treatment may be challenging, as it should be patient-tailored.

Methods

An online survey was conducted among European Nail Society (ENS) members to provide recommendations on the diagnosis and assessment of distal lateral subungual onychomycosis (DLSO) in non-specialized clinical environments, as well as recommendations for patient referral.

Results

DLSO diagnosis is predominantly based on clinical aspects, and microscopy and fungal culture are commonly employed to establish the diagnosis. Assessment of clinical features is the main method for DLSO follow-up, and the main criterion to define cure is a combination of mycologic cure and clinical cure. The most commonly selected treatments for onychomycosis include oral antifungals, topical antifungals, and nail debridement. According to the nail experts, predisposing factors of DLSO to be evaluated include concurrent tinea pedis diagnosis, immunocompromised status, and diabetes. The minimum clinical aspects to be evaluated for DLSO diagnosis should include subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration. Recommendations for clinical signs that should be evaluated to confirm treatment effectiveness include normal appearance and color of the nail, reduction or absence of scales under the nail, and absence of onycholysis. Recommendations for specialist referral include lack of treatment effectiveness, need of additional therapies, concurrent presence of other diseases or comorbidities, severe DLSO, and presence of a dermatophytoma or involvement of the nail matrix.

Conclusions

According to the surveyed nail experts, after evaluating clinical signs and predisposing factors for DLSO, the diagnosis should include subungual hyperkeratosis, nail color (yellow-orange), and onycholysis and thickening. In cases of severe DLSO, when there is treatment failure, concomitant diseases/comorbidities, presence of a dermatophytoma or involvement of the nail matrix, or involvement of several/all nails, referral should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00698-x.

Pathogenesis, Immunology and Management of Dermatophytosis

Dermatophytic infections of the skin and appendages are a common occurrence. The pathogenesis involves complex interplay of agent (dermatophytes), host (inherent host defense and host immune response) and the environment. Infection management has become an important public health issue, due to increased incidence of recurrent, recalcitrant or extensive infections. Recent years have seen a significant rise in incidence of chronic infections which have been difficult to treat. In this review, we review the literature on management of dermatophytoses and bridge the gap in therapeutic recommendations.

Deferring Nail Mycological Sampling during the COVID-19 Pandemic: Recommendations from a Multidisciplinary Panel of Nail Specialists

Onychomycosis is the most common nail condition seen in clinical practice, with significant impact on quality of life. Clinical examination alone is insufficient for accurate diagnosis, but mycological confirmation can be challenging during the COVID-19 pandemic. In this letter, a multidisciplinary panel of dermatologists, a podiatrist, dermatopathologists, and a mycologist, discuss considerations for mycological sampling during the pandemic.

Dermoscopy of skin infestations and infections (entomodermoscopy) - Part II: viral, fungal and other infections

In addition to the infestations and bacterial infections reported in part I, the study of entomodermoscopy also involves descriptions of dermoscopic findings of a growing number of viral and fungal infections, among others. In this article, the main clinical situations in viral infections where dermoscopy can be useful will be described, that is in the evaluation of viral warts, molluscum contagiosum, and even in recent scenarios such as the COVID-19 pandemic. As for fungal infections, dermoscopy is particularly important, not only in the evaluation of the skin surface, but also of skin annexes, such as hairs and nails. The differential diagnosis with skin tumors, especially melanomas, can be facilitated by dermoscopy, especially in the evaluation of cases of verruca plantaris, onychomycosis and tinea nigra.

Dermoscopy of Onychomycosis for the Podiatrist

Onychomycosis is one of the most frequent nail pathologies in podiatry practices. Differential diagnoses with the clinical presentation may delay an accurate diagnosis and timely treatment. This article discusses the technique and benefits of using a dermatoscope to improve patient care of this common disorder.

Sulphur Nuggets

BACKGROUND

Dermoscopy is a new method to diagnose and manage nail disorders. The definite dermoscopic finding for onychomycosis, however, is still debatable.

