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

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

OBJECTIVES

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

DESIGN

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

SETTING

Primary care, recruitment from February 2020 to August 2022.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

WHO ICTRP NL8193.

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

INTRODUCTION

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Retrospective Analysis of Onychomycosis Risk Factors Using the 2003-2014 National Inpatient Sample

INTRODUCTION

Onychomycosis, a fungal nail infection, is associated with significant morbidity and negative impact on quality of life. Therefore, understanding associated risk factors may inform onychomycosis screening guidelines.

OBJECTIVES

This retrospective study investigated common demographic and comorbidity risk factors among hospitalized patients using the National Inpatient Sample.

METHODS

The 2003-2014 National Inpatient Sample (NIS) database was used to identify onychomycosis cases and age and sex matched controls in a 1:2 ratio. Chi-square tests and T-tests for independent samples were utilized to compare categorical and continuous patient factors. Demographic and comorbidity variables significant (P < 0.05) on univariate analysis were analyzed via a multivariate regression model with Bonferroni correction (P < 0.0029).

RESULTS

119,662 onychomycosis cases and 239,324 controls were identified. Compared to controls, onychomycosis patients frequently were White (69.0% versus 68.0%; P < 0.001), Black (17.9% versus 5.8%; P < 0.0001), and insured by Medicare or Medicaid (80.1% versus 71.1%; P < 0.0001). Patients had greater hospital stays (9.69 versus 5.39 days; P < 0.0001) and costs ($39,925 versus $36,720; P < 0.001) compared to controls. On multivariate analysis, onychomycosis was commonly associated with tinea pedis (odds ratio [OR]: 111.993; P < 0.0001), human immunodeficiency virus (OR: 4.372; P < 0.001), venous insufficiency (OR: 6.916; P < 0.0001), and psoriasis (OR: 3.668; P < 0.001).

CONCLUSIONS

Onychomycosis patients had longer hospital stays and greater costs compared to controls. Black patients were disproportionately represented among cases compared to controls. Onychomycosis was associated with tinea pedis, venous insufficiency, human immunodeficiency virus, psoriasis, obesity (body mass index [BMI] ≥ 30 kg/m2), peripheral vascular disease, and diabetes with chronic complications, suggesting that inpatients with onychomycosis should be screened for these conditions.

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

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

Thamnostylum piriforme, a novel etiological agent of superficial mycosis

Fungi are opportunistic eukaryotic entities often taking advantage of susceptibilities offered by a host due to its immunocompromised status, changed microbiome, or ruptured physical barriers and eventually cause infections. They either invade the skin superficially or are deep-seated. Superficial mycosis affects the skin, hair, and nails inhabiting the outermost layer, stratum corneum. In the present study, we report a case of superficial mycosis (onychomycosis in particular) in a 45-year-old immunocompetent man who was an ex-defense personnel and presently serving as a security guard at the University of Jammu, District Jammu, Jammu and Kashmir, India. The infection evolved 17 years ago and negatively affected the quality of life of the patient. For the identification of the causal agent, direct microscopy, cultural, micro-morphological, molecular characterization (ITS sequencing), and phylogenetic analysis were taken into account. A mucoralean fungal species, Thamnostylum piriforme, was isolated from the fingernails (left hand) of the investigated patient, which represents a new global report as the causal agent of superficial mycosis. In vitro antifungal susceptibility testing showed T. piriforme sensitivity to itraconazole, amphotericin B and ketoconazole while resistance to fluconazole. Careful selection of optimal therapy for fungal infection based primarily on correct identification and antifungal susceptibility testing could provide effective results during treatment against these opportunistic human fungal pathogens.

Infrequent Pediatric Subungual Injury Diagnosed by Intraoperative Anatomopathological Material: A Case Report

Subungual lesions are very common in clinical practice. We present the clinical case of a 10-year-old female patient who presented with progressive nail deformity. The onset of the condition was approximately five years prior to presentation with an injury in the left hallux, according to the mother. She denied pain or change in the color of the area from the onset of the injury to the day of consultation. There was no previous trauma. Examination revealed subungual bone injury to the distal extremity (distal phalanx of the left hallux), and imaging tests (X-ray and soft tissue ultrasound) found bone injury. Subungual exostosis was considered as a possible diagnosis, thus prompting the indication for exeresis of the tumoral process. After surgical removal, the resected specimen was sent for pathological assessment, which found that an intraosseous hemangiolymphangioma was the origin of the tumor. A subungual exostosis is a slow-growth benign osseous tumor mainly located in the distal phalanx of the hallux that especially affects young adults, being less frequent in children. This condition results from a process of bone neoformation involving different stages, the clinical symptoms of which depend on its size and associated processes. Hemangiolymphangiomas are angiomatous lesions of the blood and lymphatic vessels that have a controversial etiology and present slow, painless, and progressive growth; these lesions are mostly benign. It is worth emphasizing that subungual injuries are not always caused by an underlying bone; therefore, potential differential diagnoses, both benign and malignant, should be considered, based on the location of the injury.

Microbiological culture combined with PCR for the diagnosis of onychomycosis: Descriptive analysis of 121 patients

BACKGROUND

Onychomycosis is the most common nail pathology, involving various pathogens such as dermatophytes, moulds and yeasts.

OBJECTIVE

The objective of this study was to observe the prevalence of onychomycosis, analyse the most appropriate diagnostic test, and assess the distribution of pathogens based on age, sex, quarter of the year, duration of symptoms and previous treatment.

METHODS

Retrospectively, mycological culture and PCR data and results were collected from 121 patients.

RESULTS

Of the 121 samples, 57% (69/121) tested positive when both microbiological study techniques were combined. The prevalence of onychomycosis was higher when PCR was performed (52.1%) compared to microbiological culture (33.1%). Among the 81 samples negative by microbiological culture, 31 were positive by PCR. Similarly, of the 58 samples negative by PCR, eight were positive by microbiological culture. Diagnostic accuracy data (with 95% confidence intervals) for PCR, using microbiological culture as the gold standard, were as follows: sensitivity of 0.8, specificity of 0.62, positive predictive value of 0.51 and negative predictive value of 0.86. The most frequently identified pathogen was Trichophyton rubrum, and the hallux nail plate was the most commonly affected location. However, no statistically significant associations were found between sex, age, quarter of the year and affected area with culture and PCR results.

CONCLUSION

Combining microbiological culture and PCR can increase the detection rate of onychomycosis and help avoid false-negative results.

Clinical and epidemiological study of onychomycosis among patients of the national institute of hygiene in rabat, Morocco (2016-2020)

Background and Purpose

 Onychomycosis is a common nail infection characterized by the discoloration, thickening, and detachment of nails. This study aimed to provide valuable insights into this pathology by assessing its prevalence, clinical aspects, related comorbidities, and causative agents in patients from a Moroccan population.

