Treatment of Dermatophytosis in Elderly, Children, and Pregnant Women

The StuA Transcription Factor and Alternative Splicing Mechanisms Drive the Levels of MAPK Hog1 Transcripts in the Dermatophyte Trichophyton rubrum

Trichophyton rubrum is a human fungal pathogen that causes dermatophytosis, an infection that affects keratinized tissues. Integrated molecular signals coordinate mechanisms that control pathogenicity. Transcriptional regulation is a core regulation of relevant fungal processes. Previous RNA sequencing data revealed that the absence of the transcription factor StuA resulted in the differential expression of the MAPK-related high glycerol osmolarity gene (hog1) in T. rubrum. Here we validated the role of StuA in regulating the transcript levels of hog1. We showed through RT-qPCR that transcriptional regulation controls hog1 levels in response to glucose, keratin, and co-culture with human keratinocytes. In addition, we also detected hog1 pre-mRNA transcripts that underwent alternative splicing, presenting intron retention in a StuA-dependent mechanism. Our findings suggest that StuA and alternative splicing simultaneously, but not dependently, coordinate hog1 transcript levels in T. rubrum. As a means of preventing and treating dermatophytosis, our results contribute to the search for new potential drug therapies based on the molecular aspects of signaling pathways in T. rubrum.

Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique

Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4-6 weeks and that for recalcitrant dermatophytosis is 6-8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.

Superficial Zoonotic Mycoses in Humans Associated with Cats

Dermatophytosis is a superficial fungal skin infection common in humans around the world and is one of the many zoonotic skin diseases that cat owners are at risk of contracting. This retrospective study was conducted based on a detailed analysis of the results of mycological examination and medical documentation of 56 patients diagnosed with cat-to-human dermatophytoses from January 2017 to July 2022. Zoonotic mycoses were diagnosed more frequently in young people and women. In children, lesions most often occurred in the scalp area, and in adults, in the glabrous skin area. Skin infections caused by Microsporum canis (M. canis) prevailed and were confirmed in 47 patients (83.9%). Trichophyton mentagrophytes (T. mentagrophytes) was found in nine (16.1%) patients. M. canis predominantly caused infections of the scalp, followed by lower limb infections. Hairy scalps were almost exclusively involved in children. The odds of diagnosing M. canis infection compared to T. mentagrophytes infection was significantly higher in the head than in other regions, especially among children. The positive predictive value of a direct macroscopic examination was relatively low.

Pruritus in Pregnancy

Pruritus is a commonly described symptom during pregnancy. Despite its high prevalence, it is often considered trivial but causes significant patient discomfort. It is important to assess and investigate the patient thoroughly as some conditions have a detrimental outcome for both mother and fetus. There is extensive literature on pruritus due to pregnancy-specific dermatoses, however, the evaluation of pruritus merits a broader approach. Various other conditions such as certain infections, systemic diseases, and pre-existing dermatological conditions should also be considered. Awareness of these conditions in obstetricians will also ensure adequate treatment and timely referral, if necessary. The purpose of this article is to describe the etiology, clinical features, diagnostic approach, and management of pruritus in pregnancy.

Molecular Verification of Trichophyton in the Brazilian URM Culture Collection

Trichophyton species cause dermatophytosis in humans, with a high, worldwide frequency of reports and important public health relevance. We evaluated 61 Trichophyton strains from different sources deposited in the University Recife Mycology (URM) culture collection of the Universidade Federal de Pernambuco, Brazil. Strains were phenotypically identified and confirmed by sequencing Internal Transcribed Spacers rDNA and partial beta-tubulin 2-exon. Additionally, we evaluated their susceptibility to terbinafine and itraconazole. Physiological analyses included urease activity and growth in casein medium. Phenotypic methods allowed the reliable identification of T. rubrum only, whereas, for other species, molecular methods were mandatory. All Trichophyton species exhibited susceptibility profiles to itraconazole (0.04-5.33 μg/mL) and terbinafine (0.17-3.33 μg/mL). Our analyses revealed a heterogeneous distribution of T. mentagrophytes, which does not support the current distribution within the species complex of T. mentagrophytes and its genotypes.

