Triamcinolone Acetonide Injections in Nail Psoriasis: A Pragmatic Analysis

Introduction

Treatment of nail psoriasis is challenging. Systemic therapies may be difficult to justify, while topical therapies may be sup-optimal. Triamcinolone acetonide (TA) injections are recommended as first-line therapy in cases with less than 3 nails involved; however, limited studies are available. This study was conducted to evaluate the reduction in NAPSI (Nail Psoriasis Severity Index) with TA injections in patients with isolated nail psoriasis.

Methods

A retrospective case record analysis of efficacy and safety of TA (5 mg/mL) nail injections (4-weekly for fingernails, 8-weekly for toenails) was done in 10 patients. NAPSI was evaluated at each visit and treatment endpoint (75% reduction or 10 injections, whichever was earlier). Dropouts and adverse effects were recorded.

Results

Among 10 patients (94 involved nails, 61 fingernails, and 33 toenails), 3 patients (30%) dropped out (2, 4, and 5 sessions, respectively), citing procedural pain. Three patients achieved NAPSI-75 (3, 6, and 7 sessions, respectively). Baseline mean NAPSI of 5.03 (4.63 fingernails and 5.78 toenails) dropped to 3.67 (3.13 fingernails and 4.42 toenails) by the 5th injection; and 2.35 (2.13 fingernails and 2.59 toenails) by the 10th injection. Adverse effects included pain (30%), subungual haematoma (1.7%), and proximal nail fold hypopigmentation with mild atrophy (1.1%).

Conclusions

TA (5 mg/mL) injections are effective in nail psoriasis and associated with minimal adverse effects.

Addressing the alternate hypothesis: Transfer and persistence of saliva beneath fingernails

This study investigated the transfer and persistence of salivary DNA under fingernails. This was performed to address a common alternate hypothesis presented to scientists in court, asserting that a relatively large quantity of DNA detected beneath the fingernails, typically from a victim of crime, originates from innocuous transfer of saliva in a casual setting. It was determined through these studies that contact with liquid saliva was an effective way to transfer foreign DNA beneath fingernails. However, when saliva was dried, DNA did not readily transfer through casual contact. When liquid saliva was placed directly beneath fingernails the amount of DNA detected from the saliva donor twenty-four hours later was several hundred-fold lower than the amount detected when sampling occurred immediately following deposition. Furthermore, when the recipients' hands were washed immediately following the deposition of liquid saliva beneath fingernails, the majority of foreign DNA was removed following one hand washing and all detectable foreign DNA was removed from most recipients' hands after three or six hand washings. This study demonstrates that casual contact with wet saliva can result in the transfer of substantial quantities of DNA beneath fingernails but that it does not typically persist for extended periods of time and is mostly removed if the hands are washed soon after deposition.

Identification of biomarkers in diabetic nails by Raman spectroscopy

BACKGROUND

The growth of Diabetes Mellitus (DM) is a serious public health issue which is more prevalent in developing countries. The main problems related to DM are the gradual changes in the structural and functional integrity of tissues caused by hyperglycemia, which calls for early diagnosis and periodic monitoring exams. Recent studies suggest that the quality of the nail plate has great potential to assess the secondary complications of DM. Hence, this study aimed to determine the biochemical characteristics of the nails of individuals with DM2 by Raman confocal spectroscopy (CRS).

METHODS

We collected fragments from the distal region of the fingernails of 30 healthy volunteers and 30 volunteers with DM2. The samples were analyzed by CRS (Xplora - Horiba) coupled to a 785 nm laser.

RESULTS

Alterations in different biochemical components, such as proteins, lipids, amino acids, and final agents of advanced glycation, and alterations in the disulfide bridges, which are important in stabilizing keratin in nails were identified.

CONCLUSION

The spectral signatures and new DM2 markers in nails were identified. Therefore, the possibility of acquiring biochemical information by evaluating the nails of diabetics, a simple and easily acquired material associated with the CRS technique, may allow health complications to be detected quickly.