OBJECTIVE

To identify the dermoscopic features that help differentiate between onychomycosis (OM) and traumatic onychodystrophy (TOD).

METHODS

A prospective study of 65 patients with toenail abnormalities was conducted. The patients were classified into OM and TOD groups using mycological tests (potassium hydroxide test, fungal culture, and histological examination). OM was diagnosed from positive results for all tests, while TOD was decided based on negative results for all tests and evidence of foot trauma. Dermoscopic features were recorded and compared between the two groups.

RESULTS

Most patients of the 65 patients were female (72.3%), and had a mean age of 67.9 years. Twenty-seven patients (41.5%) were diagnosed with OM, all of which were distal and lateral subungual onychomycosis. TOD, on the other hand, was determined in 38 patients. Dermoscopic findings revealed that the yellow, clumping, sulphur-nugget-like debris in the ruin appearance was significantly associated with onychomycosis (p = 0.002), while ruin appearance without sulphur nugget was not statistically correlated with onychomycosis (p = 0.068).

CONCLUSION

The presence of sulphur nuggets in the ruin appearance is a new and helpful dermoscopic feature for onychomycosis diagnosis.

The value of dermoscopy of the nail plate free edge and hyponychium

The non-invasive examination of the nail unit using a dermoscope is known as onychoscopy. This technique has become increasingly appreciated to facilitate the clinical diagnosis of nail disorders, opening up a valuable second front with a potential to avoid invasive diagnostic procedures. During a nail consultation, the nail unit should always be examined with the aid of a dermatoscope in all its components. The aim of this paper is to provide practical information about onychoscopy of the nail plate free edge and hyponychium, two components of the nail unit difficult to evaluate at naked eye and often forgotten, but of paramount importance.

Onychoscopy in a Colombian population with a diagnosis of toenail onychomycosis: an evaluation study for this diagnostic test

BACKGROUND

Onychoscopy is a technique that uses a dermatoscope for the evaluation of specific features of different skin conditions that are not visible to the naked eye. There are few studies establishing parameters for the diagnosis of onychomycosis based on onychoscopy. Determining the sensitivity and specificity of a potentially new diagnostic test for onychomycosis requires an evaluation study of this new diagnostic test, as there are limited studies reporting onychoscopy results.

AIM

To determine the sensitivity, specificity, positive predictive value and negative predictive value of onychoscopy findings in a Colombian population with onychomycosis.

METHODS

We assessed outpatients with a diagnosis of toenail onychomycosis confirmed by potassium hydroxide preparation or fungal culture. Onychoscopy was performed using a dermatoscope, and digital images collected using a smartphone.

RESULTS

The onychoscopy findings were: longitudinal striae, distal spiked pattern, distal irregular termination, linear edge and ruins aspect, while some patients were confirmed as having traumatic onycholysis. A statistically significant association was found between the clinical symptoms of onychomycosis and both the clinical feature of dyschromia and the onychoscopy feature of longitudinal striae.

CONCLUSION

We suggest that this technique is an alternative method that should be used in patients with onychopathies because it has the potential to differentiate onychomycosis from traumatic onycholysis and another nail involvement.

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

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

Onychomycosis in patients with multiple sclerosis: prevalence, clinical description, mycological, and dermoscopic study in a Mexican population

BACKGROUND

Multiple sclerosis (MS) is a chronic demyelinating disease related to HLA-DR8. Susceptibility to onychomycosis has been found in Mexican mestizos with HLA-DR8. The frequency of onychomycosis in this neurological disease is unknown.

OBJECTIVES

To determine the frequency of onychomycosis and its clinical, mycological, and dermoscopic characteristics in patients with MS in comparison with the general population.

