Number of Affected Nails Is the Primary Determinant of Efinaconazole 10% Solution Usage for Onychomycosis

Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112.    doi:10.36849/JDD.7676.

Comparing the Efficacy for Pulse Versus Continuous Dose Terbinafine Therapy in Patients With Onychomycosis

Recently, treatment outcomes in patients with toenail onychomycosis have improved considerably due to more effective oral antifungal medications such as terbinafine and itraconazole. These medications can either be used continuously for several weeks at a lower dose or intermittently (pulsed) at a higher dose. Previous literature comparing pulse and continuous therapy has generated mixed results.  Our study aims to compare the efficacy, in terms of clinical cure rate, of continuous vs pulse dose terbinafine regimens for toenail onychomycosis. Sixty patients with onychomycosis of Fitzpatrick skin types IV to VI, between 15 and 65 years of age, were divided into a continuous treatment group receiving 250 mg terbinafine once daily for 12 weeks and a pulse treatment group receiving 250 mg twice daily terbinafine for 1 week repeated every 4 weeks for 12 weeks. Each patient was followed up at weeks 4, 8, and 12.  Efficacy of the continuous treatment group was significantly greater at 76.67% compared with 26.67% in the pulse treatment group. Thus, we conclude that the clinical cure rate of a continuous dose regimen of terbinafine is a superior treatment option for toenail onychomycosis. However, we also suggest further studies including combinations of multiple agents and hybrid regimen models for the optimal onychomycosis treatment.   J Drugs Dermatol. 2023;22(10):     doi:10.36849/JDD.7323R1.

Therapeutic Recommendations for the Treatment of Toenail Onychomycosis in the US

BACKGROUND

Onychomycosis affects around 14% of individuals in North America and Europe and is undertreated. Treatment is challenging as toenail growth can take 12–18 months, the nail plate may prevent drug penetration, and disease recurrence is common. National guidelines/consensus documents on onychomycosis diagnosis and treatment were last published more than 5 years ago and updated medical guidance is needed.

METHODS

This document aims to provide recommendations for the diagnosis and pharmaceutical treatment of toenail onychomycosis following a roundtable discussion with a panel of dermatologists, podiatrists, and a microbiologist specializing in nail disease.

RESULTS

There was a general consensus on several topics regarding onychomycosis diagnosis, confirmatory laboratory testing, and medications. Onychomycosis should be assessed clinically and confirmed with microscopy, histology, and/or culture. Terbinafine is the primary choice for oral treatment and efinaconazole 10% for topical treatment. Efinaconazole can also be considered for off-label use for maintenance to prevent recurrences. For optimal outcomes, patients should be counseled regarding treatment expectations as well as follow-up care and maintenance post-treatment.

CONCLUSIONS

This article provides important updates to previous guidelines/consensus documents to assist dermatologists and podiatrists in the diagnosis and treatment of toenail onychomycosis. J Drugs Dermatol. 2021;20(10):1076-1084. doi:10.36849/JDD.6291.

Actinomycetoma Caused by Actinomadura mexicana, A Neglected Entity in the Caribbean

Mycetoma is a chronic infection that is slow to develop and heal. It can be caused by fungi (eumycetoma) or bacteria (actinomycetoma). We describe a case of actinomycetoma caused by Actinomadura mexicana in the Caribbean region.

High prevalence of mixed infections in global onychomycosis

Onychomycosis is estimated at a prevalence of 10% worldwide with the infecting organism most commonly Trichophyton rubrum (T. rubrum). Traditional culture identification of causative organisms has inherent risks of overestimating dermatophytes, like T. rubrum, by inhibiting the growth of possible nondermatophyte mould (NDM) environmental contaminants which could be causative agents. Recently, molecular methods have revealed that a proportion of onychomycosis cases in North America may be caused by mixed infections of T. rubrum as an agent co-infecting with one or more NDM. Determining the global burden of mixed infections is a necessary step to evaluating the best therapies for this difficult-to-treat disease. To determine the prevalence of mixed infections in a global population, nail samples from onychomycosis patients in Brazil, Canada, and Israel (n = 216) were analyzed by molecular methods for the presence of dermatophytes and five NDMs. If an NDM was detected, repeat sampling was performed to confirm the NDM. T. rubrum was detected in 98% (211/216) of infections with 39% mixed (84/216). The infection type was more likely to be mixed in samples from Brazil, but more likely to be a dermatophyte in samples from Canada and Israel (Χ² = 16.92, df = 2, P<0.001). The most common cause of onychomycosis was T. rubrum. In all countries (Brazil, Canada and Israel combined) the prevalence of dermatophyte (Χ² = 211.15, df = 3, P<0.001) and mixed (dermatophyte and NDM; Χ² = 166.38, df = 3, P<0.001) infection increased with patient age. Our data suggest that mixed infection onychomycosis is more prevalent than previously reported with the aging population being at increased risk for mixed infections.