Old age as a risk factor for liver diseases: Modern therapeutic approaches

Recent scientific interest has been directed towards age-related diseases, driven by the significant increase in global life expectancy and the growing population of individuals aged 65 and above. The ageing process encompasses various biological, physiological, environmental, psychological, behavioural, and social changes, leading to an augmented susceptibility to chronic illnesses. Cardiovascular, neurological, musculoskeletal, liver and oncological diseases are prevalent in the elderly. Moreover, ageing individuals demonstrate reduced regenerative capacity and decreased tolerance towards therapeutic interventions, including organ transplantation. Liver diseases, such as non-alcoholic fatty liver disease, alcoholic liver disease, hepatitis, fibrosis, and cirrhosis, have emerged as significant public health concerns. Paradoxically, these conditions remain underestimated despite their substantial global impact. Age-related factors are closely associated with the severity and unfavorable prognosis of various liver diseases, warranting further investigation to enhance clinical management and develop novel therapeutic strategies. This comprehensive review focuses specifically on age-related liver diseases, their treatment strategies, and contemporary practices. It provides a detailed account of the global burden, types, molecular mechanisms, and epigenetic alterations underlying these liver pathologies.

Antifungal activity of citronellal against Trichophyton rubrum and its predictive mechanism of action by CYP51 inhibition through molecular docking

The present study aimed to investigate the antifungal activity of citronellal (CIT) against clinical isolates of T. rubrum and to show the possible mechanism of action involved. The antifungal potential of CIT was evaluated from the Minimum Inhibitory Concentration (MIC), Minimum Fungicide Concentration (MFC) and assays with ergosterol and sorbitol, to elucidate the possible mechanisms of action, and molecular docking. MIC and MFC values ranged from 4 to 512 µg/mL. Regarding the mechanism of action, the monoterpene demonstrated interaction with fungal ergosterol. In addition, it is possible to observe that CIT acts on crucial enzymes for the biosynthesis and maintenance of the fungal cell membrane, due to the ability of the monoterpene to bind to CYP51. The results obtained in this research demonstrate that CIT has the potential to become, in the future, a product for the treatment of dermatophytosis.

Development, Optimization, and In Vitro/In Vivo Evaluation of Azelaic Acid Transethosomal Gel for Antidermatophyte Activity

Treatment of dermatophytosis is quite challenging. This work aims to investigate the antidermatophyte action of Azelaic acid (AzA) and evaluate its efficacy upon entrapment into transethosomes (TEs) and incorporation into a gel to enhance its application. Optimization of formulation variables of TEs was carried out after preparation using the thin film hydration technique. The antidermatophyte activity of AzA-TEs was first evaluated in vitro. In addition, two guinea pig infection models with Trichophyton (T.) mentagrophytes and Microsporum (M.) canis were established for the in vivo assessment. The optimized formula showed a mean particle size of 219.8 ± 4.7 nm and a zeta potential of -36.5 ± 0.73 mV, while the entrapment efficiency value was 81.9 ± 1.4%. Moreover, the ex vivo permeation study showed enhanced skin penetration for the AzA-TEs (3056 µg/cm²) compared to the free AzA (590 µg/cm²) after 48 h. AzA-TEs induced a greater inhibition in vitro on the tested dermatophyte species than free AzA (MIC₉₀ was 0.01% vs. 0.32% for T. rubrum and 0.032% for T. mentagrophytes and M. canis vs. 0.56%). The mycological cure rate was improved in all treated groups, specially for our optimized AzA-TEs formula in the T. mentagrophytes model, in which it reached 83% in this treated group, while it was 66.76% in the itraconazole and free AzA treated groups. Significant (p < 0.05) lower scores of erythema, scales, and alopecia were observed in the treated groups in comparison with the untreated control and plain groups. In essence, the TEs could be a promising carrier for AzA delivery into deeper skin layers with enhanced antidermatophyte activity.

