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Litaiem N, Mnif E, Zeglaoui F. Dermoscopy of Onychomycosis: A Systematic Review. Dermatol Pract Concept 2023; 13:dpc.1301a72. [PMID: 36892372 PMCID: PMC9946122 DOI: 10.5826/dpc.1301a72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Onychomycosis represents a global burden accounting for about 50% of nail consultations. Several studies have tried to assess the dermoscopic features of onychomycosis. With the multiplication of papers, several "new" dermoscopic signs keep being added leading to some inconsistency in onychoscopic terminology. OBJECTIVE This study aimed to summarize the existing literature on the dermoscopic features of onychomycosis and propose a unified onychoscopic terminology. METHODS The literature search was performed using PubMed and Scopus databases up to October 30, 2021 to identify eligible contributions. In total, 33 records (2111 patients) were included. RESULTS The main dermoscopic signs of onychomycosis are "ruin appearance", "longitudinal striae" and "spikes" on the proximal margin of onycholytic areas, with a specificity of 99.38%, 83.78%, and 85.64% respectively. The "aurora borealis" sign had the highest sensitivity and specificity. CONCLUSIONS The current review provides a framework for issues related to the onychoscopic terminology of onychomycosis and is intended to serve as an aid for students, teachers, and researchers. We proposed a unifying terminology to describe dermoscopic signs of onychomycosis. Dermoscopic signs of onychomycosis show good specificity and are useful in distinguishing nail psoriasis, trauma, and onychomycosis. It helps differentiate fungal melanonychia from nail melanoma, nevi, and melanocytic activation.
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Affiliation(s)
- Noureddine Litaiem
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia.,University of Tunis El Manar, Faculté de Médecine de Tunis, Tunisia
| | - Emna Mnif
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Faten Zeglaoui
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia.,University of Tunis El Manar, Faculté de Médecine de Tunis, Tunisia
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Lim SS, Hui L, Ohn J, Cho Y, Oh CC, Mun JH. Diagnostic accuracy of dermoscopy for onychomycosis: A systematic review. Front Med (Lausanne) 2022; 9:1048913. [PMID: 36388930 PMCID: PMC9659606 DOI: 10.3389/fmed.2022.1048913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Dermoscopy is a non-invasive adjuvant diagnostic tool that allows clinicians to visualize microscopic features of cutaneous disorders. Recent studies have demonstrated that dermoscopy can be used to diagnose onychomycosis. We performed this systematic review to identify the characteristic dermoscopic features of onychomycosis and understand their diagnostic utility. Methods We searched the Medline, Embase, Scopus, and Cochrane databases from conception until May 2021. Studies on the dermoscopic features of onychomycosis were screened. The exclusion criteria were as follows: fewer than 5 cases of onychomycosis, review articles, and studies including onychomycosis cases that were not mycologically verified. Studies on fungal melanonychia were analyzed separately. We adhered to the MOOSE guidelines. Independent data extraction was performed. Data were pooled using a random effects model to account for study heterogeneity. The primary outcome was the diagnostic accuracy of the dermoscopic features of onychomycosis. This was determined by pooling the sensitivity and specificity values of the dermoscopic features identified during the systematic review using the DerSimonian-Laird method. Meta-DiSc version 1.4 and Review Manager 5.4.1 were used to calculate these values. Results We analyzed 19 articles on 1693 cases of onychomycosis and 5 articles on 148 cases of fungal melanonychia. Commonly reported dermoscopic features of onychomycosis were spikes or spiked pattern (509, 30.1%), jagged or spiked edges or jagged edge with spikes (188, 11.1%), jagged proximal edge (175, 10.3%), subungual hyperkeratosis (131, 7.7%), ruins appearance, aspect or pattern (573, 33.8%), and longitudinal striae (929, 54.9%). Commonly reported features of fungal melanonychia included multicolor (101, 68.2%), non-longitudinal homogenous pigmentation (75, 50.7%) and longitudinal white or yellow streaks (52, 31.5%). Conclusion This study highlights the commonly identified dermoscopic features of onychomycosis. Recognizing such characteristic dermoscopic features of onychomycosis can assist clinicians diagnose onychomycosis by the bedside.
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Affiliation(s)
| | - Laura Hui
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Jungyoon Ohn
- Department of Dermatology, Seoul National University College of Medicine, Seoul, South Korea
- Institute of Human-Environment Interface Biology, Seoul National University, Seoul, South Korea
| | - Youngjoo Cho
- Department of Applied Statistics, Konkuk University, Seoul, South Korea
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Je-Ho Mun
- Department of Dermatology, Seoul National University College of Medicine, Seoul, South Korea
- Institute of Human-Environment Interface Biology, Seoul National University, Seoul, South Korea
- *Correspondence: Je-Ho Mun
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Falotico JM, Lipner SR. Poor Antifungal Coverage for Onychomycosis in a Cross-Sectional Analysis of Medicaid Formularies. J Am Podiatr Med Assoc 2022; 112:21-221. [PMID: 36251605 DOI: 10.7547/21-221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Onychomycosis is the most common nail disease seen in clinical practice. Medication safety, severity of disease, comorbidities, concomitant medications, patient age, and cost are all important considerations when treating onychomycosis. Because cost may affect treatment decisions, we sought to analyze Medicaid formulary coverage of onychomycosis antifungals. METHODS Public state Medicaid formularies were searched for coverage of US Food and Drug Administration-approved onychomycosis medications and off-label oral fluconazole. Total drug cost for a single great toenail was calculated using the National Average Drug Acquisition Cost. Pearson correlation coefficients were calculated to compare coverage and cost, mycologic cure rate, and complete cure rate. RESULTS Oral terbinafine and off-label fluconazole were widely covered for onychomycosis treatment. There was poor coverage of oral itraconazole and topical ciclopirox, and there was no coverage of topical efinaconazole and tavaborole without step-edits or prior authorization. There was a significant negative correlation between medication coverage and cost (r = -0.758; P = .040). There was no correlation between medication coverage and mycologic (r = 0.548; P = .339) and complete (r = 0.768; P = .130) cure rates. CONCLUSIONS There is poor Medicaid coverage of antifungals for the treatment of onychomycosis, with step-edits and prior authorization based on cost rather than treatment safety and efficacy. We recommend involving podiatrists and dermatologists in developing criteria for insurance approval of onychomycosis treatments.