Materials and Methods

 This retrospective study was conducted on 1,606 subjects at the Mycology-Parasitology laboratory of the National Institute of Hygiene in Rabat, Morocco, over five years (2016-2020). Nail samples were collected from both fingernails and toenails and processed through microscopic examination and culture. The incubated tubes were kept at a temperature range of 28-30°C for 4-5 weeks.

Results

 Onychomycosis was mycologically confirmed in 1,794 samples (93.24%). It occurred commonly in the 41-60 age group, with a higher incidence among females (74.53%). Diabetes, alongside other chronic diseases, was prevalent among patients with underlying conditions, comprising 131 cases (40.56%). Disto-lateral subungual onychomycosis emerged as the most prevalent clinical presentation, comprising 1,536 cases (79.92%). Fingernails primarily affected by yeasts, notably Candida albicans, accounted for 565 cases (29.80%), while toenails were predominantly impacted by dermatophytes, primarily Trichophyton rubrum (n=1,230, 64.87%). Mixed infections exclusively featured yeasts and dermatophytes, predominantly T. rubrum and C. albicans, which accounted for 79 (4.40%) cases. The study explored the influence of molds, yielding insights into their rarity in onychomycosis.

Conclusion

 These findings hold significant implications for the clinical management and diagnosis of onychomycosis, particularly in patients with underlying chronic conditions. Further epidemiological studies across Morocco are needed for meaningful comparisons.

The accuracy of clinical diagnosis of onychomycosis in Dutch general practice: a diagnostic accuracy study

BACKGROUND

Onychomycosis, the most common cause of nail dystrophy, is generally diagnosed by clinical examination. Current guidelines for Dutch general practice advise confirmatory testing only in cases of doubt or insufficient response to treatment. However, making a correct diagnosis can be challenging given the wide variety of clinical features and differential diagnosis.

AIM

To establish accuracy of clinical diagnosis of onychomycosis by GPs.

DESIGN & SETTING

A diagnostic accuracy study based on GPs' clinical diagnosis of primary care patients suspected of onychomycosis.

METHOD

Using 137 complete datasets from the Onycho Trial, diagnostic accuracy of clinical diagnosis as the index test was compared with confirmatory testing as the reference test. A sensitivity analysis was performed to determine diagnostic values for different combinations of index and reference test. Logistical regression was used to assess which clinical characteristics were associated with the positive predictive value (PPV) of the index test.

RESULTS

Clinical accuracy, that is the PPV of the index test, was 74.5%. Sensitivity analysis showed no significant difference in diagnostic values. Male sex and a history of any previous treatment significantly increased clinical accuracy with an odds ratio (OR) of 3.873 (95% confidence interval [CI] = 1.230 to 12.195, P = 0.021) and OR 4.022 (95% CI = 1.075 to 15.040, P = 0.039), respectively.

CONCLUSION

The study demonstrated that the GPs' clinical diagnosis of onychomycosis was insufficiently accurate to initiate treatment without confirmatory testing. Further research is needed to investigate how to increase clinical accuracy and reduce potentially unnecessary exposure to treatment.

Comparative analysis of onychomycosis in Puerto Rico using molecular and conventional approaches

Onychomycosis is the most prevalent nail ailment in adults, accounting for 50% of all nail infections. Dermatophyte fungi are the primary cause, but non-dermatophyte molds (NDM) and yeasts can also cause onychomycosis. It remains important to precisely determine the fungal cause of onychomycosis since the response to current treatments may vary between fungal classes. Real-time polymerase chain reaction (qPCR) has become a widespread tool for detecting fungal organisms for diagnosis due to its sensitivity and ability to detect down to the species level. This retrospective study aims to evaluate the qPCR Onycho+ test for dermatophyte detection using remnants of toenails from a cohort of patients from Puerto Rico.  Two hundred forty-two toenail samples submitted for histological examination via Periodic acid Schiff (PAS) staining for suspected onychomycosis were analyzed by the Onycho+ test and Sanger sequencing of the internal transcribed spacer (ITS-2). Compared to the gold standard Sanger sequencing method, the Onycho+ test reported an agreement of 91.39%, a sensitivity of 100% and a specificity of 84.5% in detecting dermatophytes, superior to the histology method which had a 69.53% agreement, 85.1% sensitivity and 57.1% specificity. The distribution of fungal organisms detected in this cohort shows a dermatophyte majority but a higher-than-expected proportion of NDMs. Nails negative for the Onycho+ test and positive for histology were mostly NDMs. This study demonstrates that the clinical performance of the Onycho+ test is superior to histology in detecting dermatophytes and that a combination of Onycho+ and histology can result in a higher clinical accuracy.

Risk Factors and Treatment Trends for Onychomycosis: A Case-Control Study of Onychomycosis Patients in the All of Us Research Program

Introda significant: Onychomycosis is the most common nail disorder seen in clinical practice, and it may have significant impact on patient quality of life. Understanding risk factors for onychomycosis may help to devise screening and treatment guidelines for populations that are more susceptible to this infection. Using a national database, we aimed to explore associations between onychomycosis and age, sex, and underlying medical conditions, as well as to examine current onychomycosis treatment trends. Materials and Methods: We performed a nested, matched, case-control study of patients in the All of Us database aged ≥ 18 years (6 May 2018-1 January 2022). Onychomycosis cases were identified using International Classification of Diseases (ICD) and Systematized Nomenclature of Medicine (SNOMED) diagnostic codes (ICD-9 110.1, ICD-10 B35.1, SNOMED 414941008). Demographic information (i.e., age, sex, and race), treatments, and co-diagnoses for onychomycosis patients and case-controls were recorded. Wald's test applied to multivariate logistic regression was used to calculate odds ratios and p-values between onychomycosis and co-diagnoses. Additionally, 95% confidence intervals were calculated with a proportion test. Results: We included 15,760 onychomycosis patients and 47,280 matched controls. The mean age of onychomycosis patients was 64.9 years, with 54.2% female, 52.8% Non-Hispanic White, 23.0% Black, 17.8% Hispanic, and 6.3% other, which was similar to controls. Patients with onychomycosis vs. controls were more likely to have a co-diagnosis of obesity (46.4%, OR 2.59 [2.49-2.69]), tinea pedis (21.5%, OR 10.9 [10.1-11.6]), peripheral vascular disease (PVD) (14.4%, OR 3.04 [2.86-3.24]), venous insufficiency (13.4%, OR 3.38 [3.15-3.59]), venous varices (5.6%, OR 2.71 [2.47-2.97]), diabetes mellitus (5.6%, OR 3.28 [2.98-3.61]), and human immunodeficiency virus (HIV) (3.5%, OR 1.8 [1.61-2.00]) (p < 0.05, all). The most frequently prescribed oral and topical medications were terbinafine (20.9%) and ciclopirox (12.4%), respectively. The most common therapeutic procedure performed was debridement (19.3%). Over the study period, ciclopirox prescriptions (Spearman correlation 0.182, p = 0.0361) and fluconazole prescriptions increased (Spearman correlation 0.665, p = 2.44 × 10^-4), and griseofulvin (Spearman correlation -0.557, p = 0.0131) and itraconazole prescriptions decreased (Spearman correlation -0.681, p = 3.32 × 10^-6). Conclusions: Our study demonstrated that age, obesity, tinea pedis, PVD, venous insufficiency, diabetes mellitus, and HIV were significant risk factors for onychomycosis. In addition, the most frequent oral and topical onychomycosis medications prescribed were terbinafine and ciclopirox, likely reflective of efficacy and cost considerations. Identifying and managing these risk factors is essential to preventing onychomycosis' primary infections and recurrences and improving treatment efficacy.