Dermatophytoses Severity Score - A novel point-of-care scoring tool to assess the severity of dermatophytosis

The rising prevalence of dermatophytosis in tropical countries coupled with drug resistance necessitates an objective scoring system to define the severity, monitor therapeutic response and predict prognoses. We attempted to establish and validate a new scoring system - Dermatophytoses Severity Score (DSS), for dermatophytoses affecting non-glabrous skin. A consensus group was convened to develop an objective and reproducible scoring system to describe the extent and severity of dermatophytosis of 200 consecutive patients with dermatophytosis. A second assessment entailed independent DSS scoring of the same patients by dermatologists and residents who were not part of the consensus group. The main outcome measured was index reliability, assessed in two steps, between the observers. A two-step assessment and DSS grading of 200 consecutive patients with clinically diagnosed dermatophytoses showed high reliability (Cronbach's α test and intraclass correlation coefficient). The DSS has demonstrated high reliability, and it could serve as a novel, reproducible and objective scoring tool for dermatophytosis.

Development of a Clioquinol Nanocarrier as a New, Promising Option for the Treatment of Dermatomycosis

Dermatomycosis is a common fungal infection, and its treatment is limited by few antifungal agents. Clioquinol (CQ) is an antiparasitic agent that has been studied for new uses, such as antifungal and antiviral applications. CQ was incorporated into a lipid-based nanocarrier as a new, promising option for dermatomycosis. This study aimed to develop a CQ-loaded lipid-based nanocarrier for cutaneous application and to evaluate its antifungal activity. CQ-loaded nanoformulation (LBN-CQ) was developed using the ultrasonication method, and the particle size, polydispersity index (PDI), pH, zeta potential, and drug content were monitored for 45 days. To evaluate antifungal activity, broth microdilution and a time-kill assay were performed. LBN-CQ presented a particle size of 91 ± 3 nm and PDI of 0.102 ± 0.009. The zeta potential and pH values were -9.7 ± 2.0 mV and 6.0 ± 0.1, respectively. The drug content was 96.4 ± 2.3%, and the encapsulation efficiency was 98.4%. LBN-CQ was able to reduce the minimum inhibitory concentration (MIC) in a 2-fold or 4-fold manner in most of the tested strains. Additionally, LBN-CQ presented stable fungistatic action that was not concentration- or time-dependent. In conclusion, the developed CQ-loaded nanocarrier is a promising treatment for skin fungal infections and a promising candidate for future randomized clinical trials.

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.

Molecular exploration of hidden pleiotropic activities of azoles on dermatophytes in human tinea corporis infection

Dermatophyte infections are widespread worldwide and are the most prevalent cause of fungal infection of the skin, hair, and nails. Tinea corporis is most commonly caused by dermatophytes belonging to three genera: Trichophyton , Microsporum , and Epidermophyton. The disease may be acquired through person-to-person transmission, typically by direct communication with an infected individual. Since dermatophytes causing tinea corporis infection are restricted to superficial keratinized tissue, topical treatments are most effective in patients with naïve tinea corporis unless the disease is widespread. Dermatophyte adherence to a keratinized structure is an essential step in dermatophytosis pathogenesis, whereby proteolytic enzyme activity is converted into a particular keratolytic activity that encourages the dermatophyte to use keratin as the sole source of carbon. Despite increasing dermatophytosis worldwide, particularly in the tropics, this research has often been neglected, appears to predominate globally, and presents practitioners with a therapeutic challenge. However, experts supported the use of allylamines in the pleiotropic molecular exploration of azoles, including reactive oxygen species (ROS) inducer, anti-inflammatory, antibacterial, and wide-spectrum antimycotic effects. Therefore, the current review aims to update and reform this essential subject and illustrate the recent advancement of the hidden pleiotropic activity of azoles at the molecular level on dermatophytes in human tinea corporis infection.