Safety, Pharmacokinetics, and Efficacy of Efinaconazole 10% Topical Solution for Onychomycosis Treatment in Pediatric Patients

BACKGROUND

Pediatric onychomycosis management is challenging as there are limited treatment options. The objective of this study was to evaluate efinaconazole 10% topical solution in children with onychomycosis.

METHODS

This phase 4, multicenter, open-label study (NCT02812771) evaluated safety, pharmacokinetics (PK), and efficacy of efinaconazole 10% topical solution in pediatric participants (6-16 years). Efinaconazole was administered once daily for 48 weeks, with a 4-week posttreatment follow up. Participants had culture-positive, mild-to-severe distal lateral subungual onychomycosis affecting at least 20% of at least 1 great toenail. The PK subset included participants 12-16 years with moderate-to-severe onychomycosis affecting at least 50% of each great toenail and onychomycosis in at least 4 additional toenails.

RESULTS

Of 62 enrolled participants, 60 were included in the safety population and 17 in the PK population. Efinaconazole 10% topical solution was well tolerated. The concentration-time profiles for efinaconazole and its major metabolite were relatively stable, with only minor fluctuations during the 24-hour dosing interval. Systemic exposure to efinaconazole was low. By week 52, 65.0% of participants achieved mycologic cure, with a 36.7% mycologic cure rate observed as early as week 12. A total of 40.0% of participants achieved complete cure, 50.0% achieved clinical efficacy, and 88.3% achieved fungal cure by week 52.

CONCLUSION

Efinaconazole was safe and efficacious in pediatric participants with mild-to-severe onychomycosis, with improved mycologic cure and complete cure rates compared with adults from two 52-week studies. J Drugs Dermatol. 2020;19(9):867-872. doi:10.36849/JDD.2020.5401.

Prospective, comparative evaluation of a deep neural network and dermoscopy in the diagnosis of onychomycosis

BACKGROUND

Onychomycosis is the most common nail disorder and is associated with diagnostic challenges. Emerging non-invasive, real-time techniques such as dermoscopy and deep convolutional neural networks have been proposed for the diagnosis of this condition. However, comparative studies of the two tools in the diagnosis of onychomycosis have not previously been conducted.

OBJECTIVES

This study evaluated the diagnostic abilities of a deep neural network (http://nail.modelderm.com) and dermoscopic examination in patients with onychomycosis.

METHODS

A prospective observational study was performed in patients presenting with dystrophic features in the toenails. Clinical photographs were taken by research assistants, and the ground truth was determined either by direct microscopy using the potassium hydroxide test or by fungal culture. Five board-certified dermatologists determined a diagnosis of onychomycosis using the clinical photographs. The diagnosis was also made using the algorithm and dermoscopic examination.

RESULTS

A total of 90 patients (mean age, 55.3; male, 43.3%) assessed between September 2018 and July 2019 were included in the analysis. The detection of onychomycosis using the algorithm (AUC, 0.751; 95% CI, 0.646-0.856) and that by dermoscopy (AUC, 0.755; 95% CI, 0.654-0.855) were seen to be comparable (Delong's test; P = 0.952). The sensitivity and specificity of the algorithm at the operating point were 70.2% and 72.7%, respectively. The sensitivity and specificity of diagnosis by the five dermatologists were 73.0% and 49.7%, respectively. The Youden index of the algorithm (0.429) was also comparable to that of the dermatologists' diagnosis (0.230±0.176; Wilcoxon rank-sum test; P = 0.667).

CONCLUSIONS

As a standalone method, the algorithm analyzed photographs taken by non-physician and showed comparable accuracy for the diagnosis of onychomycosis to that made by experienced dermatologists and by dermoscopic examination. Large sample size and world-wide, multicentered studies should be investigated to prove the performance of the algorithm.