Environmental effects on trace elements in the fingernails of centenarians and their offspring

Bio-monitoring is commonly used to investigate trace elements, and the human nail provides an ideal medium for such testing. Toxic and essential trace metals (Cd, Pb, Fe, and Se) in the fingernails of participants from the Hainan Province were investigated. Samples included 136 centenarians and 197 offspring (101 older adult children and 96 middle-aged grandchildren) who were also sampled for comparison. As a hotspot for longevity, participants in the Hainan Province were found to have high essential nutrients of Fe and Se, and lacked the toxic element Pb. A similar trend was found for trace elements in soil and rice in the Hainan Province. The trace elements preserved in nails revealed dietary and environmental influences that varied among different generations. For the grandchildren's generation, the environment played an important role in elements in their nails, and a significant correlation and linear relationships were found, especially for Fe and Se. As the participants increased in age (from the grandchildren to the centenarians), the correlation between various elements decreased. For centenarians, the influence of beneficial or harmful properties of the elements became more important than their environment. The results also pointed to the important role of trace elements in human health, especially Fe and Se as essential elements. This study can provide information on the factors that influence the existence of trace elements in the human body and demonstrate the advantage of using the human fingernail in bio-monitoring.

Understanding the excretion rates of methylmercury and inorganic mercury from human body via hair and fingernails

Effective biomarkers are necessary to better understand the human mercury (Hg) exposure levels. However, mismatched biomarker sampling method causes extra uncertainty in assessing the risk of Hg exposure. To compare the differences between hair and fingernail, and further understand the excretion rates of methylmercury (MeHg) and inorganic mercury (IHg) via hair and fingernails, the total mercury (THg), MeHg, and IHg concentrations in paired hair and fingernail samples were investigated through paired samples collected from two typical mining areas, Wanshan mercury mine area (WMMA) and Hezhang zinc smelting area (HZSA). The positive correlation in THg, MeHg, and IHg concentrations (p <0.01) between hair and fingernail samples indicated that those two biomarkers can be corrected in application of assessing human Hg exposure. Compared to fingernails, the hair was suggested to be a more sensitive biomarker as the concentration of THg, MeHg and IHg were 2 ∼ 4 times higher than those in fingernails. Furthermore, the amounts of THg, MeHg, and IHg excreted via hair were 70 ∼ 226 times higher than that excreted via fingernails, and the hair plays a more important role than fingernails in the excretion of Hg from human bodies. Present study therefore provides some new insights to better understand the fate of human assimilated Hg.

Identifying dust as the dominant source of exposure to heavy metals for residents around battery factories in the Battery Industrial Capital of China

Heavy metals (HMs) are constantly released into the environment during the production and use of batteries. Battery manufacturing has been ongoing for over six decades in the "Battery Industrial Capital" (located in Xinxiang City) of China, but the potential exposure pathways of residents in this region to HMs remain unclear. To clarify the exposure pathways and health risk of human exposure to HMs, hand wipe samples (n=82) and fingernail samples (n=36) were collected from residents (including young children (0-6 years old), children (7-12 years old) and adults (30-60 years old)) living around battery factories. The total concentrations of the target HMs (Zn, Mn, Cu, Pb, Ni, Cr, Cd, Co) in hand wipes ranged from 133 to 8040 μg/m², and those in fingernails ranged from 9.7-566 μg/g. HM levels in the hand wipe and fingernail samples both decreased with age, and higher HM levels were observed for males than females. The HM composition profiles in these two matrices represented a high degree of similarity, with Zn as the predominant element, and thus, oral ingestion and dermal exposure via dust were expected to be the most important HM exposure pathways for residents in this region. The non-carcinogenic risks (HQs) from dermal and oral ingestion exposure to Cd, Cr, and Pb were higher than those of the other five elements for all three populations, and the HQ_derm of Cd for young children was 2.1 (HQ_oral=0.6). Moreover, the hazard index (HI) values of ∑₈HMs for young children (HI_total=5.2, HI_oral=2.0, HI_dermal=3.2) and children (HI_total=1.6, HI_oral=1.3, HI_dermal=0.3) exceeded the safe threshold (1.0). Therefore, young children and children should be prioritized for protection from HM pollution, and more attention should be paid to young children's dermal exposure to Cd in this region.