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Affiliation(s)
| | - Shari R Lipner
- †Department of Dermatology, Weill Cornell Medicine, New York, NY
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Gupta AK, Wang T, Cooper EA. Dermatophytomas: Clinical Overview and Treatment. J Fungi (Basel) 2022; 8:jof8070742. [PMID: 35887497 PMCID: PMC9323405 DOI: 10.3390/jof8070742] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023] Open
Abstract
Dermatophytomas are characterized as a hyperkeratotic fungal mass in the subungual space, showing as dense white or yellow, typically in longitudinal streaks or patches. Masses can be visualized by traditional microscopy or histology. Newer technologies such as dermoscopy and optical coherence tomography also provide visual features for dermatophytoma diagnosis. The density of fungal mass, and lack of adherence to the nail structures, as well as possible biofilm development, may play a role in the reduction in drug penetration and subsequent lack of efficacy with traditional oral therapies such as terbinafine and itraconazole. A combination of drug treatment with mechanical or chemical debridement/avulsion has been recommended to increase efficacy. The topical antifungal solutions such as tavaborole, efinaconazole, and luliconazole may reach the dermatophytoma by both the transungual and subungual routes, due to low affinity for keratin and low surface tension. Current data indicates these topicals may provide efficacy for dermatophytoma treatment without debridement/avulsion. Similarly, fosravuconazole (F-RVCZ) has an improved pharmacological profile versus ravuconazole and may be an improved treatment option versus traditional oral therapies. The availability of improved treatments for dermatophytomas is crucial, as resistance to traditional therapies is on the increase.
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Affiliation(s)
- Aditya K. Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
- Mediprobe Research Inc., 645 Windermere Road, London, ON N5X 2P1, Canada; (T.W.); (E.A.C.)
- Correspondence: ; Tel.: +1-519-851-9715; Fax: +1-519-657-4233
| | - Tong Wang
- Mediprobe Research Inc., 645 Windermere Road, London, ON N5X 2P1, Canada; (T.W.); (E.A.C.)
| | - Elizabeth A. Cooper
- Mediprobe Research Inc., 645 Windermere Road, London, ON N5X 2P1, Canada; (T.W.); (E.A.C.)
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Tinea Gladiatorum: Epidemiology, Clinical Aspects, and Management. J Clin Med 2022; 11:jcm11144066. [PMID: 35887830 PMCID: PMC9315553 DOI: 10.3390/jcm11144066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tinea gladiatorum (TG) is a fungal skin infection that occurs among wrestlers and other contact sport athletes with a varied prevalence rate. The most common causative factor responsible as well for local outbreaks of the infection is an anthropophilic dermatophyte species—Trichophyton tonsurans (T. tonsurans). The purpose of this study was to gather current data about TG, including epidemiology, possible diagnosing methods, clinical features, treatment approaches, and potential prevention techniques. We also performed a systematic review of studies describing TG incidence. The prevalence of the disease varied from 2.4% up to 100%. That wide range of variability forces medical practitioners to update knowledge about TG and points to the fact that it still may be a diagnostic and therapeutic challenge. Spreading awareness among athletes and trainers is one of the most important preventive steps.
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Vlahovic TC, Garcia M, Wotring K. Dermoscopy of Onychomycosis for the Podiatrist. Clin Podiatr Med Surg 2021; 38:505-511. [PMID: 34538427 DOI: 10.1016/j.cpm.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Onychomycosis is one of the most frequent nail pathologies in podiatry practices. Differential diagnoses with the clinical presentation may delay an accurate diagnosis and timely treatment. This article discusses the technique and benefits of using a dermatoscope to improve patient care of this common disorder.
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Affiliation(s)
- Tracey C Vlahovic
- Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
| | - Michelle Garcia
- Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA
| | - Kevin Wotring
- Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA
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Leung AKC, Lam JM, Leong KF, Hon KL, Barankin B, Leung AAM, Wong AHC. Onychomycosis: An Updated Review. ACTA ACUST UNITED AC 2020; 14:32-45. [PMID: 31738146 PMCID: PMC7509699 DOI: 10.2174/1872213x13666191026090713] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Shatin, Hong Kong
| | | | - Amy A M Leung
- Department of Family Medicine, The University of Alberta, Edmonton, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
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