Onychomycosis, the Active Invasion of a Normal Nail Unit by a Dermatophytic Versus the Colonization of an Existing Abnormal Nail Unit by Environmental Fungus

Onychomycosis was described by early investigators as the presence of an abnormal nail unit and a member of the order Mycota, producing the abnormality. This interpretation has caused more than 50 years of confusion in the dermatologic literature. Unquestionably, the clinician sees more abnormal toenails than fingernails, and investigators have described a multitude of fungi as the cause of the clinically abnormal toenail. In 2010, developmental scientists proved, what we have long recognized, that there is no bilateral symmetry in living organisms and, therefore, one sole is different from the other. This causes a gait asymmetry, coupled with the pressure the closed shoe exerts on toenails while walking. This produces a series of abnormalities, which are clinically identical to what has been described for dermatophytic onychomycosis. These are fungus free and result in toenail niches. These toenail abnormalities were recently described as the asymmetric gait nail unit syndrome (AGNUS). It is possible that environmental fungi can colonize these toenail niches and, therefore, were described by investigators as a new onychomycosis entity In the normal host, onychomycosis should be only used to describe the active invasion of the nail bed (NB) corneocytes by a dermatophyte, as seen in dermatophytic onychomycosis. Dermatophytes only affect those hosts who have inherited the dermatophytosis susceptibility gene, transmitted as an autosomal dominant trait. In studies encompassing 3,000 abnormal toenails, only 27%-30% were found as dermatophyte culture positive, 25% were negative and the rest environmental fungi were recovered.

[Case Report of Pseudomonas Hot-Foot Syndrome in Uppsala, Sweden]

During February and March 2019, an accumulation of clinically similar erythematous plantar nodules was observed at the University Children's Hospital and several primary care facilities in Uppsala, Sweden. At least 20 children sought medical advice, and all cases presented with a recurrent plantar hidradenitis after within a day after visiting Uppsala's largest waterpark and arena for swimming. The presented symptoms were identical with a condition called pseudomonas hot-foot syndrome described in the literature. An investigation led by the local public health authorities revealed heavy growth of Pseudomonas aeruginosa in water-filled toys in a children's play area and in samples taken from the floor of a pool where the surface was partly damaged. After closing the affected part of the pool and removal of the contaminated toys, no more people sought medical advice. Pseudomonas hot-foot syndrome is believed to be more frequent than diagnosed today, and increased awareness is essential to avoid unwarranted diagnostic tests and treatments, and to identify and eradicate the source of infection.

Characteristics, Associated Diseases, and Management of Gram-negative Toe-web Infection: A French Experience

Gram-negative toe-web infection can cause pain and disability, be complicated by a long healing time, management failure, and cellulitis, and recur due to persistent predisposing factors. To describe the clinical features and management of Gram-negative toe-web infection and evaluate predisposing factors and associated diseases, their management, and the effect of controlling them on the rate of recurrence, we conducted a retrospective real-life study of patients with Gram-negative toe-web infection. Among the 62 patients (sex ratio 9:1), 31 experienced more than one episode of Gram-negative toe-web infection. Pseudomonas aeruginosa was the most prominent bacteria. Predisposing factors/associated diseases were eczema (66%), suspected Tinea pedis (58%), humidity (42%), hyperhidrosis (16%), psoriasis (11%), and vascular disorders (40%). Patients in whom associated diseases, such as eczema or psoriasis, were controlled did not relapse, suggesting the benefit of management of such conditions. We suggest that management of Gram-negative toe-web infection be standardised, with a focus on diagnosis and treatment of associated diseases.

Eruptive Nevi on the Palms and Soles with no Association with an Underlying Disease or Medications

Eruptive melanocytic nevi are an unusual phenomenon characterized by sudden onset of multiple melanocytic nevi on previously unaffected skin. The majority of case reports have linked this condition with blistering skin disease or immunosuppression. There are only three reports of eruptive nevi developing on the palms and /or soles in healthy individuals. Herein we present the clinical and dermoscopic features of two cases of eruptive acral nevi that developed in healthy individuals in the absence of any recognizable underlying disease and review the current literature of eruptive nevi.