Foreign DNA in cosmetic gel nails

In this case study it was investigated whether foreign DNA may get encapsulated in a cosmetic gel nail. It was inspired by a murder case in which the main suspect claims that he was wrongly convicted. Most of the evidence in the case was circumstantial. The most direct piece of evidence was DNA of the suspect found beneath the victim's fingernails. According to the prosecution and the judges, the DNA meant that the suspect had murdered the victim. However, according to the suspect, the fact that his DNA was found could be explained by a physical altercation between him and the victim 17 days prior to the murder. In that alternative scenario, the suspect's DNA became encapsulated in the victim's gel nails and remained there up until her death 17 days later. In this article, we describe an experiment designed to assess the plausibility of the alternative scenario. In the experiment we tested whether foreign DNA could be recovered in gel nails of four female individuals two weeks after transfer. In six out of eight hands the profile of the donor could be detected. Hence, in situations resembling the circumstances of this case study, the encapsulation of DNA in a gel nail prior to the attack of interest must be considered.

Are fingernail lead levels a reliable biomarker of lead internal dose?

BACKGROUND

Potentially toxic elements, such as lead, can bioaccumulate and alter human physiology. Human biomonitoring is an essential tool to evaluate chemical exposures in different biological matrices (blood, urine, saliva, nails, and hair). Of these biological matrices, nails are favorable for their ease of sampling, transport and storage. The aim of this study was to investigate possible correlations between blood lead levels (BLL) and washed and non-washed fingernail lead levels (FLL) in 55 adults living in a lead-contaminated area.

METHOD

Venous blood and fingernail (thumbs and forefingers) samples were collected. Nails from the left hand were washed with Triton X-100 (0.5 % m/v) and HNO₃ solution, while nails from the right hand were not submitted to the pre-analytical procedures. Samples were analyzed by graphite furnace atomic absorption spectrometry, and pairwise correlations were used to correlate lead concentrations between BLL and FLL; nails from fingers of the same hand and between washed and unwashed fingernails. Principal component analysis was performed and scatter diagrams were plotted to investigate correlations.

RESULTS

A non-significant positive correlation was found between BLL and washed forefinger nails lead (r = 0.219, p = 0.112) and between BLL and thumbnail lead levels (r = 0.182, p = 0.191). Comparison of fingernails from the same hand (thumb and forefinger), showed that lead concentrations of non-washed nails varied widely, even on analyses of transversal fragments from the same nail. Lead levels in non-washed forefinger nails were not correlated with non-washed thumbnails (r = 0.169, p = 0.219). Conversely, washed thumb and forefinger nails were found to be correlated (r = 0.39, p = 0.003). Washed and non-washed nails were also found to be correlated (p < 0.0001).

CONCLUSION

In conclusion, the results showed that non-washed nails are not a reliable biomarker for lead exposure. Although washing nails before analysis may reduce external contamination, the correlation of lead concentrations between fingers is poor for fingernail lead levels to serve as an internal dose biomarker to lead exposure. In addition, levels in washed nails were not significantly correlated with blood lead levels. Fingernail lead levels seem to serve as an indicator of lead exposure sources in contact with the individual, but not as a reliable biomarker of internal dose.

A comparative study for the isolation of exogenous trace DNA from fingernails

Often fingernails from a victim or suspect involved in a physical assault, such as murder or sexual assault, are submitted to crime laboratories for DNA testing of foreign/exogenous biological material; however, very few studies have been conducted comparing the effectiveness of different sampling methods on the removal of foreign/exogenous DNA while minimizing the fingernail endogenous DNA. In this study three different sampling methods (swabbing, PBS soak, and PrepFiler® lysis buffer soak) were compared in order to identify one that minimizes the amount of endogenous DNA removed and maximizes the amount of foreign/exogenous male DNA removed. The samples were processed using the Tecan HIDEVO150 robot in order to reduce analyst time and the DNA mixtures were interpreted using the probabilistic genotyping software STRmix™. For each sampling method the quantity of male DNA, the mixture proportions, the number of foreign/exogenous male alleles detected, the amount of DNA degradation, and the discrimination power via the likelihood ratio obtained for the foreign/exogenous male DNA donor were determined and compared. The PrepFiler® lysis buffer soak and swabbing sampling methods appear to be equally effective at removing foreign/exogenous DNA from fingernails; however, the lysis buffer soak sampling method extracts more female endogenous DNA from the fingernail and the female DNA is degraded. Marginally higher likelihood ratios were obtained for the swab samples versus the PrepFiler® lysis buffer soak samples; therefore, it was determined that the swabbing sampling method was the best sampling method for the recovery of foreign exogenous DNA from fingernails while minimizing the amount of endogenous DNA removed.

