Overall Prevalence and Prevalence Compared among Psoriasis Treatments of Onychomycosis in Patients with Nail Psoriasis and Fungal Involvement

BACKGROUND

Whether nail psoriasis can increase the risk of onychomycosis is still being debated, and data relating to the prevalence of onychomycosis among psoriasis patients receiving different treatments is limited.

OBJECTIVES

To investigate the overall prevalence and prevalence compared among psoriasis treatments of onychomycosis in patients with nail psoriasis and fungal involvement.

METHODS

A prospective study of three groups of nail psoriasis being treated with only topical medication, methotrexate, or biologics (25 patients per group, 150 nails) was conducted at Siriraj Hospital (Bangkok, Thailand) during November 2018 to September 2020. Demographic data, psoriasis severity, and nail psoriasis severity were recorded. The nail most severely affected with psoriasis on each hand was selected for mycological testing. Potassium hydroxide, periodic acid-Schiff stain, and fungal culture were performed.

RESULTS

The prevalence of onychomycosis in nail psoriasis was 35.3%. Among the treatment groups, the prevalence of onychomycosis was significantly higher in the methotrexate group than in the topical treatment and biologic treatment groups (p = 0.014). Candida spp. was the main causative organism, followed by Trichophyton rubrum. Thumb was most commonly affected (59.3%). The most common abnormality of the nail matrix and the nail bed was pitted nail (71.3%) and onycholysis (91.3%), respectively. Multivariate analysis revealed diabetes, wet-work exposure, and methotrexate treatment to be predictors of onychomycosis.

CONCLUSIONS

Several factors, including psoriasis treatment, were shown to increase the risk of onychomycosis in nail psoriasis. Further research is needed to determine whether biologic agents, especially interleukin-17 inhibitors, can increase risk of onychomycosis and Candida infection/colonization of the nails.

Assessment of the nail penetration of antifungal agents, with different physico-chemical properties

Onychomycosis, or fungal nail infection, is a common fungal infection largely caused by dermatophyte fungi, such as Trichophyton rubrum or Trichophyton mentagrophytes, which affects a significant number of people. Treatment is either through oral antifungal medicines, which are efficacious but have significant safety concerns, or with topical antifungal treatments that require long treatment regimens and have only limited efficacy. Thus, an efficacious topical therapy remains an unmet medical need. Among the barriers to topical delivery through the nail are the physico-chemical properties of the antifungal drugs. Here, we explore the ability of a range of antifungal compounds with different hydrophilicities to penetrate the nail. Human nail discs were clamped within static diffusion (Franz) cells and dosed with equimolar concentrations of antifungal drugs. Using LC-MS/MS we quantified the amount of drug that passed through the nail disc and that which remained associated with the nail. Our data identified increased drug flux through the nail for the more hydrophilic compounds (caffeine as a hydrophilic control and fluconazole, with LogP -0.07 and 0.5, respectively), while less hydrophilic efinaconazole, amorolfine and terbinafine (LogP 2.7, 5.6 and 5.9 respectively) had much lower flux through the nail. On the other hand, hydrophilicity alone did not account for the amount of drug associated with/bound to the nail itself. While there are other factors that are likely to combine to dictate nail penetration, this work supports earlier studies that implicate compound hydrophilicity as a critical factor for nail penetration.

Nail clipping in onychomycosis and comparison with normal nails and ungual psoriasis

BACKGROUND

Of all nail disorders seen in dermatology offices, half of them are due to onychomycosis. The main differential diagnosis is nail psoriasis. The objective of this study was to compare the microscopic findings, other than the presence of fungi, in the clipping of onychomycosis versus normal nails and nail psoriasis.

METHODS

Cross-sectional study of onychomycosis cases, analyzed by clipping and compared with data on normal nails and those with nail psoriasis.

RESULTS

Sixty-two onychomycosis samples were compared with 30 normal nails and 50 nails with psoriasis. In onychomycosis, measurement of subungual region, serous lakes, neutrophils and number of layers of parakeratosis are more intense than in psoriasis. Onychocariosis is less common in psoriasis, while bacteria are more frequent. The nail transition zone is more commonly blurred and irregular in onychomycosis.

CONCLUSION

Clipping helps in the differential diagnosis of onychomycosis and nail psoriasis and may be useful even when fungi are not found.

Green fingernail

The patient hadn't injured her thumb and it didn't hurt. So why had her nail turned green?