Two Novel Human Leukocyte Antigen Alleles Are Associated with Decreased Risk of Onychomycosis in a Large Cohort of Danish Blood Donors

Introduction

Antigen presentation and antimicrobial immune responses involve the human leukocyte antigen (HLA) system. Onychomycosis is primarily caused by dermatophytes and affects around 5.5% of the population worldwide. Yet, only limited data exist on the associations between the HLA system and onychomycosis. Thus, the objective of the study was to investigate if there is an association between HLA alleles and onychomycosis.

Methods

Participants in the Danish Blood Donor Study were defined as cases of onychomycosis and controls based on antifungal prescriptions in the national prescription registry. Associations were investigated using logistic regressions adjusted for confounders and were Bonferroni corrected for multiple tests.

Results

A total of 3,665 participants were considered onychomycosis cases, and 24,144 participants were considered controls. We found two protective HLA alleles of onychomycosis: DQB1*06:04, odds ratios (OR) 0.80 (95% confidence interval (CI) 0.71-0.90), and DRB1*13:02, OR 0.79 (95% CI: 0.71-0.89).

Conclusion

The finding of two novel protective alleles of onychomycosis indicates that certain HLA alleles have certain antigen presentation properties affecting the risk of fungal infection. These findings may provide the basis for future research identifying immunologically relevant antigens of fungi causing onychomycosis, which could ultimately lead to targets of new drugs with antifungal effects.

Onychomycosis associated with diabetic foot syndrome: A systematic review

BACKGROUND

A systematic review was conducted to investigate the prevalence of onychomycosis in patients with diabetes. The association of onychomycosis with risk factors in patients with diabetic foot syndrome was also examined.

METHODS

The recommendations in the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist were applied, and the included studies were assessed using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) method. Searches were conducted in October 2022 using PubMed (Medline) and Scopus for clinical studies, clinical trials, comparative studies, observational studies, and randomised clinical trials or controlled clinical trials addressing the prevalence and consequences of onychomycosis in patients with diabetes, diagnoses or treatments. Two authors performed the study selection and data extraction, and any discrepancies between the two reviewers were resolved through discussion with a third reviewer.

RESULTS

The systematic review included ten studies that met the inclusion criteria, and these studies enrolled 5664 patients with diabetes. Among these patients, 29.18% had onychomycosis that was mainly caused by Trichophyton rubrum. A significant association was found between the occurrence of onychomycosis and the presence of diabetic neuropathy (p = .012) and elevated glycosylated haemoglobin values (p = .039). There was no significant association between onychomycosis and ulceration (p = .185). Eight studies had a grade 4 level of evidence and a grade C recommendation, and one study had a grade 1b level of evidence and a grade A recommendation.

CONCLUSION

The information described in the literature is insufficient and heterogeneous regarding the association of risk factors and ulceration in patients with diabetic foot compared with developing onychomycosis. There is also a need to implement onychomycosis diagnostic testing instead of relying only on a clinical diagnosis. Additional prospective, randomised, comparative studies are needed to increase the quality of studies in the literature.

An Increase in Specialist Treatment for Onychomycosis: An Unexplained Tendency. A Retrospective Study of Patients Treated for Onychomycosis in Danish Hospitals from 1994 to 2018

Onychomycosis is a common disease with a significant negative impact on quality of life. While the disease is usually manageable in general practice, a proportion of patients need specialist treatment in academic hospital clinics. However, it is an unknown question whether the incidence in those needing specialist treatments is changing. Furthermore, the comorbidity burden in this patient population severely affected by onychomycosis has never been characterized. We conducted a retrospective study on patients treated for onychomycosis in Danish hospitals from 1994 to 2018. The cohort was observed for 24 years, and the data comprise 7.2 million Danes and their hospital diagnoses. A disease trajectory algorithm was used to examine the comorbidity burden in the cohort. A total of 2,271 patients received hospital treatment for onychomycosis during the time period, of which 1358 (59.8%) were men. The data show an increase in the incidence of hospital-treated cases since 2012 and that the most common comorbidities in this patient population include cardiovascular disease, alcohol-related diagnoses, and diabetes. One explanation of the increase in specialist treatment may include a general increase in patients with decreased resilience to fungal disease. This lack of resilience may both include an increasing elderly population with atherosclerosis, diabetes, and immunosuppression but also a potential increase in patients treated with immunosuppressive agents. Another possible explanation may include a shift in patient expectations in the case of treatment failure. Thus, patients may have an increasing demand for specialist treatment. While our data document an increase in the number of patients in need of specialist treatment for onychomycosis, we suggest future research to examine the general incidence of onychomycosis but also whether this increase in an apparently recalcitrant disease may be attributed to increased antifungal resistance, more specialist treatment options, or increased attention to dermatomycoses.

The effectiveness of matrix ablation with silver nitrate in the treatment of ingrown toenails. A single-center case-control study

BACKGROUND

Partial onychectomy with chemical matrixectomy is considered the gold standard treatment for stage II-III ingrown toenails (IT). However, there are scarce reports describing the use of silver nitrate in IT management in adolescents. Our aim is to analyze the effectiveness of matrix ablation with silver nitrate and compare it with partial onychectomy by electrocautery.

METHODS

A retrospective study of adolescent patients with stage II-III IT was performed. Those who underwent electrocautery matricectomy in a major outpatient surgical center (Group A) and those who were treated with silver nitrate at an outpatient clinic (Group B) were compared. Efficacy was determined by recurrence and postoperative infection rates.

RESULTS

Two hundred and nine patients were included (86 group A; 123 group B), with a total of 382 partial onychectomies (151 group A; 231 group B). Group B patients exhibited a lower recurrence rate (4.7%) when compared to group A (11.2%, p = .02), and had a lower postoperative infection rate (4.0% group A vs. 1.7% group B; p = .18), although not statistically significant.

CONCLUSION

Silver nitrate chemical matricectomy after partial onychectomy is an effective treatment for IT in adolescents, with few postoperative complications and low recurrence rate. Therefore, it should be considered as a possible alternative to electrocautery matricectomy.