Cortisol levels in fingernails, neurocognitive performance and clinical variables in euthymic bipolar I disorder

OBJECTIVES

Neurocognitive impairment has been found in bipolar patients. Hypercortisolemia is one possible cause but there has been no agreement on this. Previous sampling methods assessed only acute cortisol levels, whereas the association between cortisol and psychopathology might be better understood by investigating chronic levels. Fingernails are a novel method for measuring chronic cortisol concentration (CCC). Here, we measured CCC in euthymic bipolar disorder I (BD-I) patients and healthy controls using fingernails to investigate whether differences in CCC influenced neurocognitive performance. We also investigated whether differences in clinical illness variables influenced CCC in euthymic BD-I patients.

METHODS

A previous study demonstrated neurocognitive impairment in euthymic BD-I patients. The current study included a portion of this sample: 40 BD-I versus 42 matched controls who provided fingernail samples.

RESULTS

There was no statistically significant difference in CCC between controls and BD-I (P = .09). Logistic regression analyses revealed that euthymic bipolar I subjects with more than five years of current euthymia had decreased odds of having higher fingernail cortisol concentration (>71.2 pg/mg) compared to those with less than 1.5 years (P = .04). There was no association between CCC and cognitive impairment in all domains before and after adjustment for age and sex.

CONCLUSIONS

The current evidence suggests CCC is not a trait biomarker in euthymic BD-I (BD-I). Longer periods of stability in affective disorders are associated with lower CCC. Fingernail cortisol does not seem to be implicated in neurocognitive impairment and BD-I. Future studies may investigate CCC in different illness phases of BD-I.

Alcohol markers in hair: an issue of interpretation

Ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEEs) are metabolites of alcohol that when detected in hair can provide evidence of a person's drinking behavior. The analysis of these compounds in hair has become commonplace in recent years and has been used as evidence in legal proceedings. Despite the routine use of such toxicological analysis, the correct interpretation of alcohol biomarker hair testing can be complex, and there may be debate as to the significance of the data. This paper considers whether the accepted norm of applying interpretative cut-off values to EtG and FAEE concentrations from hair samples is appropriate, and asks whether Bayesian theory, using a likelihood ratio approach may offer greater insight as to the strength of evidence. In addition to the complexity of result interpretation in this field, the sensitivity of alcohol biomarkers in hair to distinguish low level drinking from abstinence also represents a significant challenge. The use of fingernail EtG testing as an alternative to hair analysis is explored in this paper and it is proposed that fingernails may in theory show a higher uptake of EtG than hair, and thus show potential as a useful alternative matrix to document long-term low to moderate alcohol consumption.

Prevalence and correlates of beta human papillomavirus detection in fingernail samples from mid-adult women

Cutaneous human papillomaviruses (HPVs) have not been evaluated in fingernails from healthy individuals. To determine prevalence and correlates of β-HPVs in fingernails from healthy mid-adult women, we tested archived samples collected from 2011 to 2012 using a multiplex PCR combined with Luminex technology for 46 β-HPV genotypes. One hundred thirteen (61.1%) of 185 fingernail samples were positive for β-HPV, and the median number of types detected in positive samples was 2 (interquartile range: 1–4). The most common genotypes detected were HPV-23 (β−2) (13.5%), HPV-38 (β−2) (13.0%), HPV-5 (β−1) (9.2%), HPV-107 (β−2) (8.7%), and HPV-120 (β−2) (8.7%). In multivariate analysis, β-HPV detection was associated with age (prevalence ratio [PR] for women 40–51 years versus 30–39 years = 1.30, 95% CI: 1.05–1.62) and race (PR for non-white versus white race = 0.65, 95% CI: 0.45–0.94). The prevalence of β-HPV in fingernail samples from healthy mid-adult women was similar to the prevalence of β-HPV reported at other cutaneous sites in prior studies. We did not identify any significant health or sexual behavior predictors of β-HPV detection in fingernails. Our results support the hypothesis that fingers may serve as a source of transmission or autoinoculation of cutaneous HPVs to other anatomic sites.