Dermoscopic Features of a Digital Myxoid Cyst

Dear Editor, We report a case of a patient admitted to our Department presenting a typical digital myxoid cyst. A 54-year-old man was referred by his general practitioner to the Department of Dermatology at our hospital due to the presence of an asymptomatic lesion on the third right toe. Physical examination revealed a rounded, red-bluish lesion in the eponychium less than 0.5 cm in diameter with a cystic appearance that secondarily caused a longitudinal depression in the nail plate (Figure 1). Dermoscopy showed arboriform telangiectasias over white, bluish, and reddish-orange diffuse areas (Figure 2, a). Direct needle puncture with a 25-gauge needle and drainage was performed showing a clear gelatinous material (Figure 2, b), confirming the diagnosis of digital myxoid cyst. No recurrence was seen during the 9-month follow-up period. A digital myxoid (or mucous) cyst is a benign recurrent cystic lesion of less than 1 cm in diameter and rounded or oval morphology typically located at the distal interphalangeal joint (DIJ) or eponychium in the digits. Digital myxoid cysts have a higher incidence in adult women and are more likely to be found on the fingers than on the toes, especially on the index finger of the dominant hand. Typically, digital myxoid cysts are recognized as unique asymptomatic lesions and do not require treatment, although there can be multiple lesions in case of osteoarthritis (1,2). Its etiology and pathogenesis remains unclear, although some theories indicate that myxoid cysts could appear as a result of a mucoid degeneration of the connective tissue, the exit of synovial fluid from the DIJ capsule, repetitive trauma, the herniation of tendon sheaths or synovial linings associated with degenerative joint diseases and osteophytes in the elderly, or due to an overproduction of mucin by fibroblasts (1,3,4). Furthermore, there is no treatment consensus nor a treatment algorithm for its management, although surgical excision has shown high cure rates. Dermoscopy is a non-invasive imaging technique that allows accurate diagnosis of the digital myxoid cyst. As reported in this case, dermoscopy examination facilitates identification of telangiectasias following different vascular patterns (arboriform, polymorphic, punctate, or linear vessels), reddish-violet lagoons, ulceration, and a bright-whitish reticulum that could be related to an increase in collagen (5,6). Differential diagnosis mainly includes ganglion, Heberden's nodes associated with osteoarthritis, glomus tumors, and dermatofibromas (5). Treatment options range from observation (when there is no symptomatology), puncture and drainage of the cyst and corticosteroid injections to surgical intervention with reported healing rates of 95%. Sclerotherapy, cryotherapy, CO2 laser vaporization, infrared coagulation, caustic elimination, and manual compression of the cyst can also be used. Within non-surgical measures sclerotherapy has reported a 77% healing rate, followed by cryotherapy (72%), corticosteroid injections (61%), and manual compression (39%) (1,7). In summary, we reported a case of a digital myxoid cyst in an adult patient presenting with its main characteristics and typical location. This cystic lesion must be considered in the differential diagnosis with other benign tumors. Dermatoscopy should be an essential diagnostic tool and must be taken into account in cases of doubtful diagnosis. Its value in the evaluation of tumor processes is already well-known but it cannot be ignored when assessing other skin lesions or cutaneous infections.

Tavaborole 5% Topical Solution for the Treatment of Toenail Onychomycosis in Pediatric Patients: Results from a Phase 4 Open-Label Study

Background: This study was designed to evaluate the safety, tolerability, pharmacokinetics (PK), and efficacy of tavaborole in pediatric patients. Study Design: In this open-label, single-arm study, pediatric patients (aged 6 to <17 years) with distal subungual onychomycosis affecting ≥20% of the target great toenail applied tavaborole once daily to all affected toenails (2 drops/great toenail, 1 drop/other toenail) for 48 weeks. In addition, a maximal-use subgroup (aged 12 to <17 years) applied tavaborole to all 10 toenails and ≤2 mm of surrounding skin for the first 28 days. Results: Treatment-emergent adverse events (TEAEs) were reported by 55.6% of patients; the most frequently reported (≥5% of patients) were nasopharyngitis, contusion, sinusitis, and vomiting. Most TEAEs and local treatment reactions (LTRs) were mild or moderate and considered unrelated to treatment. There was 1 serious AE (severe appendicitis, considered unrelated to treatment) and there were no deaths, discontinuations because of AEs, or dose adjustments because of AEs. The most frequently reported LTRs were erythema and scaling. The incidence of LTRs diminished over time. Tavaborole was absorbed systemically, and plasma concentrations were measurable. The PK parameters determined in this study under maximal-use conditions indicate that steady state was achieved within the study period. For efficacy, 8.5% of patients achieved complete cure (clear nail and negative mycology [negative fungal culture and negative potassium hydroxide wet mount]) at week 52, and 14.9% achieved complete/almost complete cure at week 52 (clear or almost clear nail [≤5% dystrophic or discolored distal toenail plate] and negative mycology). Conclusion: Tavaborole was well tolerated in this pediatric population, and safety, PK, and efficacy profiles were comparable with those in adults. Trial registration: ClinicalTrials.gov identifier: NCT03405818 J Drugs Dermatol. 2019;18(2):190-195.