Itraconazole and Difluorinated-Curcumin Containing Chitosan Nanoparticle Loaded Hydrogel for Amelioration of Onychomycosis

Onychomycosis is a nail infection caused by a fungus, Trichophyton mentagrophytes, that is responsible for major nail infections. The best method suited for treating such infections generally includes a topical remedy. However, conventional oral or topical formulations are associated with various limitations. Therefore, a more efficient and compatible formulation is developed in this study. The primary objective of the current study is to formulate and evaluate chitosan nanoparticle-based hydrogel for ameliorating onychomycosis. The sole purpose of this research was to increase the permeation of the lipophilic drug itraconazole and difluorinated curcumin, and its synergistic antifungal activity was also evaluated for the first time. Both in vitro and ex vivo drug release evaluations confirmed the sustained release of both drugs from the hydrogel, which is a prerequisite for treating onychomycosis. The results overall highlighted the promising activity of a synergistic approach that could be implemented for the treatment of onychomycosis. The hydrogel-based formulation serves as an effective method of delivery of drugs across the layers of the skin, resulting from its hydrating characteristics.

Surgical repair for deformities of the nail unit

The nail apparatus is the largest and most complex skin appendage. Defects in this unit can result in significant functional insufficiency and cosmetic disfigurement. Common nail deformities include split nail, short nail, onycholysis, nail malalignment, hooked nail, and absent nail. Currently, surgical repair is the primary treatment for such deformities. Based on the etiological and anatomical classifications, one or more appropriate operations can be selected to repair nail unit deformities. These include autologous fat grafting, longitudinal cicatrectomy, Z-plasties, nail bed elongation, split-thickness sterile matrix grafting, volar V-Y advanced flap reconstruction, sterile matrix particle grafting, germinal matrix flaps, and germinal matrix grafting. This review discusses the fundamental classification of nail unit deformities, common reconstructive surgical techniques, and their features.

Antifungal Nail Lacquer for Enhanced Transungual Delivery of Econazole Nitrate

The fungal disease of the nail, onychomycosis, which is also the most prevalent nail disturbance, demands effective topical treatment options considering the possible adverse effects of systemic antifungal therapy. The current work is focused on development of an adhesive and resistant, drug-delivering and permeation-enhancing polymeric film containing econazole nitrate (ECN) for topical antifungal treatment. The development of the lacquer formulation was guided by the Quality by Design approach to achieve the critical quality attributes needed to obtain the product of desired quality. Eudragit RSPO at 10% w/w was found to be the ideal adhesive polymer for the application and an optimal permeation-enhancing lacquer formulation was achieved by the optimization of other formulation excipients, such as plasticizer and the solvent system. Additionally, novel experimental enhancements introduced to the research included refined D₅₀ drying time and drying rate tests for lacquer characterization as well as a multi-mechanism permeation-enhancing pre-treatment. Moreover, a practical implication was provided by a handwashing simulation designed to test the performance of the lacquer during actual use. In vitro drug release testing and ex vivo nail permeation testing demonstrated that the optimized nail lacquer performed better than control lacquer lacking the permeation enhancer by achieving a faster and sustained delivery of ECN. It can be concluded that this is a promising drug delivery system for topical antifungal treatment of onychomycotic nails, and the novel characterization techniques may be adapted for similar formulations in the future.

Effect of Topical Antifungal Luliconazole on Hyphal Morphology of Trichophyton mentagrophytes Grown on in vitro Onychomycosis Model

Luliconazole, recently launched in Japan, is a novel topical imidazole antifungal agent for the treatment of onychomycosis. Using in vitro onychomycosis model, the effect of luliconazole on the morphology of the growing hyphae of Trichophyton mentagrophytes was investigated by scanning electron microscopy (SEM). The model was produced by placing human nail pieces on an agar medium seeded with conidia of T. mentagrophytes. After incubating the agar medium for 3 days, luliconazole was applied to the surface of the nail in which hyphal growth was recognized, then cultured for up to 24 h. The initial change after treatment with the drug was the formation of fine wrinkles on the surface of the hyphae, eventually, the hyphae were flattened, and after that, no hyphal growth was observed. On the other hand, when the nails were pretreated with luliconazole for 1 h, no hyphal growth was observed even after culturing for 24 h. This study suggests that luliconazole has a strong antifungal activity by inhibiting the ability of fungi to grow and the drug has both excellent nail permeation and retention properties.

Evaluation of different DNA extraction methods based on steel-bullet beating for molecular diagnosis of onychomycosis

BACKGROUND

Considering increased trends toward molecular methods for detection/identification of fungi causing onychomycosis, the aim of this study is comparison three DNA extraction methods based on steel-bullet beating to extract DNA from nail.

METHODS

Ex -vivo onychomycosis model was developed using bovine hoof with Candida albicans and Aspergillus flavus. For two models, total DNA was extracted using the three different methods. In method 1, the extraction and purification were performed by steel-bullet beating and phenol chloroform protocol, respectively. In method 2, a freezing step were applied before beating. The purification step in method 3 was carried out using a commercial kit, although DNA extraction was done similarly to method 1 in that approach. To evaluate the efficacy of each method, the extracted genomic DNA was amplified with Polymerase Chain Reaction (PCR) using Internal Transcribed Spacer (ITS) regions. Moreover, 50 nail samples were evaluated for onychomycosis using direct microscopy examination as well as PCR in order to evaluate the diagnostic efficiency of the optimal DNA extraction method.

RESULTS

Regarding the desirable quality of the extracted DNA, cost effectiveness, and simplicity, method 1 could be used to extract DNA effectively. Additionally, the obtained data showed that PCR had a higher detection rate of fungal agents in the nail samples than direct microscopic examination.

CONCLUSIONS

This study demonstrated that the mechanical disruption of the cell wall by steel-bullet beating is a useful and practical method to improve the quantity and quality of fungal DNA thorough the extraction process.