Luliconazole Nail Lacquer for the Treatment of Onychomycosis: Formulation, Characterization and In Vitro and Ex Vivo Evaluation

Onychomycosis is the most common fungal infection of the nail affecting the skin under the fingertips and the toes. Currently, available therapy for onychomycosis includes oral and topical therapies, either alone or in combination. Oral antifungal medication has been associated with poor drug bioavailability and potential gastrointestinal and systemic side effects. The objective of this study was to prepare and evaluate the luliconazole nail lacquer (LCZ-NL) for the effective treatment of onychomycosis. In the current work, LCZ-NL was formulated in combination with penetration enhancers to overcome poor penetration. A 3² full factorial formulation design of experiment (DOE) was applied for optimization of batches with consideration of dependent (drying time, viscosity, and rate of drug diffusion) and independent (solvent ratio and film former ratio) variables. The optimized formulation was selected based on drying time, viscosity, and rate of drug diffusion. The optimized formulation was further evaluated for % non-volatile content assay, smoothness of flow, water resistance, drug content, scanning electron microscope (SEM), atomic force microscope (AFM), X-ray diffraction (XRD), differential scanning calorimetry (DSC), in vitro drug release, ex vivo transungual permeation, antifungal efficacy, and stability study. The optimized LCZ-NL contained 70:30 solvent ratio and 1:1 film former ratio and was found to have ~ 1.79-fold higher rate of drug diffusion in comparison with LULY™. DSC and XRD studies confirmed that luliconazole retains its crystalline property in the prepared formulation. Antifungal study against Trichophyton spp. showed that LCZ-NL has comparatively higher growth inhibition than LULY™. Hence, developed LCZ-NL can be a promising topical drug delivery system for treating onychomycosis.

Species Distribution and Antifungal Susceptibility Profile of Dermatophytes from a Tertiary Care Centre in North India

Objective Dermatophytoses, one of the most ancient diseases, is becoming a menace in recent times. This has made the knowledge of antifungal susceptibility a priority in today's times.

Material and Methods This is a prospective study conducted over 18 months including all dermatophytes isolated during the period. Dermatophytes were identified by routine phenotypic methods. Antifungal susceptibility testing was performed for griseofulvin, terbinafine, and itraconazole as per the Clinical Laboratory Standard Institute M38 A2, and minimum inhibitory concentrations (MICs) were read after 5 days.

Results Patient details and associated risk factors were recorded. Fixed dose combinations with steroids were associated with 79.3% (46 out of 58) of patients with dermatophytosis of skin. Among the 72 dermatophytes isolated during the study period, 58 (80.5%) were isolated from skin scrapings and 14 (19.4%) from nail samples. Tinea corporis with cruris was the most common presentation. The most common dermatophyte isolated from skin scrapings was Trichophyton mentagrophytes complex (70.6%, 41 out of 58), while from nail samples it was Trichophyton rubrum complex (78.57%, 11 out of 14). Based on the MIC50 and MIC90 results, itraconazole showed the lowest MICs, followed by terbinafine and then griseofulvin.

Conclusion With the changing epidemiology of species distribution and antifungal resistance, there is a need for continuous surveillance of these parameters of dermatophytes.

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

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

Perception among the sufferers of recalcitrant dermatophytosis regarding its causation, prevention, care-seeking behaviour and their personal hygiene: A qualitative research

Background:

Recalcitrant dermatophytosis has become a menace in recent times. The perception of the hosts or patients regarding the disease gives a real-life picture of the deep-rooted host-factors and the way to overcome the socio-economic and cultural milieu that becomes a hindrance in preventing the relapse and recurrence of this infection.

Aims:

This qualitative study was conducted to assess the perception regarding the patients’ understanding of causation and prevention of dermatophytosis, role of personal hygiene, and healthcare seeking behavior, and consequently, exploring the socio-economic and cultural milieu that contributes to the menace of recalcitrant dermatophytosis.

Materials and Methods:

Two focus group discussions (FGDs) consisting 12 patients with recalcitrant dermatophytosis, who speak the vernacular, were conducted with the help of a predetermined FGD-guide. Both FGD sessions were recorded, transcribed, and translated into English. These verbatims were thematically analyzed and emerging themes were identified with illustrative quotations. Free listing and pile sorted data obtained were analyzed by Visual Anthropac version 1.0 software for Smith's salience value, cognitive mapping with two-dimensional scaling and hierarchical cluster analysis.