METHODS

Observational, cross-sectional, case-control study in patients with MS from October 2017 to February 2018. Age, gender, MS type, and time of progression from diagnosis to date and baseline treatment were collected after signed informed consent. A neurological exploration and clinical examination of fingernails and toenails for onychomycosis was conducted. Mycological and dermoscopic studies of the infected nails were performed on patients with clinical diagnosis of onychomycosis. A healthy control group was taken for each case (1:1), paired by age and gender.

RESULTS

The frequency of onychomycosis in patients with MS was higher than the healthy population (32% vs. 26%, P = 0.509). A higher frequency of non-dermatophyte fungi was found, although it was not statistically significant. The clinical manifestations and dermoscopic findings in patients with MS and onychomycosis were similar to those of the general population.

CONCLUSION

The frequency of onychomycosis in patients with MS is slightly higher than that of the general population. A possible association of HLA-DR8 as a susceptibility factor for onychomycosis is proposed. The etiology of opportunistic fungi in MS patients with onychomycosis may be related to immunosuppressive treatment.

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.

Entodermoscopy Update: A Contemporary Review on Dermoscopy of Cutaneous Infections and Infestations

Infectious cutaneous diseases are very common, especially in certain geographic and tropical regions. Sometimes they may simulate other dermatoses, ordering verification of diagnosis with particular investigations. Dermoscopy is among one of the most important tools readily available in the outpatient setting for the dermatologist to confirm the diagnosis. In this up-to date review, literature concerning the various dermoscopic features of parasitic, viral, dermatophytic and bacterial cutaneous infections is composed. In addition artefacts as well as practical issues in dermoscopy usage are discussed; with the aim to empower dermatologists to promptly and non-invasively diagnose and manage cutaneous infections and infestations.

Dermoscopy of the Nail Unit

Nail dermoscopy (onychoscopy) is being used for a more accurate diagnosis of all nail disorders and has become a routine diagnostic instrument. In daily practice, nail signs can be magnified, and dermoscopy may confirm the clinical diagnosis and guides in management of nail diseases and treatments, permitting a better visualization of symptoms. Onychoscopy is used by the experts in almost all nail diseases. It can be performed dry or with ultrasound gel in order to make the stratum corneum translucent, depending on which part of the nail unit has to be evaluated.

Fungal infections of the feet in patients with erysipelas of the lower limb: is it a significant clinical problem?

BACKGROUND

Erysipelas is a bacterial infection of the superficial layers of the skin usually caused by Group A Streptococci, often seen in clinical practice. Fungal infections of the feet and elderly age are some of the most significant risk factors for the infection. The aim of the study was to evaluate the frequency of fungal infections from different regions of the feet in patients with erysipelas.

METHODS

56 patients with clinically diagnosed erysipelas and 56 healthy individuals were clinically examined and tested for fungal infection in three locations: toenails, interdigital space, and soles. The collected samples were evaluated under a microscope and then mycological cultures on Sabouraud's medium were prepared. After 4 weeks of incubation, the cultures were analysed with the identification of particular pathogens.

RESULTS

42.9% (24/56) of the patients with erysipelas had positive mycological cultures. Toenails and interdigital spaces (both 62.5%) were the most frequently affected areas, followed by soles (37.5%). The most common pathogen was T. rubrum (43.18%), followed by Candida spp. (27.27%), and T. mentagrophytes var.interdigitale (13.63%). Only 14.3% (8/56) of the samples taken from the control group were positive and T.rubrum was the only type of fungus cultured.

CONCLUSIONS

Fungal infections of the feet are important risk factors for the first episode as well as recurrent erysipelas. Prevention and early treatment of fungal infections, especially in elderly people, can significantly reduce the incidence of erysipelas.