The results of open-label, randomized, actively-controlled study of the efficacy, safety and tolerability of the novel combined product (terbinafine hydrochloride + econazole nitrate), medicinal nail polish for local monotherapy of onychomycosis

Background. Currently, onychomycosis is an urgent and widespread problem in dermatology. The defeat of the nail plates is the cause of a cosmetic defect and a decrease in the quality of life of patients. Systemic antimycotics are effective, but have a number of side effects when used. Thus, a modern and effective approach to the treatment of patients with this pathology is needed. The aim of the study. To prove the efficacy, safety and tolerability of Ekzilak as local monotherapy of onychomycosis compared with cyclopyrox monotherapy. Materials and methods. А randomized open-label study with active control included 172 outpatient subjects: men and women aged 18 to 75 years, with microscopically confirmed onychomycosis of the big toe (one or both feet), a superficial or distal form of onychomycosis with a lesion of no more than 1/3 of the nail length (KIOTOS from 1 to 6). Patients were randomized into two groups: the 1st group of patients applied Ekzilak locally daily for 6 months, the 2nd group of patients applied Ciclopirox nail lacquer topical solution 8% as follows: 1 time a day for the first month, 2 times a week for the second one and 1 time a week for the months third-sixth. The preparations were applied in a thin layer to the affected nail. The primary efficacy endpoint in the study was the proportion of patients who achieved complete recovery of the target toenail at the end of therapy (clinical + mycological recovery). Secondary endpoints included the proportion of patients who achieved clinical recovery after 6 months of treatment (clinical recovery is a complete restoration of the normal morphology of the affected nail), the proportion of patients who achieved mycological recovery (microscopy with KOH solution) after 3 months of treatment, the proportion of patients who achieved complete recovery of the target toenail in 4 weeks after the end of treatment; IGA (Investigator's Global Assessment), Integrated Medicine Patient Satisfaction Scale (IMPSS); the safety Analysis was carried out throughout the study and included an assessment of adverse events, laboratory data, vital signs. Results. The results of the study showed that Ekzilak is superior in terms of efficacy to the registered drug Ciclopirox nail lacquer topical solution 8% as a local monotherapy of onychomycosis. The difference in the proportion of patients who achieved complete recovery between the study drug and the reference drug was 22.09%, 95% CI for the difference in the proportion was [8.21%; 35.97%], the differences between the groups are statistically significant (p=0.002). At the same time, the analysis of safety data, including the assessment of adverse events, laboratory studies and impact on vital signs, did not reveal statistically and clinically significant differences between the treatment groups. Conclusions. New combination drug Ekzilak is an effective and safe treatment option for patients with onychomycosis.

Ciclopirox Hydroxypropyl Chitosan (CPX-HPCH) Nail Lacquer and Breathable Cosmetic Nail Polish: In Vitro Evaluation of Drug Transungual Permeation Following the Combined Application

Background: Onychomycosis produces nail chromatic alterations that lead patients to mask them with cosmetic enamels. Objectives: Evaluate drug transungual permeation and antimycotic activity against selected strains after application of CPX-HPCH nail lacquer (NL) on the nail pre-covered with breathable cosmetic polish. Methods: CPX transungual permeation after applying CPX-HPCH NL once or twice a day on bovine hoof membranes pre-covered with a breathable cosmetic nail polish was compared to that obtained applying CPX-HPCH NL directly on the membrane. The relevant experimental permeates underwent an in vitro susceptibility test. Results: After CPX-HPCH NL application once a day, the drug transungual flux in the presence of cosmetic product tended to decrease while maintaining the antifungal activity. Two daily applications of CPX-HPCH NL on the membrane pre-covered with cosmetic polish exhibited the same permeation profile as daily application of the medicated lacquer directly on the nail as well as the same microbiological activity. Conclusions: The breathable cosmetic nail polish can be applied on the nail affected by onychomycosis in association with CPX-HPCH NL to mask the imperfections. The application of CPX-HPCH NL twice a day appears to be a good solution to obtain the same results as for a daily application without the presence of the cosmetic layer.

Fractional CO2 laser ablation leads to enhanced permeation of a fluorescent dye in healthy and mycotic nails-An imaging investigation of laser-tissue effects and their impact on ungual drug delivery

Purpose

Conventional oral antifungal therapies for onychomycosis (OM) often do not achieve complete cure and may be associated with adverse effects, medical interactions, and compliance issues restricting their use in a large group of patients. Topical treatment can bypass the systemic side effects but is limited by the physical barrier of the nail plate. Ablative fractional laser (AFL) treatment can be used to improve the penetration of topical drugs into the nail. This study visualized the effects of laser ablation of nail tissue and assessed their impact on the biodistribution of a fluorescent dye in healthy and fungal nail tissue.

Methods

For the qualitative assessment of CO₂ AFL effects on healthy nail tissue, scanning electron microscopy (SEM), coherent anti‐Stokes Raman scattering microscopy (CARS‐M), and widefield fluorescence microscopy (WFM) were used. To quantitate the effect of laser‐pretreatment on the delivery of a fluorescent dye, ATTO‐647N, into healthy and fungal nail tissue, ablation depth, nail plate thickness, and ATTO‐647N fluorescence intensity in three nail plate layers were measured using WFM. A total of 30 nail clippings (healthy n = 18, fungal n = 12) were collected. An aqueous ATTO‐647N solution was directly applied to the dorsal surface of 24 nail samples (healthy n = 12, fungal n = 12) and incubated for 4 hours, of which half (healthy n = 6, fungal n = 6) had been pretreated with AFL (30 mJ/mb, 15% density, 300 Hz, pulse duration <1 ms).

Results

Imaging revealed a three‐layered nail structure, an AFL‐induced porous ablation crater, and changes in autofluorescence. While intact fungal samples showed a 106% higher ATTO‐647N signal intensity than healthy controls, microporation led to a significantly increased fluorophore permeation in all samples (p < 0.0001). AFL processing of nail tissue enhanced topical delivery of ATTO‐647N in all layers, (average increase: healthy +108%, fungal +33%), most pronounced in the top nail layer (healthy +122%, fungal +68%). While proportionally deeper ablation craters correlated moderately with higher fluorescence intensities in healthy nail tissue, fungal samples showed no significant relationship.

Conclusion

Fractional CO₂ laser microporation is a simple way of enhancing the passive delivery of topically applied ATTO‐647N. Although the impaired nail plate barrier in OM leads to greater diffusion of the aqueous solution, AFL can increase the permeability of both structurally deficient and intact nails.

Onychomycosis Caused by Fusarium Species

Onychomycosis is a nail fungal infection that produces nail discolouration, thickness, and separation from the nail bed. The species of the Fusarium genus that cause onychomycosis are emerging and the number of cases has increased throughout the years. Microscopic examination, as well as cultures, are required for the accurate diagnosis of onychomycosis. The goal of treatment is to eliminate the organism that causes the disease and restore the nail’s normal appearance. Here, we provide an overview of the onychomycosis cases that have been reported in literature over the last 24 years, which have been caused by the Fusarium species. We performed a review on the onychomycosis cases caused by the Fusarium species from January 1997 to January 2021. Patients aged between 40 and 49 years made up 30.23% of the cases. The most common aetiologic species was Fusarium solani species complex (FSSC), which accounted for 44.11% of the cases, followed by F. fujikuroi species complex (FFSC), which accounted for 17.64%; 14.70% of the cases were due to F. dimerum species complex (FDSC) and 14.70% of the cases were due F. oxysporum species complex (FOSC). Europe accounted for 29.06% of the cases caused by FOSC, whereas Africa accounted for 46.67% of the cases due to FSSC. The clinical presentation of onychomycosis due to Fusarium spp. is commonly the distal–lateral pattern of onychomycosis. Identification of the infectious agent in onychomycosis cases due to Fusarium is crucial in deciding the proper treatment. Although antifungal susceptibility tests have only been performed in a few cases, susceptibility testing can help with patient management.