[Species distribution and antifungal susceptibility of Candida spp. causing superficial mycosis. Coro, Falcon state, Venezuela]

Candida species other than C. albicans are often described as causative agents of superficial mycosis and are more resistant to treatment with azoles. In order to determine the distribution of species and in vitro antifungal susceptibility of Candida spp., one ambispective study, which analyzed 18 yeast isolates obtained from samples from patients diagnosed with superficial mycosis, was performed. Taxonomic identification was performed by macroscopic visualization of the growth characteristics in chromogenic agar and by conventional methods. The susceptibility to fluconazole and voriconazole was evaluated by the disc diffusion method. Most of the isolates (88.8%), came from nail samples. C. parapsilosis was the most common species, followed by C. tropicalis, C. albicans and C. krusei, which confirmed the prevalence of non-albicans species as a cause of superficial mycoses. The pattern of susceptibility to fluconazole and voriconazole was similar: all isolates of C. parapsilosis and C. albicans were susceptible, while 83.3% of C. tropicalis showed sensitivity to both antifungals. C. krusei, fluconazole-resistant species showed intermediate susceptibility io voriconazole. The use of chromogenic agar allowed to detect mixed infections in nail samples, involving Candida spp. and C. tropicalis in one case, the latter with resistance to both fluconazole and voriconazole. The results demonstrate the importance of species identification and susceptibility testing to avoid therapeutic failures in superficial mycoses.

Subungual abscess caused by Staphylococcus lugdunensis

Although Staphylococcus lugdunensis is a constituent of the normal human skin flora, it does have pathogenic potential. Infections can range from severe (eg, endocarditis, osteomyelitis) to less invasive skin and soft-tissue infections. We report a case of a subungual abscess in a patient with S lugdunensis infection.

[Melanonychia: The purpose of a case of ungual mycotization mimicking melanoma]

INTRODUCTION

Phialophora sp. dematiaceous fungus frequently isolated from soil and organic debris from animals and plants. There have been no reports of nail involvement caused by this fungus. We report the case of a 77-year-old male with blackish-brown pigmentation involving a single finger for one year. The identification of the fungus was determined by macromorphological and micromorphological study of the colony and we discuss the clinical, microbiological, differential diagnosis, and treatment.

COMMENT

We describe the first case of nail infection caused by Phialophora sp.

An 8-year-old boy with autoimmune hepatitis and Candida onychosis as the first symptoms of autoimmune polyglandular syndrome (APS1): identification of a new homozygous mutation in the autoimmune regulator gene (AIRE)

An 8-year-old boy presented in 1995 with a 2-year history of hypertransaminasemia and hypergammaglobulinemia. Afterwards the patient displayed onychosis with a positive culture test for Candida albicans (CA). Because of the persistence of hypertransaminasemia, a percutaneous liver biopsy was performed showing 'low grade chronic active autoimmune hepatitis' (AIH), positive for liver-kidney microsomal autoantibodies and antibodies to the hepatic autoantigen cytochrome P450-1A2. Immunosuppressive treatment was initiated. In 2003 he developed Addison's disease resulting in the diagnosis of autoimmune polyendocrinopathy candidiasis-ectodermal dysplasia (APECED) syndrome, also known as autoimmune polyendocrine syndrome type 1 (APS1). Anti-17OH hydroxylase antibodies tested negative, anti-21-OH hydroxylase autoantibodies were positive. Among the other relevant organ- and non organ- specific autoantibodies, aromatic L-amino acid decarboxylase (ADDC) autoantibodies and anti-tryptophan hydroxylase autoantibodies were positive. The patient also presented polyuria and polydypsia with diabetes insipidus. Because of the presence of two diagnostic criteria of APS1, mutations in the autoimmune regulator gene (AIRE) were performed, which revealed the presence of a novel mutation (c1314- 1326 del 13/insGT) in exon 11. In conclusion, the diagnosis of APECED should be suspected in any child with minimal hypertransaminasemia, anti-microsomal autoantibodies and Candida albicans onychosis.