Dermatophytic melanonychia: A case series of an increasing disease

BACKGROUND

Melanonychia refers to brown-black colour pigmentation due to melanin or not-melanin deposition in the nail plate. Onychoscopy allows to distinguish if the pigmentation is due by melanin or not. The main causes of non-melanic pigmentation are subungual haematoma and pigmented onychomycosis. Fungal melanonychia (FM) is rare and may present as diffuse or longitudinal pigmentation. Differential diagnosis includes melanic activation, such as ethnic-type nail pigmentation or frictional melanonychia, but also versus melanic proliferation, such as nevus or nail melanoma. Fungal melanonychia can be due to a colonisation by fungi with black variant or by melanin activation due to inflammation of fungal invasion.

OBJECTIVES

The aim of paper is to increase clinical and dermoscopic knowledge of this increasingly frequent disease.

METHODS

In this retrospective observational study, twenty patients with dermatophytic melanonychia were collected, with available clinical and dermoscopic pictures. The diagnosis of dermatophytic melanonychia was made based on clinical manifestation and mycological examination. KOH smear was performed in all cases. For each patient, clinical data included: age, gender, type of melanonychia and involved fingers.

RESULTS

This study aimed to show increased incidence of dermatophytic melanonychia and its correct management. In addition, we reviewed our collected cases and described the clinical and dermoscopic features of dermatophytic melanonychia.

CONCLUSIONS

The results of this study showed that physicians should keep in mind the diagnosis of this increasing disease, and that it cannot be performed relying only on clinical grounds. We would like to highlight the importance of tools as KOH examination, culture and dermoscopy.

Cutaneous T-cell lymphoma in erythrodermic cases may be suspected on the basis of scalp examination with dermoscopy

Erythrodermic variants of cutaneous T-cell lymphoma (CTLC) are one of the case of erythroderma. The aim of the study was to assess the value of scalp dermoscopy in differentiation between erythrodermic CTCL, psoriasis, and atopic dermatitis. A total of 76 patients were included into the study (16 patients with erythrodermic CTCL, 20 patients with psoriatic erythroderma, 20 with erythrodermic atopic dermatitis, and 20 healthy volunteers). The most common trichoscopic features of erythrodermic CTCL were: numerous pili torti, numerous broken hairs, white thick interfollicular bands, and patchy hyperpigmentation of the background. They were observed in 81% (13/16), 75% (12/16), 56% (9/16), and 37.5% (6/16) of patients with CTCL, respectively (p < 0.001). Other specific features of erythrodermic CTCL were 8-shaped hairs (19%; 3/16) and visible anagen bulbs (12.5%; 2/16) (p < 0.05 and p = 0.052, respectively). The most common vascular pattern of erythrodermic CTCL was perifollicular arrangement of glomerular (50%; 8/16; p < 0.001) or linear vessels (31%; 5/16; p < 0.05). Follicular spicules-like scaling was pathognomonic for erythrodermic CTCL (12%, 2/16) although its presence did not reach statistical significance (p = 0.052). In conclusion, the characteristic trichoscopic findings of erythrodermic CTCL are numerous pili torti, eight-shaped hairs, thick white interfollicular bands, color heterogeneity of the background and perifollicular arrangement of vessels.

Dermatoscopic features of onychomycosis and its correlation with nail plate potassium hydroxide mount (KOH), culture, and periodic acid schiff stain (PAS) in North East India

Context:

Dermatoscopy has been used recently for identifying the specific features of onychomycosis. Very few studies have used it as a diagnostic tool. Our study highlights the specific patterns in different clinical types of onychomycosis and the novel features that have never been reported previously.

Aims:

To study the dermatoscopic patterns in patients with onychomycosis and determine the sensitivity, specificity, positive, and negative predictive values of the different features.

Study Design:

A cross-sectional study.

Materials and Method:

Dermatoscopic picture using dinolite video dermatoscope was taken in patients diagnosed with onychomycosis either with a positive KOH, culture, and/or PAS.