Bullous lupus erythematosus with an erythema gyratum repens-like pattern

Bullous lupus erythematosus is a rare clinical form of lupus. The diagnosis is challenging and involves the exclusion of other subepidermal bullous dermatoses. We present a 21-year-old woman with erythematosus, polycyclic plaques with vesiculobullae along the periphery, creating an erythema gyratum repens-like pattern on acral regions. The cutaneous biopsy, analytical, and autoimmune studies support the diagnosis of systemic lupus erythematosus. Dapsone and glucocorticosteroids were given with prompt resolution of the lesions within two weeks. To our knowledge this is the first case of bullous lupus erythematosus with this atypical acral presentation.

Amelanotic acral melanoma misdiagnosed as verruca plantaris

We report a case of amelanotic acral melanoma in a 42-year-old Chinese woman. Ten months previously the patient found a 2-cm asymmetric erythematous macular plaque on her left sole. The lesion was diagnosed as verruca plantaris by every physician the patient consulted. One month ago, an enlarged lymph node was detected in the left groin, which biopsy reported as metastatic melanoma. Dermoscopy suggested verruca plantaris, and positron emission tomography (PET) revealed increased glucose metabolism in the macular plaque. Finally, biopsy of the plaque revealed amelanotic melanoma. Misdiagnosis and diagnostic delay are usually associated with poorer patient outcomes. Awareness of atypical presentations of acral melanoma is thus important for decreasing misdiagnosis rates and improving patient outcomes.

Generalized essential telangiectasia

The pathophysiology of generalized essential telangiectasia is not well understood. Generalized essential telangiectasia is an uncommon disorder in which widespread telangiectasias of unknown cause develop without associated systemic or antecedent dermatologic disease. We report a case of generalized essential telangiectasia in an otherwise healthy 49-year-old man.

Two Cases of Proximal Subungual Onychomycosis Caused by Trichophyton rubrum in HIV-negative Patients During Treatment with TNF-α Inhibitors Combined with Methotrexate

Proximal subungual onychomycosis (PSO) is a rare subtype of onychomycosis with a clinical presentation characterized by proximal leukonychia in the lunular area of the nail. PSO is associated with immunosuppression and regarded a sign of Human Immunodeficiency Virus (HIV) infection when caused by Trichophyton (T.) rubrum. We present two cases of PSO caused by T. rubrum developed during treatment with TNF-α inhibitors combined with methotrexate (MTX).

Frequency of Fungal Species of Onychomycosis between Diabetic and Non-Diabetic Patients

Onychomycosis is a common nail problem in our country. Diabetic patients are more prone to develop onychomycosis. Various types of fungi are the causative agents of nail infections. This cross sectional explorative study was designed to find out the pattern of onychomycosis among diabetic and non-diabetic patients attending the out patient Department of Dermatology and Venereology and Endocrinology of Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh from July 2012 to June 2013. Clinically diagnosed patients of onychomycosis with diabetic or non-diabetic were included purposively in this study. Scraping or clipping from infected nail materials were processed for microscopy and culture in Sabouraud's dextrose agar media and Dermatophyte test media. Clinical features, microscopic examination results and culture interpretations were recorded and compared in two groups. A total of 87 clinically diagnosed patients of onychomycosis were included in this study. Out of 87 patients of onychomycosis, 54 patients were diabetic and 33 patients were non-diabetic. Trichophyton rubrum and Trichophyton mentagrophytes were found in 24(44.44%) and 19(35.18%) diabetic patients. Candida albicans and non-albicanscandida species were found in 1(1.85%) and 2(3.70%) diabetic patients. On the other hand, Trichophyton rubrum and Trichophyton mentagrophytes were found in 1(3.03%) and 2(6.06%) non-diabetic patients. Candida albicans and non-albicanscandida species were found in 8(24.24%) and 8(24.24%) non-diabetic patients. Growth of fungus was found in 46(85.19%) diabetic patients which was significant (p=0.004) compared to that found in 19(57.58%) non-diabetic patients. No growth was found in 8(14.81%) diabetic and in 14(42.42%) non-diabetic patients. Dermatophytes were more found in diabetic patients and Candida albicans and non-albican Candida spp. were more found in non-diabetic patients. So, the pattern of onychomycosis was different in diabetics compared to non-diabetics. Further study may be done with large number of sample to determine more accurate pattern of onychomycosis among diabetics.