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.

Transmission of Onychomycosis and Dermatophytosis between Household Members: A Scoping Review

Onychomycosis is a common fungal infection of the nail, caused by dermatophytes, non-dermatophytes, and yeasts. Predisposing factors include older age, trauma, diabetes, immunosuppression, and previous history of nail psoriasis or tinea pedis. Though many biological risk factors have been well characterized, the role of the environment has been less clear. Studies have found evidence of transmission in 44% to 47% of households with at least one affected individual, but the underlying mechanisms and risk factors for transmission of onychomycosis between household members are incompletely understood. A scoping literature review was performed to characterize and summarize environmental risk factors involved in the transmission of onychomycosis within households. A total of 90 papers met the inclusion criteria, and extracted data was analyzed in an iterative manner. Shared household surfaces may harbor dermatophytes and provide sources for infection. Shared household equipment, including footwear, bedding, and nail tools, may transmit dermatophytes. The persistence of dermatophytes on household cleaning supplies, linen, and pets may serve as lasting sources of infection. Based on these findings, we provide recommendations that aim to interrupt household transmission of onychomycosis. Further investigation of the specific mechanisms behind household spread is needed to break the cycle of transmission, reducing the physical and social impacts of onychomycosis.

MOLECULAR DETECTION OF THE TWO VIRULENCE GENES HWP1 AND ALS1 IN CANDIDA SPECIES ISOLATED FROM ONYCHOMYCOSIS

OBJECTIVE

The aim: This article was aimed to assess the prevalence of Candida species causing nail infections and to investigate the most important virulence genes that cause adhesion.

PATIENTS AND METHODS

Materials and methods: Samples were collected from General Hospital and the outpatient's clinics in Thi-Qar Province, southern Iraq, during the period from January 2021 to May 2021. Samples were inoculated on Sabouraud Dextrose Agar plates containing 0.5 mg chloramphenicol, then Petri dishes were incubated at 30°C under aerobic conditions and observed for Candida species growth for 24-72 hrs. All isolates were identified by morphologic and chromatic properties on CHROMagar and by Api Candida.

RESULTS

Results: Twenty five isolates were obtained from hundred samples, which belong to five species of the genus Candida, distributed in percentage 9(36%), 4(16%), 4(16%), 4(16%) and 3(12%) of C. glabrata, C. krusei, C. albicans, C. famata and C. tropicalis consecutively and one isolate was not identified. Monoplex PCR technique was used to detect virulence genes (hwp1 and als1) of Candida species. Four Candida albicans isolates (16%) were carried of both hwp1 and als1 genes.

CONCLUSION

Conclusions: The virulence gene (hwp1) can be relied upon in molecular detection as a special diagnostic tool of Candida albicans species except other types causing Candidal onychomycosis.

Preliminary Evidence of the Efficacy of Nitric Acid Treatment in Onychomycosis

Onychomycosis is the main cause of toenail disorders and is produced by a fungal infection. It is becoming more prevalent because of new lifestyles and immunosuppression statuses. The therapeutic approach to onychomycosis is under considerable study because of the lengthy treatments that require strong patient commitment, the limited efficacy of treatments, the inclusion of active substances that can be hepatotoxic and cause pharmacological interactions, and/or the questionable efficacy of treatments due to a lack of clinical trials. This study responds to the demand for rapid treatment with minimal pharmacological interactions. Methods: The efficacy of nitric acid 60% treatment in patients with onychomycosis was monitored and studied. The antifungal efficacy of nitric acid was measured by microbiological culture before and after treatment and the clinical evolution of nail dystrophy was quantitatively measured by monitoring with the Onychomycosis Severity Index (OSI). Results: The results show that, with the protocol used, nitric acid 60% painlessly cured 40% (microbiologic cure) of the cases treated, and in all cases, clinical improvement was observed (p = 0.011). Conclusions: The treatment with nitric acid 60% is as efficient as conventional treatments, requires less patient compliance of the treatment and produces no pharmacological interactions, providing alternative treatment in the case of hepatotoxicity.

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

BACKGROUND

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

OBJECTIVES

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

PATIENTS/METHODS

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

RESULTS

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

CONCLUSIONS

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

Solubilization in vitro of tea tree oil and first results of antifungal effect in onychomycosis

INTRODUCTION

Onychomycosis is the main cause of nail alteration. Hepatotoxicity, interference and low adherence to pharmacological treatment are associated. Therefore, our objective was to assess the in vitro effectiveness of tea tree essential oil (less harmful) against main causative agents of these infections.

MATERIAL AND METHODS

Thrichophyton rubrum and Thrichophyton mentagrophytes were isolated and inoculated at a concentration of 3 × 10⁵ CFU/mL in potato agar dextrose and tea tree essential oil at different concentrations to assess its effect by counting colony forming units and radial growth.

RESULTS

Trichophyton rubrum growth inhibition was obtained at concentrations higher than 0.04% of the essential tea tree oil (p = 0.004). In the case of Thrichophyton mentagrophytes, inhibition was obtained at 0.02% (p = 0.017), and even complete inhibition at a final concentration of the oil at 0.07%.

CONCLUSIONS

Tea tree essential oil inhibits the in vitro growth of the fungus and may be a less harmful alternative to the onychomycosis treatment.

Onychomycosis in older adults: The age and associated factors affecting the complete cure rate

BACKGROUND

Limited studies exist on the factors associated with a complete cure of onychomycosis in older adults.

OBJECTIVES

To determine the age and factors associated with a complete cure among older adults diagnosed with toenail onychomycosis.

METHODS

A retrospective cohort study was conducted of 95 older adult patients (aged ≥ 60 years) diagnosed with toenail onychomycosis between January 2016 and December 2017. Demographic data, mycological findings, treatments and durations to a complete cure were reviewed.

RESULTS

The complete cure rates of the patients aged < 70 years and ≥70 years were 67.4% and 44.9%, respectively (P = 0.027). Patients aged ≥ 70 years were significantly higher in male gender, had higher history of smoking, peripheral arterial disease, impaired renal function, antihypertensive drug and amorolfine nail lacquer usage, and polypharmacy. A multivariate analysis revealed that being aged ≥70 years and having a nail thickness >2 mm were associated with failure to achieve a complete cure. The median times to a complete cure for older adults aged <70 years and ≥70 years were 20 months and 47 months, respectively (P = 0.007).

CONCLUSIONS

An age ≥ 70 years was related to a lower cure rate and delays in achieving a complete cure. A nail thickness > 2 mm was a poor prognostic factor for a complete cure. Moreover, very old adults were more likely to suffer side effects arising from the use of systemic antifungal medications.