Result:

A total of 80 patients were included. Onychomycosis was identified in 68 individuals. Clinically, 73.52% presented with distal lateral subungual onychomycosis (DLSO) and 26.47% had total dystrophic (TD). PAS was positive in 85.29% of patients, KOH in 75%, and culture in 66.17%. Trichophyton species were isolated in 53.33%, whereas Candida species in 40% of patients. Dermatoscopic features were seen in all 68 patients (100%). The most common finding in decreasing order includes spike pattern, ruin appearance, distal irregular terminations (DIT), longitudinal striations, chromonychia, focal homogeneous opacities, microsplitting, and uniform homogeneous pattern. Three novel patterns were observed: homogeneous opacity with a-z pattern border, microsplitting in a Christmas tree pattern, and focal homogeneous opacities.

Conclusion:

To our knowledge, this is the first study conducted in northeast India where dermatoscopy was used as a diagnostic tool and it was found to have the highest sensitivity. New features that have not been described before have been identified.

Onychomycosis: An Updated Review

Background: Onychomycosis is a common fungal infection of the nail.

Objective: The study aimed to provide an update on the evaluation, diagnosis, and treatment of onychomycosis.

Methods: A PubMed search was completed in Clinical Queries using the key term “onychomycosis”. The search was conducted in May 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. The search was restricted to English literature. Patents were searched using the key term “onychomycosis” in www.freepatentsonline.com.

Results: Onychomycosis is a fungal infection of the nail unit. Approximately 90% of toenail and 75% of fingernail onychomycosis are caused by dermatophytes, notably Trichophyton mentagrophytes and Trichophyton rubrum. Clinical manifestations include discoloration of the nail, subungual hyperkeratosis, onycholysis, and onychauxis. The diagnosis can be confirmed by direct microscopic examination with a potassium hydroxide wet-mount preparation, histopathologic examination of the trimmed affected nail plate with a periodic-acid-Schiff stain, fungal culture, or polymerase chain reaction assays. Laboratory confirmation of onychomycosis before beginning a treatment regimen should be considered. Currently, oral terbinafine is the treatment of choice, followed by oral itraconazole. In general, topical monotherapy can be considered for mild to moderate onychomycosis and is a therapeutic option when oral antifungal agents are contraindicated or cannot be tolerated. Recent patents related to the management of onychomycosis are also discussed.

Conclusion: Oral antifungal therapies are effective, but significant adverse effects limit their use.Although topical antifungal therapies have minimal adverse events, they are less effective than oral antifungal therapies, due to poor nail penetration. Therefore, there is a need for exploring more effective and/or alternative treatment modalities for the treatment of onychomycosis which are safer and more effective.

Recent developments in dermoscopy for dermatology

BACKGROUND

Dermoscopy is considered to be a bridge between clinical observation and histopathological examination, allowing the in vivo examination of skin microstructures that are not visible to the naked eye, from the epidermis to the superficial dermis. Dermoscopy has undergone rapid development, witnessing the history from natural light to polarized light, from handheld dermoscopy to videodermoscopy, and from classic dermoscopy to digital dermoscopy. Its application extends from the initial differential diagnosis of pigmented skin diseases (melanocytic and nonmelanocytic) to general dermatology, including appendage (nail and hair) abnormalities and diseases related to infection and inflammation.

AIMS

We aimed to provide the latest developments in dermoscopy from the perspective of handheld dermoscopy, videodermoscopy, fluorescence-advanced videodermatoscopy, polarized transilluminating dermoscopy, and digital dermoscopy.

METHODS

In this review, we searched the PubMed, Embase, Web of Science, and Cochrane Library databases for reviews, case reports, and observational studies on dermoscopy.

RESULTS

We provided an updated review of dermoscopy based on published literature.

CONCLUSION

Dermoscopy is an indispensable diagnostic tool in dermatology, and it is expected to be further developed in the future.

The change of causative pathogens in toenail onychomycosis

BACKGROUND

Toenail dystrophies are among the most common diseases in adulthood. Onychomycosis is one of the most frequently observed infectious diseases of the nail.

