Pilot study to evaluate a plasma device for the treatment of onychomycosis.

Onychomycosis is a fungal infection of the nail unit, and is the most common of the nail disorders. Current therapies for onychomycosis have less than ideal efficacy and have the potential for adverse effects. As previous studies have shown that nonthermal plasma inhibits the in vitro growth of Trichophyton rubrum, we conducted a pilot study on 19 participants with toenail onychomycosis. The primary endpoint was safety of the device, and secondary outcome measures were clinical efficacy and mycological cure. Patient satisfaction was measured using questionnaires at the completion of the study. All but one patient met the primary endpoint of safety and there were no long-term sequelae. The overall clinical cure was 53.8% and the mycological cure was 15.4%. The majority of patients were satisfied with the treatment. Our conclusions are that nonthermal plasma is a safe treatment and may have a beneficial effect on toenail onychomycosis.

Onychomycosis in clinical practice: factors contributing to recurrence.

The treatment of onychomycosis has improved in recent years and many patients can now expect a complete and lasting cure. However, for up to 25% of patients, persistent disease remains a problem, thus presenting a particular challenge to the clinician. For these patients, it is obviously important to ensure that a correct diagnosis of onychomycosis has been made, as misdiagnosis will inevitably jeopardize the perception of therapeutic effectiveness. Although onychomycosis accounts for about 50% of all nail diseases seen by physicians, nonfungal causes of similar symptoms include repeated trauma, psoriasis, lichen planus, local tumours vascular disorders and inflammatory diseases. Predisposing factors that contribute to a poor response to topical and/or oral therapy include the presence of a very thick nail, extensive involvement of the entire nail unit, lateral nail disease and yellow spikes. However, poor penetration of systemic agents to the centre of infection, or the inability of topical agents to diffuse between the surface of the nail plate and the active disease below, probably contributes to this. Other factors contributing to recurrence may be related to the patient's family history, occupation, lifestyle or underlying physiology. In addition, patients with concomitant disease (e.g. peripheral vascular disease, diabetes) or patients who are immunosuppressed (e.g. those with human immunodeficiency virus/acquired immunodeficiency syndrome) are more susceptible to onychomycosis. In the elderly, the prevalence of onychomycosis may be as high as 60%, and increases with age; in this population, physical trauma plays a major role in precipitating recurrence, especially in patients with faulty biomechanics due to underlying arthritis and bone abnormalities. It is also possible that recurrence in some cases is due to early termination of treatment or use of an inappropriate dose, and these possibilities should be eliminated before further investigations are undertaken. There is good evidence to suggest that a combination of oral and topical therapies, when given at the same time, yield excellent clinical outcomes, although there remains a need for more effective topical agents with greater nail penetration and more effective oral antifungal agents.

A psychometric study of patients with nail dystrophies.

BACKGROUND: Survey studies suggest that patients with various dermatologic conditions experience concomitant psychologic distress. OBJECTIVE: The purpose of this study was to determine which types of psychologic distress may be correlated with dystrophic disease of the nail in nonpsychiatric patients. METHODS: Fifty-seven adult subjects presenting for treatment of nail dystrophies completed a survey instrument, which included 5 psychometric measures. RESULTS: On average, patients rated the severity of their nail dystrophy and functional deficit higher (7.40/10 and 6.00, respectively) than investigators (6.15 and 3.75, respectively). Compared with age- and sex-matched nonpsychiatric patients, subjects in the study were moderately more anxious and minimally to mildly more depressed. Subjects had moderately depressed total self-concept, but their body image was approximately normal. Overall, subjects exhibited markedly more severe psychologic symptoms (84th percentile) than the normal sample, with the scores on the psychoticism, obsessive-compulsive, and paranoid ideation subscales being the most elevated. CONCLUSION: The subjects with nail dystrophy had markedly exacerbated psychologic symptoms compared with age- and sex-matched nonpsychiatric patients.

Complications of nail surgery: a review of the literature.

BACKGROUND: The realm of nail unit surgery encompasses the dermatologist as well as the hand surgeon. Nail surgery complications may include allergy to anesthetic, infection, hematoma, nail deformity, and persistent pain and swelling. OBJECTIVE: To review the pertinent literature regarding nail unit surgery complications. METHODS: A Medline literature search was performed for relevant publications. RESULTS: Nail unit surgery complications appear to be relatively infrequent. The majority of postoperative nail deformity complications result from nail matrix damage. CONCLUSION: Complications may be reduced to a minimum by preventive measures, such as careful patient selection, sterile technique, and gentle treatment of the nail matrix.

Systemic antifungal therapy.

Systemic antifungal therapy for superficial mycoses has advanced greatly since the introduction of griseofulvin in 1958. The discovery of the azole antifungal compounds, ketoconazole, itraconazole, and fluconazole, allowed for a broader spectrum of treatment and a shorter treatment duration. Terbinafine, through a unique mechanism of action, has a fungicidal power not seen previously in the other antifungals. It is important to use our knowledge of the pharmacology in combination with clinical experience and cost of therapy in order to select the proper drug. The search to identify new oral antifungal agents should continue, since none of the five currently used drugs fulfill the criteria of the "ideal" antifungal.

Tazarotene 0.1% gel in the treatment of fingernail psoriasis: a double-blind, randomized, vehicle-controlled study.