Results:

Washing of clothes with soap antiseptics and drying the clothes under the sun prevents diseases, whereas, not changing undergarments for prolonged periods of time, bathing in ponds using mustard oil spreads the disease, furthermore, staying in wet clothes, working for more than five hours under sun, playing outdoors, household jobs cause tinea, etc. were the most common reported perceptions. Overall, five themes emerged after pile sorting the data, namely, ignorance about the disease, understanding of the predisposing factors of the disease, prevention, role of personal and traditional belief, and care-seeking behavior.

Conclusions:

There is a dire need to address the myths or traditional beliefs, which are not supported by scientific evidence. Expense of the treatment of dermatophytosis calls for price control of the commonly prescribed antifungals. Poor socio-economic conditions and professional responsibilities hinder people from implementing the preventive measures in spite of their knowledge.

The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

In Vitro Antifungal Activity of Green Synthesized Silver Nanoparticles in Comparison to Conventional Antifungal Drugs Against Trichophyton Interdigitale, Trichophyton Rubrum and Epidermophyton Floccosum

BACKGROUND

Dermatophytosis is a globally distributed fungal infection. Treatment failure and relapse is common in this disease. Silver nanoparticles are known for their promising antimicrobial activity. The aim of this study was to determine the antifungal activity of these nanoparticles against common dermatophyte species.

METHODS

A set of 30 molecularly identified dermatophytes including Trichophyton interdigitale (n=10), Trichophyton rubrum (n=10), and Epidermophyton floccosum (n=10) were used in this study. Green synthesized silver nanoparticles using chicory (Cichorium intybus) were tested for their antifungal activity in comparison to fluconazole, itraconazole and terbinafine. Interspecies differences in minimum inhibitory concentrations of antifungal drugs and silver nanoparticles were tested using Kruskal-Wallis test in SPSS software version 21.

RESULTS

The highest minimum inhibitory concentrations (MICs) among antifungal drugs were observed for fluconazole [range: 4-64 μg/mL, geometric mean (GM) =17.959 μg/mL], followed by itraconazole (range: 0.008-0.5, GM= 0.066) and terbinafine (range: 0.004-0.25 μg/mL, GM=0.027 μg/mL). Silver nanoparticles showed potent antifungal activity against all dermatophyte isolates with MICs (range: 0.25-32 μg/mL, GM=4.812 μg/mL) higher than those of itraconazole and terbinafine, but lower than fluconazole. MIC values of silver nanoparticles demonstrated significant differences between species (P=0.044), with E. floccosum having the highest MICs (GM=9.849 μg/mL) compared to T. interdigitale (GM=3.732 μg/mL) and T. rubrum (GM=3.031 μg/mL).

CONCLUSION

Silver nanoparticles demonstrated promising anti-dermatophyte activity against the studied dermatophytes. Due to their wide-spectrum activity against other fungal and bacterial pathogens, they could be a potential choice, at least in the case of cutaneous and superficial infections.

A Review on Antifungal Efficiency of Plant Extracts Entrenched Polysaccharide-Based Nanohydrogels

Human skin acts as a physical barrier; however, sometimes the skin gets infected by fungi, which becomes more severe if the infection occurs on the third layer of the skin. Azole derivative-based antifungal creams, liquids, or sprays are available to treat fungal infections; however, these formulations show various side effects on the application site. Over the past few years, herbal extracts and various essential oils have shown effective antifungal activity. Additionally, autoxidation and epimerization are significant problems with the direct use of herbal extracts. Hence, to overcome these obstacles, polysaccharide-based nanohydrogels embedded with natural plant extracts and oils have become the primary choice of pharmaceutical scientists. These gels protect plant-based bioactive compounds and are effective delivery agents because they release multiple bioactive compounds in the targeted area. Nanohydrogels can be applied to infected areas, and due to their contagious nature and penetration power, they get directly absorbed through the skin, quickly reaching the skin's third layer and effectively reducing the fungal infection. In this review, we explain various skin fungal infections, possible treatments, and the effective utilization of plant extract and oil-embedded polysaccharide-based nanohydrogels.