Occurrence of Scopulariopsis and Scedosporium in nails and keratinous skin. A 5-year retrospective multi-center study

A 5-year retrospective multicenter study was performed for microascaceous moulds (Microascaceae, Ascomycetes) in Finnish clinical specimens. The files from 1993-1997 of six clinical mycology laboratories in Finland were searched for reports of these fungi, mainly Scopulariopsis and Scedosporium anamorphs in keratinous specimens. From the 521 primary findings, 165 cases were selected for further study based on direct microscopy, colony numbers and accompanying fungi. The clinical records of 148 cases (141 Scopulariopsis, 7 Scedosporium) were studied. Of the nail infections from which Scopulariopsis was recovered, 39 cases were further separated which showed clinical or laboratory-based evidence of dermatophytosis. In the remaining 90 'non-dermatophyte' nail cases, Scopulariopsis spp. were the only documented fungal agents (c. 6 cases/million/year). The patients were mainly elderly, 66% of whom had problems involving their big toe nails. For 74% of them, the nail problem was mentioned as their reason for visiting the physician. However, only 18% had documented benefit from treatment. The Scopulariopsis nail infections seem to be treatment-resistant and the pathogenesis and etiological role of Scopulariopsis remain poorly understood.

Treating cosmetically induced nail problems

Smooth, lustrous nails are a sign of health and beauty in our society and fuel the US$6-billion nail salon industry in the United States. Although many women can use nail cosmetics without adverse consequences, when problems occur it is important to recognize the causes and treat the problem condition. The cornerstone of management of nail cosmetic problems is prevention through education. In spite of efforts to that end, nail salon procedures and materials can cause nail disease that must be recognized and treated in order to restore the nails to health.

Onychoprotothecosis: report of the first case in Brazil

The present report describes a case of onychoprotothecosis caused by Prototheca wickerhamii in a nonimmunocompromized female. Dermatological examination showed yellowish discoloration of the left and right forefinger nails, showing onicolysis and hyperkeratosis. The repeated isolation of the algae Prototheca (organisms morula-like) as well as the repeated culture in media, Sabouraud agar, confirmed the diagnosis. The patient was successfully treated with tioconazol 1% topic solution. The aim of this paper was to present a rare condition.

[Septic polyarthritis due to an infected nail bed around an ingrown toenail in a previously healthy boy]

A 17-year-old, previously healthy boy was admitted with complaints of fever, malaise and pain in the pubic region and groin. His left elbow was also warm and swollen and could not be extended fully. Cultures of fluid drained from both hips and the elbow, blood and inflamed tissue from the nail bed of the right big toe yielded Staphylococcus aureus. The patient was treated with intravenous antibiotics for septic arthritis of both hips, the left elbow and possibly the pubic symphysis. The infected nail bed, which was the most likely port of entry, was also treated. One year later, the original painful symptoms had disappeared but the right hip was almost immobile. In a patient with indications of septic arthritis, timely diagnosis and adequate therapy reduce the risk of permanent damage to the joint.

The nail under fungal siege in patients with type II diabetes mellitus

Few studies have examined the prevalence of onychomycosis among diabetic patients. Given the morbidity linked to onychomycosis, and the ever-growing size of the diabetic population, a better recognition of this nail infection is welcome. To revisit the relative prevalence of dermatophyte, yeast and non-dermatophytic mould onychomycoses in diabetic adults in a prospective study using combined histomycology and cultures. Toenail clippings were collected for 3 years in 190 type II diabetic patients (136 men and 54 women) and from an age- and gender-matched group of non-diabetic subjects. All sampled nails showed clinical alterations reminiscent of onychomycosis. Histomycology and cultures were performed on each sample to distinguish onychomycosis from non-infectious onychodystrophy. Compared to non-diabetic subjects with nail alterations, diabetics showed a higher proportion of onychomycosis relative to non-fungal onychodystrophy. Diabetic men suffered more frequently from onychomycosis and onychodystrophy than diabetic women. When considering the nature of the fungal pathogens, dermatophytes predominated largely over yeast and non-dermatophytic moulds, both in diabetic and non-diabetic patients. Diabetic patients, particularly men, are at increased risk of developing onychomycosis. The morbidity linked to this disorder, and its impact on the foot status in diabetic subjects merit to be better appreciated by clinicians.

Subungual erythema in lymph node tuberculosis with erythema nodosum

We encountered a case of tuberculous lymphadenitis with erythema nodosum presenting with an unusual manifestation as subungual erythema in all the digits. Relevant literature and the possible explanation for the subungual erythema have been discussed.