Allergic contact dermatitis to shoes: contribution of a specific series to the diagnosis

BACKGROUND

In our country, the Brazilian Standard Series is the most used for the etiological diagnosis of allergic contact dermatitis to shoes. However, there is no assessment of the usefulness of specific allergens for shoes.

OBJECTIVES

To measure the improvement in diagnostic accuracy of allergic contact dermatitis to shoes with the use of a specific complementary series in patch testing and describe the characteristics of the affected population, such as gender, location of lesions, time of evolution, and the most common allergens.

METHODS

This retrospective study evaluated the results of 52 patients with suspected shoe dermatitis subjected to patch tests with the standard and specific series to quantify the gain in diagnostic accuracy.

RESULTS

Among the 52 suspected cases, 29 cases (56%) were confirmed. In 13 (45%) cases the diagnosis was determined through the specific series, which results in an 81% increase in the number of diagnoses.

STUDY LIMITATION

Small sample size.

CONCLUSIONS

Women were more commonly affected, with a mean time for the final diagnosis of 45 months, and the most common localization was the dorsum of the feet. There was an increase in diagnostic accuracy with the introduction of new haptens in the patch test of patients with suspected shoes dermatitis.

An unusual giant serpiginous lesion of secondary syphilis

Syphilis is a worldwide sexually transmitted infection caused by Treponema pallidum subspecies pallidum. Its association with other STIs, including HIV, demands early diagnosis and immediate treatment of patients. We herein report an unusual serpiginous form of secondary syphilis.

Case for diagnosis. Solitary violaceous nodule on the toe

Reticulohistiocytomas represent a group of benign histiocytic dermal proliferations, which occur either sporadically as solitary cutaneous nodules or, when multiple, in association with systemic disease. Due to its nonspecific clinical presentation, reticulohistiocytoma may mimic other benign or malignant skin neoplasms; therefore, in most cases, a biopsy is needed in order to establish the correct diagnosis. The histology is typically characterized by the presence of large histiocytes with abundant eosinophilic cytoplasm with immunohistochemical profile positive for CD68, CD163, and vimentin. The authors report the case of a patient with solitary reticulohistiocytoma with illustrative clinical, dermoscopic, and histologic features.

Proximal Subungual Onychomycosis in the Immunocompetent: A Case Report and Review of the Literature

Proximal subungual onychomycosis (PSO), which predominantly involves the nail plate from the proximal nail fold, is the rarest form of onychomycosis. Classically associated with an immunocompromised state, PSO is an uncommon diagnosis in individuals without immunodeficiency. We present a case of a healthy 51-year-old man, who presented with a three-month history of white discoloration of multiple toenails. Physical examination revealed white, opaque patches on the proximal third nail plates of multiple toenails. The affected digits also demonstrated proximal onycholysis, subungual debris, and mild paronychia. Laboratory examinations, including routine serologic studies as well as human immunodeficiency virus and antinuclear antibodies, were within normal limits. Proximal nail fragments of the left hallux showed sections of dystrophic nail plate with mounds of parakeratosis, collections of neutrophils, and hyphae that highlighted with periodic acid-Schiff staining. The patient was diagnosed with PSO and tinea pedis bilaterally and treated with oral fluconazole with gradual improvement. This case of PSO highlights the potential for its rare occurrence in a healthy host. However, the clinical presentation of PSO should trigger an evaluation for possible immunodeficiency. <p><em>J Drugs Dermatol. 2018;17(4):475-478.</em></p>.