Molecular Epidemiology and Antifungal Susceptibility of Trichophyton Isolates in Greece: Emergence of Terbinafine-Resistant Trichophytonmentagrophytes Type VIII Locally and Globally

Trichophyton isolates with reduced susceptibility to antifungals are now increasingly reported worldwide. We therefore studied the molecular epidemiology and the in vitro antifungal susceptibility patterns of Greek Trichophyton isolates over the last 10 years with the newly released EUCAST reference method for dermatophytes. Literature was reviewed to assess the global burden of antifungal resistance in Trichophyton spp. The in vitro susceptibility of 112 Trichophyton spp. molecularly identified clinical isolates (70 T. rubrum, 24 T. mentagrophytes, 12 T. interdigitale and 6 T. tonsurans) was tested against terbinafine, itraconazole, voriconazole and amorolfine (EUCAST E.DEF 11.0). Isolates were genotyped based on the internal transcribed spacer (ITS) sequences and the target gene squalene epoxidase (SQLE) was sequenced for isolates with reduced susceptibility to terbinafine. All T. rubrum, T. interdigitale and T. tonsurans isolates were classified as wild-type (WT) to all antifungals, whereas 9/24 (37.5%) T. mentagrophytes strains displayed elevated terbinafine MICs (0.25–8 mg/L) but not to azoles and amorolfine. All T. interdigitale isolates belonged to ITS Type II, while T. mentagrophytes isolates belonged to ITS Type III* (n = 11), VIII (n = 9) and VII (n = 4). All non-WT T. mentagrophytes isolates belonged to Indian Genotype VIII and harbored Leu393Ser (n = 5) and Phe397Leu (n = 4) SQLE mutations. Terbinafine resistance rates ranged globally from 0–44% for T. rubrum and 0–76% for T. interdigitale/T. mentagrophytes with strong endemicity. High incidence (37.5%) of terbinafine non-WT T. mentagrophytes isolates (all belonging to ITS Type VIII) without cross-resistance to other antifungals was found for the first time in Greece. This finding must alarm for susceptibility testing of dermatophytes at a local scale particularly in non-responding dermatophytoses.

Safety and efficacy of allylamines in the treatment of cutaneous and mucocutaneous leishmaniasis: A systematic review

Cutaneous and mucocutaneous leishmaniasis affect a million people yearly, leading to skin lesions and potentially disfiguring mucosal disease. Current treatments can have severe side effects. Allylamine drugs, like terbinafine, are safe, including during pregnancy. This review assesses efficacy and safety of allylamines for the treatment of cutaneous and mucocutaneous leishmaniasis. It followed the PRISMA statement for reporting and was preregistered in PROSPERO(CRD4201809068). MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Global Health Library, Web of Science, Google Scholar, and clinical trial registers were searched from their creation to May 24^th, 2020. All original human, animal, and in vitro studies concerning allylamines and cutaneous or mucocutaneous leishmaniasis were eligible for inclusion. Comparators—if any—included both placebo or alternative cutaneous or mucocutaneous leishmaniasis treatments. Complete cure, growth inhibition, or adverse events served as outcomes. The search identified 312 publications, of which 22 were included in this systematic review. There were one uncontrolled and two randomised controlled trials. The only well-designed randomised controlled trial that compared the treatment efficacy of oral terbinafine versus intramuscular meglumine antimoniate in 80 Leismania tropica infected patients showed a non-significant lower cure rate for terbinafine vs meglumine antimoniate (38% vs 53%). A meta-analysis could not be performed due to the small number of studies, their heterogeneity, and low quality. This systematic review shows that there is no evidence of efficacy of allylamine monotherapy against cutaneous and mucocutaneous leishmaniasis. Further trials of allylamines should be carefully considered as the outcomes of an adequately designed trial were disappointing and in vitro studies indicate minimal effective concentrations that are not achieved in the skin during standard doses. However, the in vitro synergistic effects of allylamines combined with triazole drugs warrant further exploration.