Longitudinal melanonychia of the toenails with presence of Medlar bodies on biopsy

A 9-year-old girl presented with a 2-year history of pigmented streaks on her second right toenail as well as on her fourth and fifth left toenails. The patient was otherwise asymptomatic with no other physical findings. Owing to parental concern, a biopsy was performed, which revealed numerous bacteria as well as Medlar bodies overlying the nail bed with no evidence of a nevomelanocytic lesion. To our knowledge, this is the first report of Medlar bodies causing pigmented streaks in the toenails.

[Nail disease due to Scytalidium in Martinique (French West Indies)]

INTRODUCTION

Scytalidium is an endemic mold in tropical and subtropial areas. Our purpose was to study the prevalence and clinical and epidemiological features of onychomycoses due to Scytalidium in Martinique (French West Indies).

PATIENTS AND METHODS

We performed a prospective study on 106 patients (46 men and 60 women) with clinical onychomycosis, in the dermatological department of the Centre Hospitalier Universitaire of Fort-de-France. All patients underwent mycological sampling and were divided into two groups depending on the presence or not of Scytalidium. Age, sex, localization, clinical aspects, time of duration and environmental factors (place of residence, garden, animals, bare foot walk, immunodepression) were compared between the two groups using chi2, Fisher and Student's t test. Ten control volonteers without clinical onycomycosis underwent mycological sampling.

RESULTS

Onychomycosis due to scytalidium represented 42 p. 100 of patients (Scytalidium hyalinum in 91 p. 100 of cases) and 56 p. 100 after elimination of patients with negative results. Medium age was significantly higher in Scytalidium group (62 versus 54 years; p<0.02). Toe nail was involved in 95 p. 100 of patients (big toe nail in 77 p. 100). Sole involvement was more frequent in Scytalidium group (47 p. 100 versus 14 p. 100; p<0.001). Sampling of controls showed scytalidium in one case.

DISCUSSION

Our study confirmed the endemicity of Scytalidium hyalinum in Martinique and the frequence of sole involvement. Presence of Scytalidium without clinical features in one control is of epidemiological interest, and may explain the frequence of the disease.

Septic arthritis of the ankle due to Salmonella enteritidis: a case report

Salmonella septic arthritis in healthy individuals is a rare phenomenon in the United States. This case report chronicles the clinical course of a 41-year-old male farmworker who presented with a 3-week history of fever, chills, night sweats with pain, and swelling and redness of his left ankle. He had an open fracture of the ankle 2 years earlier that healed and was asymptomatic despite prior radiographic evidence of avascular necrosis of the talar dome. One month before presentation, he had an ipsilateral periungual abscess of the great toe that he opened and drained himself. Joint cultures were positive for Salmonella enteritidis that was successfully treated with a 6-week course of i.v. ceftriaxone.

Onychomycosis due to Emericella quadrilineata

Nondermatophytic fungi are increasingly being reported as etiological agents of onychomycosis. We describe here a case of hand nail infection caused by Emericella quadrilineata (anamorph Aspergillus tetrazonus), a species not so far known to be an etiological agent of onychomycosis.

Toenail onychomycosis in Estonia. Zehennagel-Onychomykose in Estland

The aim of our study was to evaluate the clinical features, predisposing factors and pathogens of toenail onychomycosis in Estonia. During study period we interviewed and examined 436 dermatological patients with clinical signs of toenail onychomycosis in all counties of Estonia. In 69% of cases, the clinical diagnosis of onychomycosis was confirmed by the mycological analysis. The most common clinical symptoms of onychomycosis both in mycologically proven and non-proven cases were discolorization of nail plate, hyperkeratosis and brittle nails. The number of infected toenails positively correlated with patients' age. On average, patient had 5.4 infected nails. In 78% of culture-positive cases, a dermatophyte was isolated as the causative agent, in 10% yeasts and in 7% moulds. In 6% of culture-positive cases we reported mixed infections. Trichophyton rubrum was the most common pathogen. The high occurrence of mixed infections, clinical symptoms characteristic to long lasting or chronic infection and high number of infected toenails indicate that Estonian patients have more advanced stage of toenail onychomycosis compared with other western and central European countries.

First Italian report of onychomycosis caused by Onychocola canadensis

Onychocola canadensis is a non-dermatophytic mould that has been associated with onychomycosis particularly in temperate climates. Until now, O. canadensis has been isolated from patients in Canada (14 cases), New Zealand (three), France (nine), UK (four) and Spain (two). We describe the first Italian case of onychomycosis caused by this fungus.

Nailing a key assessment. Learn the significance of certain nail anomalies

Discover how a patient's fingernails can point out specific health problems.