Qualitative and quantitative analysis of human nails to find correlation between nutrients and vitamin D deficiency using LIBS and ICP-AES

In this work, we analysed human fingernails of people who suffer from vitamin D deficiency using the laser-induced breakdown spectroscopy(LIBS) and inductively coupled plasma atomic emission spectroscopy (ICP-AES)techniques. The measurements have been conducted on 71 nail samples collected randomly from volunteers of different genders and ages ranged between 20 and 50 years. The main aim of this study is to find the correlation between vitamin D deficiency and the intensity of some dominated lines in the LIBS spectra. A LIBS spectrum consists of dominant lines of fifteen elements including calcium, magnesium, sodium, potassium, titanium, iron, chloride, sulphur, copper, chromium, zinc, nitrogen, phosphor, and oxygen. By recording the spectrum in specific ranges and focusing on calcium, magnesium, sodium, and potassium, we found a correlation between the intensity of the potassium (K) lines at (766.5 and 769.9 nm)and vitamin D level in both age groups (20 and 25 years old), with weak correlation for the calcium (Ca), magnesium (Mg), and sodium (Na) lines. To verify the validity of the LIBS results, we analysed the nail samples with ICP, a standard analytical technique. The elements detected with our LIBS technique are in a good agreement with those identified by ICP-AES. From the health and physiological perspectives, the LIBS system, which is used for spectral analysis in this work, is appropriate for diagnostic purposes such as to find the correlation between vitamin D deficiency and potassium content, especially for hypertensive patients who simultaneously take potassium-based medication and vitamin D supplement.

Parrot Beak Nails Revisited: Case Series and Comprehensive Review

The term "parrot beak nail" describes a morphologic change of the nail plate characterized by excessive forward curvature. It may be associated with systemic disease or, most commonly, occurs as an idiopathic finding complicated by delayed nail plate trimming. The characteristics of parrot beak nails in ten men are described, and the features of this acquired nail deformity are reviewed. Of the ten patients, six presented with concurrent neuropathies that resulted in frequent foot injuries or falls. While the true incidence of parrot beak nails is unknown, this nail deformity occurred in 2.1 % of patients seen by a single physician during a 3-month period. In conclusion, parrot beak nails secondary to poor nail care may lead to functional impairment, tissue injury, and subsequent infections. Therefore, it is important for clinicians to look for these nail lesions on cutaneous examination and recommend frequent nail trimmings to individuals with parrot beak nails.

Investigating relations among stress, sleep and nail cortisol and DHEA

In the current study, we present data investigating the relationships among stress, sleep disturbance, self-control, and levels of cortisol (CORT) and dehydroepiandrosterone (DHEA) in fingernail clippings. Currently, hair CORT is the only routinely used noninvasive, validated, biomarker of chronic exposure to stress-related hormones. Nail clippings represent an important potential alternative sample matrix for assessing chronic hormone exposure, as it offers a different timeline of hormone incorporation than scalp hair, and may be obtainable from populations in which hair either is lacking or is unavailable for cultural reasons. Moreover, there is established precedent for using fingernail clippings to attain biomarker data. However, the value of nail hormone assessment for psychological research is currently unknown due to a paucity of information on the relations between nail hormone concentrations and environmental or psychological variables. In the present study, we collected data from a low income, minority population (N = 47; 97% African American) to demonstrate feasibility and acceptability of nail collection and analysis of the adrenal steroids CORT and DHEA. Participants reported on perceived stress, sleep and self-control abilities. Correlational analyses suggest that exposure to stressful events, disturbances in sleep and waking were associated with higher levels of nail DHEA, while self-control was associated with higher levels of nail CORT. We discuss the potential importance of this methodology for investigating biological, behavioral, and subjective indices of stress and well-being.

The use of tree barks and human fingernails for monitoring metal levels in urban areas of different population densities of Porto Alegre, Brazil