Solubility enhancement, formulation development and antifungal activity of luliconazole niosomal gel-based system

Luliconazole is a potential prescription candidate drug for the treatment of topical fungal infections. However, it has water solubility and skin permeability limitations. To overcome these limitations, a niosomal gel of luliconazole was formulated using Span 60, cholesterol, and chloroform to improve its bioavailability and to reduce its toxicity. Niosomes were analyzed by transmission electron microscopy (TEM) and Fourier transform infrared spectroscopy (FTIR) for morphological and spectral studies respectively. The formulations had ideal nanometric vesicle sizes, encapsulation efficiency (88.891% ± 0.0364%), Zeta potential (-40.1 mV), and storage instability was not observed. The sustained-release profile of niosomal gel was observed for up to 24 h. The highest R² value was 0.913; the Higuchi model was considered the best fit model for the niosomal formulations. Cytotoxicity studies confirmed the biocompatibility of the niosomal gel of luliconazole. Based on the results, it can be concluded that niosomal luliconazole may enhance the activity of luliconazole against Candida albicans (C. albicans).

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.

Dermoscopic Characterization of Dermatophytosis: A Preliminary Observation

Introduction:

Dermatophytosis has become resistant and relapsing infection in India. Diagnosis of dermatophytosis is easy, however, poses diagnostic challenge in partial treatment, steroid abuse. Dermoscopy is noninvasive tool for diagnosis of many infestations and infections. Dermoscopy in dermatophytosis is not well documented. We evaluated dermatoscopic patterns to correlate with histopathological changes.

Materials and Methods:

Study was conducted in tertiary hospital after obtaining ethical clearance and informed consent. DermLite 3 dermoscope was used to examine the lesions. Polarized and nonpolarized modes were used and ultrasound gel was utilized. Potassium hydroxide mount and skin biopsy was done to confirm the diagnosis.

Results:

About 30 patients with 16 males and 14 females were present. Median duration was 3.5 months and median age was 30 years. The most common site was waist and crural area affecting 20 (66.66%). Dermoscopy revealed brown to black dots, globules, and white scales in all patients (100.0%). Lesions of shorter duration (26.66%) demonstrated red dots, dotted vessels, reddish-brown dots, and globules, and brown to black dots and globules were noted in lesions of longer duration (73.33%). Hair changes were noted in five (16.66%) patients.

Conclusion:

Dermoscopy showed particular patterns in dermatophytosis. Patterns were consistent irrespective of age, sex, and site of involvement. Presence of reddish-brown and black globules with white scales was found to be the most characteristic dermoscopic feature.

Major challenges and perspectives in the diagnostics and treatment of dermatophyte infections

Dermatophytes are the aetiological factors of a majority of superficial fungal infections. What distinguishes them from other pathogenic filamentous fungi is their unique ability to degrade keratin. The remarkable ability of this group of fungi to survive in different ecosystems results from their morphological and ecological diversity as well as high adaptability to changing environmental conditions. Paradoxically, despite the progress in medicine, the prevalence of dermatophyte infections is increasing from year to year. At the beginning of the third millennium, practical diagnostic and therapeutic options are still very limited. This review focuses on understanding the major problems in this aspect of dermatophyte infections and indicates future strategies and perspectives for novel approaches to identification and drugs for elimination of dermatophytes. Particular importance is placed on development of a strategy for a diagnostic pathway and implementation of rapid and reliable diagnostics methods designed by international teams. Furthermore, among compounds that currently arouse great interest, representatives of terpenoids, alkaloids, saponins, flavonoids and essential oils deserve attention. Many of these compounds are undergoing clinical trials as potential antifungal agents, and future research should focus on attempts at determination of the applicability of tested substances. Finally, the advantages and disadvantages in implementation of new diagnostic paths and medicinal substances for routine use are indicated.

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

Background

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

Methods

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

Result

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

Conclusion

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

Onychomycosis: Treatment and prevention of recurrence

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.