Psoriatic nails: a prospective clinical study

BACKGROUND

Psoriasis is a widespread skin disorder in which nail involvement is a common symptom. Many psoriatic patients have nail changes morphologically resembling onychomycosis.

OBJECTIVE

The present study was undertaken (1) to evaluate the frequency of nail involvement in psoriatic patients, (2) to assess the types of nail changes in psoriasis, (3) to find eventual relationships between nail involvement and some clinical parameters, and finally (4) to determine the prevalence of fungal nail infections in psoriatic individuals.

MATERIAL AND METHODS

One hundred six patients hospitalized in our department due to exacerbation of psoriasis participated in the study. Each patient underwent dermatologic examination with special attention paid to the nail changes. In any case of abnormalities clinically suspected of fungal infection, further mycological investigations were performed.

RESULTS

Nail changes were present in 83 patients (78.3%) with psoriasis. The most common nail abnormality observed on both fingernails and toenails was subungual hyperkeratosis. Hyperkeratosis, onychorrexis, and discoloration of nail plates were observed significantly more often on toenails. Pitting and longitudinal ridges were significantly more frequent on fingernails. Patients with psoriatic nail dystrophy were significantly older than psoriatic patients without nail abnormalities. Nails were involved statistically more often in patients with arthropathic psoriasis. Positive mycological cultures were obtained from 18% of patients with nail changes. The most commonly isolated fungi were molds.

CONCLUSIONS

Dystrophic nails are frequently found in psoriatic individuals, especially those suffering from arthropathic psoriasis. Subungual hyperkeratosis and pitting are the most typical lesions. It is difficult to assess definitively whether psoriasis is a predisposing factor to the development of fungal infections of the nails.

Susceptibility to fungal infections of nails in patients with primary antibody deficiency

Primary antibody deficiencies are rare diseases, which require early treatment with intravenous immunoglobulins to prevent fatal infections. The cell mediated immunity in patients with those immunodeficiencies remains unimpaired and usually they do not develop fungal infections. The aim of the study was to determine the susceptibility to fungal infections of nails in children with X-linked agammaglobulinaemia (XLA) and common variable immunodeficiency (CVID). Nail plate fragments collected from five patients with XLA and five with CVID were experimentally infected with a Candida albicans and Trichophyton mentagrophytes strains. The same procedures were carried out with the nails from a control group of 10 healthy volunteers. The intensity of the infection was evaluated on the basis of hyphae ingrown into the nail fragments. The main finding of the study was the increased susceptibility of antibody deficient patients to experimental nail infection with C. albicans and T. mentagrophytes.

Fungal infections of the perionychium

There are two types of fungi (yeasts and molds) both of which can cause superficial infections of the perionychium. Yeasts (such as Candida albicans) grow as single cells and reproduce by asexual budding. In contrast, molds grow in long filaments, called hyphae. There are approximately 100,000 species of fungi that have been characterized. Most of these are ubiquitous. Fortunately only about 200 are human pathogens, and only a handful are commonly found to be associated with human disease. This article discusses causes, symptoms, diagnosis, and treatment of the most common fungal infections of the perionychium, including superficial dermatophytosis, onychomycosis, and chronic paronychia.

[Green nail syndrome or chloronychia]

"Green nails" or chloronychia is an infection mostly caused by Pseudomonas ueruginosa but also by other bacterial or fungal contamination. The clinical appearance consists in a typical triad: green discoloration of the nail plate associated with proximal chronic paronychia and disto-lateral onycholysis. Exposition to moist environment, microtraumatisms, oaychotillomania and associated nail diseases such as psoriasis may promote infection by Pseudomonas. Treatment consists in cutting of the detached nail plate, brushing the nail bed with a 2% sodium hypochlorite solution twice daily and eviction of the repeated immersions by wearing cotton and latex gloves.

[Nail plate susceptibility to Scopulariopsis brevicaulis infection]

Nail plate susceptibility to Scopulariopsis brevicaulis infection. Experimental Scopulariopsis brevicaulis infection of toe and finger nails collected from 79 persons of both sexes and at various age is presented. Crumbled nail fragments were incubated with a S. brevicaulis strain isolated from toenail acauliosis. The culture was inspected and evaluated under light microscope after seven days of incubation. Hyphe intensively penetrating nail fragments were found in 67.1% of toenails and 38% of fingernails. The infection was most intensive in the nails collected from males and elderly persons.