Is Severity of Disease a Prognostic Factor for Cure Following Treatment of Onychomycosis?

BACKGROUND

Onychomycosis is a common disease that remains a difficult disorder to treat despite the introduction of new topical agents; and not all patients are cured. Clinical experience leads us to suggest a number of host-related factors can affect the chance of cure, but studies supporting these observations are currently lacking. Although many studies, particularly on topical agents, rely on severity classification when selecting patients for inclusion, a pilot study was unable to demonstrate any prognostic value of the extension of nail involvement. In addition, no universal severity classification exists, and most studies do not report prognostic factors.

OBJECTIVE

To investigate the efficacy of efinaconazole topical solution, 10% in patients with mild-to-moderate onychomycosis and determine the impact of baseline severity on treatment outcome.

METHODS

Post hoc pooled analysis of two identical, multicenter, randomized, double-blind, vehicle-controlled studies in 1655 patients aged 18-70 years with a clinical and mycological diagnosis of mild-to-moderate dermatophyte toenail onychomycosis (20-50% clinical involvement). Patients were randomized (3:1) to efinaconazole 10% solution or vehicle, once-daily for 48 weeks, with 4-week post treatment follow-up. Efficacy criteria included clear nail (0% target nail plate involvement), almost clear nail (≤5% target nail plate involvement), and clinical treatment success (≤10% target nail plate involvement) at week 52. For the post hoc analysis, patients were classified as mild (20%-29% nail involvement), moderate (30%-39%), and moderately severe (40%-50%) at baseline.

RESULTS

Overall, 25%, 23%, and 52% of patients had mild, moderate, or moderately severe disease at baseline. Baseline nail involvement did not appear to predict treatment outcomes. The proportion of patients with mild disease who had a clear nail progressively reduced by week 36 (58%) and week 48 (41%), and even further by week 52 (37%). Of the 237 patients treated with efinaconazole who were 'clear' at week 52, 37%, 24%, and 39% had mild, moderate or moderately severe disease respectively at baseline. The majority of patients (N=634) saw at least a 50% improvement in their target toenail by week 52. Almost half of these patients (N=312, 49.2%) were moderately severe at baseline.

CONCLUSIONS

This post hoc analysis supports previous data showing good efficacy of efinaconazole in mild onychomycosis. The relative contribution to overall efficacy results at week 52 of patients with moderate or moderately severe disease was unexpected for a topical therapy, and warrants further study, especially as they represent the majority of patients enrolled in the two studies. It is possible that comparable efficacy can be achieved in these more severe patients with longer treatment courses, or follow-up. J Drugs Dermatol. 2018;17(2):175-178.

Planimetric Post-hoc Analysis of Women With Onychomycosis from Tavaborole 5% Phase III Studies: Evidence of Greater Improvements in Patients With >50% Baseline Infection

Women with onychomycosis may suffer more effects on their quality of life than men. There is limited female-specific data on the treatment of onychomycosis. Tavaborole is a topical treatment option for onychomycosis. This post-hoc study evaluated the nail plates of women using data from the tavaborole 5% Phase III studies at baseline and end of study for the areas of healthy nail and infected nail. Over 52 weeks (48-week treatment, 4-week follow up), women treated with tavaborole had an average 32% increase in healthy nail and 21% decrease in infected nail. Patients with baseline infection involving >50% of the nail plate had an average increase in percentage of unaffected nail surface area of 81% and a corresponding 51% decrease in infected nail. These analyses suggest that patients with the greatest toenail involvement at baseline had greater overall improvements than those who were less affected. This evaluation provides additional clinical guidance for treating women with onychomycosis using tavaborole. J Drugs Dermatol. 2018;17(2):168-172.