The aim of this study was to evaluate the use of tree barks as a bioindicator of atmospheric pollution in areas of contrasting population densities and to associate the levels of elements found in this bioindicator with those obtained in fingernail samples collected from students living in the same study areas. Tree bark samples were collected from urban areas near highways in regions with high (Area A), intermediate (Area B), and low (Area C) population densities of Porto Alegre, Brazil, and evaluated for chemical elements concentration. Since these areas also differed in traffic density, NO₂ was measured by passive sampling. For a comparative purpose, the elements were also determined in fingernail samples collected from students living in the same areas. Accumulated elements were determined by inductively coupled plasma mass spectrometry (ICP-MS) and principal component analysis (PCA) was used as a tool in exploratory data analysis to identify possible sources. We found that Ba, Cd, Co, Cu, Mg, Mn, Ni, Pb, Sb, Sr, V, and Zn were at higher concentrations in tree barks in Area A, while Cd, Co, Cu, Mg, Mn, Ni, and Sr were at higher levels in students' fingernails of Area A as well. Furthermore, concentrations of elements found in barks were associated with those identified in fingernails collected from students living in the same areas. PCA demonstrated that vehicular traffic explained 66.4 % of the variance in tree bark and 50.8 % of the variance in fingernails. NO₂ levels were significantly different among the areas, what is consistent with their respective vehicular flow and population density. In conclusion, we found conformance of elements levels accumulated in barks and fingernails at three monitoring areas with different profiles. The amount of traffic-related elements accumulated appears to be associated with the degree of urbanization and vehicular flow. Overall, data suggests a relationship between fingernails and tree bark as bioindicators of exposure to metals from air pollution.

Glycation in human fingernail clippings using ATR-FTIR spectrometry, a new marker for the diagnosis and monitoring of diabetes mellitus

OBJECTIVES

Although HbA1c is a good diagnostic tool for diabetes, the precarity of the health system and the costs limit the use of this biomarker in developing countries. Fingernail clippings contain ±85% of keratins, which are prone to glycation. Nail keratin glycation may reflect the average glycemia over the last months. We explored if attenuated total reflection Fourier transform infrared spectroscopy (ATR-FTIR) can be used as a non-invasive tool for assessing glycation in diabetes.

DESIGN AND METHODS

Using ATR-FTIR spectroscopy, glycation and deglycation experiments with fructosamine 3-kinase allowed to identify the spectrum that corresponds with keratin glycation in fingernail clippings. Clippings of 105 healthy subjects and 127 diabetics were subjected to the standardized ATR-FTIR spectroscopy method.

RESULTS

In vitro glycation resulted in an increased absorption at 1047cm^-1. Following enzymatic deglycation, this peak diminished significantly, proving that the AUC between 970 and 1140cm^-1 corresponded with glycated proteins. Within-run CV of the assay was 3%. Storage of nail clippings at 37°C for 2weeks did not significantly change results. In diabetics, glycated nail protein concentrations (median: 1.51μmol/g protein, IQR: 1.37-1.85μmol/g protein) were significantly higher than in the controls (median: 1.19μmol/g protein, IQR: 1.09-1.26μmol/g protein) (p<0.0001). ROC analysis yielded an AUC of 0.92 at a cut-off point of 1.28μmol/g nail (specificity: 82%; sensitivity: 90%). No correlation was observed between the glycated nail protein concentrations and HbA1c.

CONCLUSIONS

Protein glycation analysis in fingernails with ATR-FTIR spectroscopy could be an alternative affordable technique for diagnosing and monitoring diabetes. As the test does not consume reagents, and the preanalytical phase is extremely robust, the test could be particularly useful in developing countries.

Fingernail Onychomycosis Due to Aspergillus niger

Onychomycosis is usually caused by dermatophytes, but some species of nondermatophytic molds and yeasts are also associated with nail invasion. Aspergillus niger is a nondermatophytic mold which exists as an opportunistic filamentous fungus in all environments. Here, we report a case of onychomycosis caused by A. niger in a 66-year-old female. The patient presented with a black discoloration and a milky white base and onycholysis on the proximal portion of the right thumb nail. Direct microscopic examination of scrapings after potassium hydroxide (KOH) preparation revealed dichotomous septate hyphae. Repeated cultures on Sabouraud's dextrose agar (SDA) without cycloheximide produced the same black velvety colonies. No colony growth occurred on SDA with cycloheximide slants. Biseriate phialides covering the entire vesicle with radiate conidial heads were observed on the slide culture. The DNA sequence of the internal transcribed spacer region of the clinical sample was a 100% match to that of A. niger strain ATCC 16888 (GenBank accession number AY373852). A. niger was confirmed by KOH mount, colony identification, light microscopic morphology, and DNA sequence analysis. The patient was treated orally with 250 mg terbinafine daily and topical amorolfine 5% nail lacquer for 3 months. As a result, the patient was completely cured clinically and mycologically.