AIM

The aim of this study was to determine the prevalence of fungal agents in the etiology of nail dystrophies such as discoloration, thickening, subungual hyperkeratosis, and onycholysis in toenails and to emphasize the importance of diagnosis by other laboratory confirmation tests since various nail diseases may mimic onychomycosis.

SUBJECTS AND METHODS

Nail samples taken from 53 patients who were admitted to the dermatology clinic with the complaint of toenail disorders were examined by using potassium hydroxide mount, fungal culture, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry methods. Each nail was photographed, and descriptive analysis of the data was performed.

RESULTS

Of 53 patients included in the study, 39 were female (73.6%) and 14 were male (26.4%). The ages of the patients ranged from 14 to 70 years, and the mean age was 37.8 years. No fungi could be isolated in 17 (32%) patients with nail dystrophy, while fungal pathogens were observed in 36 (68%) patients on potassium hydroxide mount, culture, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry examinations. Among nondermatophyte molds, Aspergillus species (52.7%) were identified as the most common fungal pathogen causing onychomycosis.

CONCLUSION

Although fungal pathogenic agents are mostly detected among the diseases causing color changes and deformities in the nails, it should be kept in mind that nail findings of systemic or other skin diseases may mimic onychomycosis and the diagnosis should be confirmed by laboratory tests in addition to clinical manifestations for accurate treatment.

STUDY LIMITATIONS

Other systemic diseases causing nail dystrophy were not questioned in the study.

Dermoscopic diagnosis of subungual hematoma: new observations

Introduction

There are very few studies focusing on the dermoscopic features of subungual hematoma which is one of the major imitators of subungual melanoma.

Aim

To identify the dermoscopic findings of subungual hematoma, which will facilitate the diagnostic process by reducing the use of more invasive diagnostic methods like nail avulsion or biopsy.

Material and methods

In this study, clinical and dermoscopic findings of the cases were reviewed. The diagnosis of subungual hematoma was confirmed by observing progression of the colour change to the distal edge of the nail plate in all the cases.

Results

A total of 47 subungual hematomas were enrolled in the study. The most common colour was purple-black (53%). Blue-white colour was observed in 12 (26%) lesions. 9 (19%) lesions showed granular leukonychia. All of the lesions had a homogenous pattern. In 25 (53%) lesions, a globular pattern was observed. 14 (30%) lesions showed a streaks pattern. Peripheral fading and periungual haemorrhage were present in 14 (30%) and 9 (9%) lesions, respectively.

Conclusions

We detected two new findings which have not been described previously for subungual hematoma: the first one is “blue-white colour” which is known as an important clue to melanoma. The second one is granular leukonychia localized on the hematoma. We suggest that in any case of the nail discoloration, a thorough dermoscopic examination should be performed. Moreover, progression of the colour change to the distal edge should be observed to ensure that a possible melanoma is not overlooked.

Dermoscopy of Onycholysis Due to Nail Psoriasis, Onychomycosis and Trauma: A Cross Sectional Study in Skin of Color

Background:

Clinical differentiation of onycholysis due to various etiologies is difficult task that compels to do invasive investigations to arrive at accurate diagnosis. Wrong diagnosis often leads to treatment failure and physicians and patient's anxiety. Dermoscopic patterns in nail psoriasis, onychomycosis are well established. Here, authors attempted to describe dermoscopic patterns in onycholysis due to psoriasis, onychomycosis and trauma in skin of color.

Methodology:

Study was conducted in a tertiary hospital in Southern India. Ethical clearance and informed consent from patients was obtained. Sixty consecutive patients who attended dermatology outpatient department with onycholysis were included in the study. Nail potassium hydroxide (KOH) study was done in all the cases. Onychoscopy was done with DermLite 3 with ultrasound gel as interface medium.