Deep neural networks show an equivalent and often superior performance to dermatologists in onychomycosis diagnosis: Automatic construction of onychomycosis datasets by region-based convolutional deep neural network

Although there have been reports of the successful diagnosis of skin disorders using deep learning, unrealistically large clinical image datasets are required for artificial intelligence (AI) training. We created datasets of standardized nail images using a region-based convolutional neural network (R-CNN) trained to distinguish the nail from the background. We used R-CNN to generate training datasets of 49,567 images, which we then used to fine-tune the ResNet-152 and VGG-19 models. The validation datasets comprised 100 and 194 images from Inje University (B1 and B2 datasets, respectively), 125 images from Hallym University (C dataset), and 939 images from Seoul National University (D dataset). The AI (ensemble model; ResNet-152 + VGG-19 + feedforward neural networks) results showed test sensitivity/specificity/ area under the curve values of (96.0 / 94.7 / 0.98), (82.7 / 96.7 / 0.95), (92.3 / 79.3 / 0.93), (87.7 / 69.3 / 0.82) for the B1, B2, C, and D datasets. With a combination of the B1 and C datasets, the AI Youden index was significantly (p = 0.01) higher than that of 42 dermatologists doing the same assessment manually. For B1+C and B2+ D dataset combinations, almost none of the dermatologists performed as well as the AI. By training with a dataset comprising 49,567 images, we achieved a diagnostic accuracy for onychomycosis using deep learning that was superior to that of most of the dermatologists who participated in this study.

The Clinical Presentation of Subcutaneous Phaeohyphomycosis: A Case Series from Yetebon, Ethiopia

Subcutaneous phaeohyphomycosis is a chronic fungal infection usually found on the lower extremity and feet of agricultural workers in the tropics. It can present with various skin manifestations, verrucous to nodular plaques, and is caused by multiple species of fungi. Laboratory confirmation requires skin samples for pathology and fungal cultures. Cure, often difficult in resource-poor countries, requires months of antifungal therapy. We describe the cases of three men from Ethiopia who were seen and are being treated by American doctors who traveled there on a medical mission.

Footwear used by older people and a history of hyperkeratotic lesions on the foot: A prospective observational study

Inadequate footwear, painful and hyperkeratotic lesions (HL) are an extremely common problems amongst older people. Such problems increase the risk of falls, hamper mobility, reduction of quality of life, dignity, and ability to remain independent. The etiology of painful and feet conditions is poorly understood.To discover footwear preferences of older people, pain tolerance may favor presence of HL for the use of inadequate footwear in old age.A sample of 100 participants with a mean age of 74.90 ± 7.01 years attended an outpatient clinic where self-reported demographic data, frequency with which they checked their feet were recorded and measurements were taken of foot sensitivity. Additionally, all participants' shoes were allocated into optimal, adequate, and dangerous categories based on design, structural and safety features, and materials.Only 12% of the sample population checked their feet every day, 37% revealed symptoms of neuropathy, 14% used optimal shoes, and 61% presented HL. In a bivariate analysis, no significant differences were observed.HL are associated with inadequate footwear, loss of sensitivity, and low frequency of foot health checks.

[Algorithm to facilitate the management of onychomycosis]

An algorithm is proposed to facilitate the management of onychomycosis and ensure a good therapeutical approach. Its aim is to simplify the diagnosis process by integrating a pertinent anamnesis and physical examination with the classic tool of mycology (direct examination, culture, eventually examination by PCR), in order to give the adequate targeted treatment.

Chronic granulomatous disease as a risk factor for cutaneous lupus in childhood

Chronic granulomatous disease (CGD) is a primaryimmunodeficiency disorder that affects the phagocyticcells of the innate immune system. It is characterizedby recurrent or persistent infections with granulomaformation. Lupus-like lesions have been reported incarriers of CGD and less frequently, in patients withCGD. Immunological study in these patients areusually negative. We describe the case of an 8-yearoldboy with CGD who developed chronic and acutecutaneous lupus erythematous with angular cheilitis,oral ulcers, Raynaud phenomenon, and positiveserologies for antinuclear, anticentromere, and anti-Saccharomyces cerevisiae antibodies.

Acquired aquagenic papulotranslucent acrokeratoderma

Aquagenic papulotranslucent acrokeratoderma isa rare condition with the development of white-totransluscentpapules and plaques after exposureto water. While the first report was described asan autosomal dominant hereditary condition,there have since been acquired cases reported inassociation with cystic fibrosis, with prior exposureto a drug, or as an idiopathic condition. We presenta 24-year-old man with acquired aquagenicpapulotranslucent acrokeratoderma that has beenpresent since infancy, without a family history,without prior drug exposure, and without anypersonal or family history of cystic fibrosis. Thus fartreatment with urea cream, calipotriene ointment,vitamin E cream, and clobetasol ointment hasbeen ineffective. Our patient will be treated withbotulinum toxin.