One size does not fit all: the need for individualized treatment based on factors that may affect the therapeutic outcome of efinaconazole 10% solution for the treatment of toenail onychomycosis

Successful management of onychomycosis is a challenge because cure rates with most antifungals are relatively low and recurrence rates are high. A drug-based approach by treating the nail alone may not suffice. There are several host-related factors (age, sex, body mass index [BMI], and patient's quality of life), disease-related factors (disease severity, duration, and the number of toenails affected), and comorbidities (tinea pedis and diabetes) that may affect treatment efficacy. Here, we review the post hoc analyses of the phase III trials of efinaconazole 10% solution that have investigated the impact of these factors on topical therapy for toenail onychomycosis. The significant clinical variables that may affect the efficacy of efinaconazole include sex, BMI, disease severity, disease duration, and tinea pedis. As older patients may have slower toenail growth and more severe, longstanding disease compared with younger patients, they may require longer treatment duration, beyond the 48-week standard regimen. Treatment compliance may need to be discussed for an improved health outcome. Therefore, these prognostic factors need to be carefully evaluated, which may aid in formulating individualized therapy to maximize treatment success.

Quality of life and therapeutic regimen management in onychomycosis patients and in vitro study of antiseptic solutions

Onychomycosis or tinea unguium (EE12.1) and Onychomycosis due to non-dermatophyte moulds (1F2D.5) (OM) is a fungal infection of the nail plates with a high prevalence that often affects vulnerable people with co-existing health problems. Gold standard pharmacological treatments for onychomycosis have been associated with low success rates and increasing antifungal resistance, suggesting that treatment outcome is dependent on multiple variables. Here, the prevalence of OM and quality of life were characterized in two vulnerable populations—Hospital patients and Homeless people. Comparing both groups, the most prevalent fungal species were identified in Hospital patients. Then, the in vitro fungicidal properties of the antiseptics povidone-iodine, polyhexamethylene biguanide-betaine, octenidine dihydrochloride, and a super-oxidized solution against two ATCC strains (Candida albicans and Aspergillus niger) and three clinical fungal isolates from Hospital patients (Candida parapsilosis, Trichophyton interdigitale, and Trichophyton rubrum) were tested. OM prevalence was high in both patient groups studied, who also reported a reduction in quality of life and concerns about the state of their feet. In addition, Hospital patients had a non-negligent therapeutic regimen management style. Antiseptics tested in vitro revealed antifungal properties. As antiseptics are low-cost and easy to apply and have few iatrogenic effects, the demonstration of fungicidal properties of these solutions suggests that they may constitute potential supportive therapeutics for OM.

More than Nail Deep: The Effect of Efinaconazole 10% Treatment on the Quality of Life in Patients with Onychomycosis: A post hoc Study

INTRODUCTION

Onychomycosis is a common, difficult-to-treat fungal nail infection. Clinical signs include nail discoloration and thickening, which patients often find embarrassing, causing a negative impact on their quality of life (QOL).

METHODS

In this post hoc study, we analyze the effect of efinaconazole 10% solution on a patient's QOL using patient-reported scores from the OnyCOE-t™ questionnaire (appearance, stigma, physical problems, symptom frequency, symptom bothersomeness, treatment satisfaction, and overall problem). Higher scores corresponded to better functioning, thus higher QOL.

RESULTS

Efinaconazole 10% treatment and clinical efficacy were positively correlated with improved QOL in all domains for all groups, except with symptom bothersomeness (how much the onychomycosis symptoms worried or concerned the patient) for female patients <40 years. While still showing improvement in most domains during efficacious treatment, female and younger patients reported lower QOL scores than their male and older counterparts, despite having better clinical outcomes at follow-ups.

DISCUSSION

Female and younger patients appear to be more emotionally bothered by their symptoms, regardless of treatment success or improvement of their nail's appearance, suggesting that onychomycosis is more than nail deep and has a greater psychological effect on these patients. Therefore, younger female patients may require more assurance and mental support.

Translation and Cross-Cultural Adaptation of Quality of Life Scale in Patients with Onychomycosis

(1) Background: Onychomycosis (OM) is a fungal nail infection, considered a risk factor for diabetic foot ulcers. It is associated with changes in quality of life, in terms of pain, self-confidence and self-esteem. The aim was to translate and adapt the OM quality of life questionnaire "OnyCOE-t^TM-Quality Of Life Questionnaire Onychomycosis (Nail Fungal Condition)". (2) Methods: This study followed the guidelines proposed by Beaton et al. (2000), where two English to Portuguese translations were performed and, after an expert consensus, a common version was obtained. This was followed by two back-translations. The expert committee achieved semantic equivalence, idioms and concepts. The pre-test was applied to 49 people. The final version and processed data were sent to the authors. (3) Results: We adapted terms semantically, modified statements syntactically, altering items from interrogative to affirmative. (4) Conclusions: The translated version of the "Quality of life-Onychomycosis" questionnaire suggested that it can be used for further studies to test validity and reliability in this population.

Nondermatophyte mould onychomycosis

Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.

Onychomycosis: An Updated Review

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

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

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

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

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

NP213 (Novexatin®): A unique therapy candidate for onychomycosis with a differentiated safety and efficacy profile

NP213 (Novexatin®) is a novel antifungal peptide specifically designed for the topical treatment of onychomycosis. NP213 was designed using host defense peptides (HDP), essential components of the innate immune response to infection, as a template. NP213 is a water-soluble cyclic fungicidal peptide that effectively penetrates human nail. NP213 demonstrated a promising preclinical and clinical safety profile, with no evidence of systemic exposure following topical application to the skin and nails. NP213 was efficacious in two phase IIa human trials with 43.3% of patients having no fungi detectable by culture of fragments from NP213-treated nails after 180 days in the first study and likewise 56.5% of patients were culture negative for dermatophytes after 360 days in the second phase IIa study. In both trials, NP213 was applied daily for only 28 days in marked contrast to other topical onychomycosis treatments that require application for up to 52 weeks. Patient reported outcomes from the phase IIa studies were positive with participants recording an improved appearance of their nails after only 14 days of application. All fungi identified in these studies were Trichophyton spp. NP213 (Novexatin®) is a promising, highly differentiated peptide-based candidate for the topical treatment of onychomycosis, addressing the infectious cause and cosmetic issues of this very common condition.

Once Weekly Application of Urea 40% and Bifonazole 1% Leads to Earlier Nail Removal in Onychomycosis

Introduction

Onychomycosis is a chronic nail fungal infection resulting in nail damage and a decreased quality of life. Chemical avulsion of the nail with urea and bifonazole -removes fungally infected debris, increasing antifungal treatment efficacy and penetration. Previous clinical ob-servations describe patients who applied their urea and -bifonazole ointment less frequently, achieving earlier nail removal. In this study, we analyzed the relationship between duration of urea and bifonazole application and time to nail avulsion.