Results:

Totally 60 patients (42 males; 18 females) with onycholysis were included. Mean age was 37 years (range; 6-68 years). KOH was positive in 22 (36.6%) cases. Onychoscopy showed proximal erythematous rim, red dots, splinter hemorrhages in 23(65.71), 26 (74.28) and 21(60) in nail psoriasis respectively. Spiked and jagged-edges, aurora borealis and ruins pattern (65%) suggestive of onychomycosis were seen in 18(90%), 17 (85%) and 13 (65%) patients respectively. Plain edges without erythema or spikes were noted in 5 (8.33%) in traumatic onycholysis group.

Conclusion:

Onychoscopy is a non- invasive modality to diagnose psoriasis, onychomycosis and traumatic involvement of nail apparatus by demonstrating characteristic patterns. Hence, it also plays an important role in effective management of such cases.

Dermoscopic findings of fungal melanonychia

Introduction

There are very few studies about dermoscopic findings of fungal melanonychia (FM) apart from the case reports.

Aim

To reveal and identify dermoscopic findings which facilitate diagnosis of the FM.

Material and methods

The study included a total of 42 nails from 33 patients diagnosed with FM on the basis of the clinical history, physical examination, dermoscopic findings and microbiological investigation. All of the dermoscopic images were retrospectively reviewed and the findings identified were recorded in a period of 1 year.

Results

The most common presentation was homogenous brown pigmentation (n = 15, 35.7%). The other presentations included: homogenous black (n = 9, 21.4%), homogenous grey (n = 9, 21.4%), clumped/granular black (n = 7, 16.6%) and irregular longitudinal black (n = 4, 9.5%) pigmentation. Superficial transverse striation was observed in 11 (26.1%) nails. Twenty (47.6%) nails showed white streaks (white longitudinal striae) and 6 (14.2%) nails showed distal white jagged edge (also known as "spikes"). Twenty-two (52.3%) nails had at least one of white streaks and jagged edge findings. 4 (9.5%) nails showed pseudo Hutchinson's sign.

Conclusions

To the best of our knowledge, this is the most comprehensive study regarding the dermoscopic patterns of FM. Here, we also evaluated onychomycosis associated dermoscopic findings like white longitudinal striae and jagged edges. Our study, along with the previous studies, showed that dermoscopy can be a very helpful method in the diagnosis of FM. Long disease duration, homogenous pigmentation pattern, presence of white streaks and jagged edges are the main clues to FM.

Dermoscopic Features of Toenail Onychomycosis

BACKGROUND

Onychomycosis is the most common infectious nail disorder. Direct mycologic examination is still the cornerstone of diagnosis; however, it may take several weeks to obtain a result. Recently some dermoscopic patterns that can be useful in the diagnosis of onychomycosis were described. However, published data on dermoscopic features of onychomycosis are still limited.

METHODS

We performed a prospective dermoscopic study of patients with positive fungal culture between April and December 2016. Patients with a final diagnosis of psoriasis or lichen planus were excluded from the study. Dermoscopy (polarized and nonpolarized) was performed.

RESULTS

Thirty-seven patients were enrolled, 24 women and 13 men (median ± SD age, 48.6 ± 16.1 years). Nail samples were culture positive for Trichophyton rubrum (89.2%), Trichophyton interdigitale (8.1%), and Candida albicans (2.7%). Distal and lateral subungual onychomycosis was the most frequent clinical subtype (59.5%). The most frequent dermoscopic features were subungual keratosis (73.0%), distal subungual longitudinal striae (70.3%), spikes of the proximal margin of an onycholytic area (59.5%), transverse superficial leukonychia (29.7%), and linear hemorrhage (13.5%). Brown chromonychia was most frequently seen with nonpolarized dermoscopy (66.6% versus 24%; P = .027).

CONCLUSIONS

Specific dermoscopic signs of onychomycosis are mostly related to the proximal invasion of the nail plate. Detection of these signs is simple and can, in some cases, help avoid mycologic testing.

Pathogenesis, Clinical Signs and Treatment Recommendations in Brittle Nails: A Review

Nail plate brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than toenail fragility. Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. According to causative factors, we can distinguish 2 forms of nail fragility (NF): a primary "idiopathic or brittle nail syndrome" form and NF secondary to different causes such as inflammatory nail disorders, infections, systemic diseases and general conditions, traumas and alteration of the nail hydration. Optimal management requires treatment of the primary cause of brittle nails, when possible. In idiopathic NF oral supplementation, vitamins (especially biotin, also known as vitamin B7), trace elements and amino acids (especially cysteine) have been reported to be useful. In addition, several products, such as topical moisturizers and lacquers could be considered to restructure the affected nail plate and to reduce psychological impacts of this common problem.

Update on Dermoscopy and Infectious Skin Diseases

Nowadays, dermoscopy is a global worldwide diffuse diagnostic tool supporting clinicians in their daily hard task of correct orientation among dermatological diseases. Born to be an instrument for early diagnosis of skin cancer, the dermatoscope is now considered the dermatologist's stethoscope, as it can be routinely used to support diagnosis in general dermatology, so spreading its utility in cutaneous inflammatory and infectious diseases, as adjuvant and not substitute to histology and potassium hydroxide examination. As concerns the latter, plenty of papers have been published since the first description of dermoscopic findings of scabies. The aim of this review is to give the clinician a practical approach to dermoscopic parameters of cutaneous infectious diseases with a focus on the latest updates in this topic.

Can Dermoscopy Serve as a Diagnostic Tool in Dermatophytosis? A Pilot Study

Background

Dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders.

Aim

The purpose of the study was to describe the dermoscopic findings in various dermatophytosis.

Materials and Methods

This cross-sectional study included 100 clinically diagnosed tinea infections of skin, hair, and nails, which were evaluated using a dermoscope (Dermlite 3 gen DL3N, California USA, 10x).

Results

Among 100 patients of dermatophytosis, 69 were males and 31 females. The maximum number of patients had tinea corporis, followed by tinea cruris and tinea capitis. Dermoscopic findings noted in cases of tinea corporis included diffuse erythema, follicular micropustules, and brown spots surrounded by a white-yellowish halo, broken hair, wavy hair, and rare, morse code hair. Dermoscopy of tinea capitis depicted comma hairs, corkscrew hairs, zigzag hairs, and morse code hairs. Proximal jagged edge, spikes, and longitudinal striations were present in the cases of onychomycosis. Dermoscopy of tinea incognito yielded morse code hairs, follicular micropustules, and easily deformable hairs that look weakened and transparent and show unusual bends.

Limitations

Dermoscopic findings were not correlated to fungal culture.

Conclusion

Dermoscopy can be used as a fast, inexpensive, and noninvasive diagnostic tool to enhance diagnosis of cutaneous fungal infections.

Onychoscopic evaluation of distal and lateral subungual onychomycosis: A cross-sectional study in Lebanon

Background and Purpose:

The aim of this study was to evaluate the onychoscopic patterns associated with distal lateral subungual onychomycosis (DLSO) in Lebanon.

Materials and Methods:

The present study was conducted on 45 patients with clinical DLSO attending two dermatology clinics in Beirut, Lebanon, between January 2018 and April 2018. The patients were subjected to dermoscopy to identify the onychoscopic patterns.

Results:

The DLSO was predominantly associated with white, yellow, and brown color changes (P<0.05). Dermoscopic patterns of longitudinal striae (n=31; 68.75%), spiked pattern (n=25; 55.5%), and jagged pattern (n=25; 55.5%) were significantly correlated with DLSO (P<0.001). Our findings are in accordance with five previous reports in which dermoscopic findings are discussed in onychomycosis.

Conclusion:

It is recommended to perform further studies on homogeneous groups with different clinical subtypes of onychomycosis including patients with suspected traumatic onycholysis or other nail diseases. Identification of onychoscopic patterns would offer the clinicians a quick, simple, and complementary tool for the diagnosis of onychomycosis.