Methods

χ² tests, multiple regression analysis, and ANOVA were performed to analyze the similarities between treatment regimens (daily, every 3 days, or once a week), association of regimens or patient characteristics to nail removal, and compare time to nail removal between each regimen, respectively.

Results

Daily application of ointment and sealing resulted in an average length of time (±SD) to nail removal of 18.7 days (±6.8 days); once every 3 days resulted in nail removal at 12.7 days (±6.2 days) and once per week at 11 days (±4.46 days) (p < 0.001). Age was the only patient factor that affected duration to nail removal.

Conclusion

Once weekly application of ointment with sealing for a 1-week duration is associated with a decrease in time to complete chemical avulsion of the nail by approximately 1 week.

Ciclopirox Hydroxypropyl Chitosan (HPCH) Nail Lacquer: A Review of Its Use in Onychomycosis

Ciclopirox 8% hydroxypropyl chitosan (HPCH) [Marketed in different countries as the following registered (®) brands: Ciclopoli, Fulcare, Kitonail, Myconail, Niogermos, Niogermox, Onytec, Ony-Tec, Polinail, Privex, Rejuvenail] is the first topical nail lacquer developed using innovative drug formulation technology. It is indicated for the treatment of mild-to-moderate fungal infections of the nails that are caused by dermatophytes and/or other ciclopirox-sensitive fungi, without nail matrix involvement. HPCH is a patented drug formulation technology for the delivery of active principles into the nails based on a hydrosoluble semisynthetic amino-polysaccharide biopolymer derivative of chitosan. The lacquer acts as a protective barrier against microbiological attack, physical damage and/or aggressive chemicals. Results from in vitro studies suggest that the application of ciclopirox 8% HPCH nail lacquer improves drug permeation into and/or drug penetration through the nail, relative to the water-insoluble ciclopirox 8%, amorolfine 5% and efinaconazole 10% reference lacquers. In addition, in vitro and clinical studies in healthy subjects found that the concentration of ciclopirox reached in subungual fluids after application of ciclopirox 8% HPCH was sufficient for inhibiting fungal growth. In clinical studies in patients with mild-to-moderate onychomycosis, ciclopirox 8% HPCH was found to be more effective than the commercial water-insoluble ciclopirox 8% and amorolfine 5% lacquers, as indicated by higher complete cure, response and mycological cure rates at 48 weeks after treatment initiation. Ciclopirox 8% HPCH has been found to be generally well tolerated, with no treatment-related adverse events reported in patients using this nail lacquer. Thus, current evidence indicates that ciclopirox 8% HPCH represents a valuable treatment option for the treatment of patients with onychomycosis.

Solubilization in vitro of tea tree oil and first results of antifungal effect in onychomycosis

INTRODUCTION

Onychomycosis is the main cause of nail alteration. Hepatotoxicity, interference and low adherence to pharmacological treatment are associated. Therefore, our objective was to assess the in vitro effectiveness of tea tree essential oil (less harmful) against main causative agents of these infections.

MATERIAL AND METHODS

Trichophyton rubrum and Trichophyton mentagrophytes were isolated and inoculated at a concentration of 3x105 CFU / mL in potato agar dextrose and tea tree essential oil at different concentrations to assess its effect by counting colony forming units and radial growth.

RESULTS

Trichophyton rubrum growth inhibition was obtained at concentrations higher than 0.04% of the essential tea tree oil (p = 0.004). In the case of Trichophyton mentagrophytes, inhibition was obtained at 0.02% (p = 0.017), and even complete inhibition at a final concentration of the oil at 0.07%.

CONCLUSIONS

Tea tree essential oil inhibits the in vitro growth of the fungus and may be a less harmful alternative to the onychomycosis treatment.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

DISCUSSION

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

Fractional CO2-assisted photodynamic therapy improves the clinical outcome and patient's satisfaction in toenail onychomycosis treatment: an intra-patient comparative single-center study

Background: Device-based therapies have been used for onychomycosis patients with intolerance to systemic treatments. Photodynamic therapy (PDT) improves onychomycosis, while fractional carbon dioxide (FrCO₂) augments the topical drug delivery. Comparative studies between PDT alone and laser-assisted one are lacking.Objective: We aimed to evaluate the efficacy of PDT alone versus FrCO₂-assisted PDT for treatment of onychomycosis.Methods: Twenty-one patients with bilateral onychomycosis of toenails with nearly the same degree of affection were enrolled in this prospective intra-patient-controlled study. The right affected toenail was treated via PDT alone. The left toenail was treated via a FrCO₂ followed immediately by PDT. The sessions were bimonthly for a total of six sessions. Direct microscopy, fungal cultures, clinical evaluation, onychomycosis severity index scoring, and patient's satisfaction were assessed before and 12 weeks after the last session.Results: Both treatments reduced significantly the onychomycosis severity index (p < .05) without significant difference between them. The improvement in nail appearance and patient's satisfaction were higher in laser-assisted PDT than PDT alone (p < .05).Conclusion: Both treatments effectively reduced the severity of onychomycosis with a high degree of safety and tolerability. Fractional CO₂-assisted PDT enhanced the clinical outcome via improving the nail appearance and patient's satisfaction.Key messagePhotodynamic therapy has a good success rate in clearing onychomycosis. Addition of fractional CO₂ to photodynamic therapy improves the nail appearance and induces better satisfaction to treatment.

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

BACKGROUND AND OBJECTIVES

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

STUDY DESIGN/MATERIALS AND METHODS

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

RESULTS

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

Effect of Nail Thickness on Visible Radiation Transmittance: Implications for New Photodynamic Therapy Technologies in Onychomycosis

Photodynamic therapy is taking importance as a nonintrusive treatment for nail onychomycosis. Knowledge of true transmittance values across nails could lead to qualitative and quantitative improvements in light-based treatments. We have characterized the spectral transmittance of healthy and fungally infected human fingernails and toenails according to nail thickness, and we propose a surface transmittance model for the small-scale optimization of light-based treatments. Transmittance of fingernails and toenails was analyzed by means of spectroradiometric measurements under solar-simulated visible light radiation (400 nm to 750 nm). The nail thickness was measured by means of microscope measurement. Transmittance was highest at longer wavelengths and decreased gradually as the wavelengths became shorter but with a significant nail transmittance of around 20% in the blue region of the spectrum. In the case of nails affected by onychomycosis, transmittance fell to under 10% because of the thickness of the nails, with no changes in spectral characteristics of transmitted light. Nail thickness is the main variable controlling exponentially light transmission in the visible spectrum and not only red radiation is effective for nail onychomycosis PDT. Blue light, the spectral band more effective for PPIX absorption is also effectively transmitted.