A double-blind, randomized, vehicle-controlled, parallel-group trial was performed to compare the efficacy and tolerability of tazarotene 0.1% gel and vehicle gel in 31 patients with fingernail psoriasis. Patients were randomized to receive tazarotene or vehicle gel, which they applied each evening for up to 24 weeks to 2 target fingernails, one under occlusion and one unoccluded. The tazarotene treatment resulted in a significantly greater reduction in onycholysis in occluded nails (P < or = .05 at weeks 4 and 12) and a significantly greater reduction in onycholysis in nonoccluded nails (P < or = .05 at week 24). Tazarotene also resulted in a significantly greater reduction in pitting in occluded nails (P < or = .05 at week 24). There were no other significant between-group differences in pitting, subungual hyperkeratosis, leukonychia, nail plate crumbling/loss, splinter hemorrhage, or nail growth rate. Tazarotene 0.1% gel was well tolerated with only 5 of the 21 tazarotene-treated patients reporting a treatment-related adverse event (all mild or moderate). In conclusion, tazarotene 0.1% gel can significantly reduce onycholysis (in occluded and nonoccluded nails) and pitting (in occluded nails) and is well tolerated in the treatment of nail psoriasis.

Fusarium fingernail infection responsive to fluconazole intermittent therapy.

A case of fingernail infection by Fusarium is presented. This nondermatophytic mold is an infrequent cause of onychomycosis, more typically involving the great toenail. Characteristic histologic features including the presence of hyphae and chlamydoconia are helpful in rapid diagnosis and selection of appropriate antifungal therapy. Although Fusarium has shown resistance to most antifungal medications in vitro, intermittent therapy with fluconazole led to improvement in this patient.

Developments in the treatment of nail psoriasis, melanonychia striata, and onychomycosis. A review of the literature.

Nail psoriasis, melanonychia striata, and onychomycosis are relatively common nail disorders that have generated much research into their pathophysiology and treatment. The authors hope this discussion of the recent therapeutic developments for treating these disorders will not only inform but will also inspire further investigation so that therapeutic advances may continue.

The ABC rule for clinical detection of subungual melanoma.

BACKGROUND: Subungual melanoma is a relatively rare disease with reported incidence between 0.7% to 3.5% of all melanoma cases in the general population. Unlike the significant improvement in the diagnosis of cutaneous melanoma, the diagnosis of subungual melanoma has shown little, if any, improvement over the years. The widespread adoption of the ABCDs of cutaneous melanoma has helped increase public and physician awareness, and thus helped increase the early detection of cutaneous melanoma; the same criteria cannot be applied to the examination of the nail pigmentation. OBJECTIVE: We reviewed the world literature on subungual melanoma and arranged the available information into a system for the identification of subungual melanoma. This system has to be thorough, easy to remember, and easy to apply by both physician and lay public. A case to illustrate the delayed diagnosis often encountered in the current evaluation of nail melanoma is presented. METHODS: A thorough review of the world literature on subungual melanoma was undertaken. The important findings of various studies and case reports were compared among themselves and the salient features were summarized. The information was then categorized under the easily recalled letters of the alphabet, ABCD, that have already become associated with melanoma. RESULTS: The most salient features of subungual melanoma can be summarized according to the newly devised criteria that may be categorized under the first letters of the alphabet, namely ABCDEF of subungual melanoma. In this system A stands for a ge (peak incidence being in the 5th to 7th decades of life and African Americans, Asians, and native Americans in whom subungual melanoma accounts for up to one third of all melanoma cases. B stands for brown to black b and with breadth of 3 mm or more and variegated borders. C stands for change in the nail band or lack of change in the nail morphology despite, presumably, adequate treatment. D stands for the digit most commonly involved; E stands for extension of the pigment onto the proximal and/or lateral nailfold (ie, Hutchinson's sign); and F stands for family or personal history of dysplastic nevus or melanoma. CONCLUSION: Although each letter of the alphabet of subungual melanoma is important, one must use all the letters together to improve early detection and thus survival of subungual melanoma. Still, as with cutaneous melanoma, the absolute diagnosis of subungual melanoma is made by means of a biopsy.

Indinavir-related recurrent paronychia and ingrown toenails.

Lamivudine and indinavir are two medications used to treat human immunodeficiency virus (HIV) that have recently been reported to cause paronychia. The nails of the great toes are commonly affected. This is the second report of paronychia and ingrown toenails due to indinavir and the first report of recurrent paronychia and ingrown toenails associated with this drug.

Safety of itraconazole pulse therapy for onychomycosis. An update.

After experience with more than 34 million patients over 10 years, the safety of itraconazole and its potential drug-drug interactions are well known. In clinical trials, the average incidence of adverse events with a 1-week pulse regimen was 18% in pooled safety data (n = 2,867); only 2.2% of patients dropped out. In direct comparative trials, the incidence of mild and reversible adverse effects was comparable for itraconazole and terbinafine (31% and 28%, respectively) during treatment. The rate of permanent withdrawal because of adverse events was 3.6% for itraconazole and 7.5% for terbinafine (P < .05). Itraconazole was significantly better tolerated as evaluated by the investigator and patients. The analysis of the elderly subpopulation showed that patients 65 and older tolerated itraconazole pulse well, with only 20% experiencing mild and reversible side effects (total group). In direct comparative trials, itraconazole also produced fewer adverse effects than terbinafine (13% vs 32%, respectively). As newer oral antifungal agents gain widespread use, clinicians need to be aware of their potential drug-drug interactions and their possibly serious adverse events. However, pooled data from the 1-week itraconazole pulse regimen indicated a favorable safety profile, and a dose increase to 400 mg had no impact on safety.

Onychomycosis: therapeutic update.

Onychomycosis is a common disease of the nail unit caused by dermatophytes, yeasts, and molds. In more than 80% of cases, onychomycosis is caused by the dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes. The prevalence of onychomycosis in the world's population is 2% to 18% or higher and accounts for approximately 50% of all nail disorders. Until recently, available therapies were inadequate because of low cure rates, high relapse rates, and often dangerous side effects. An increased understanding of nail pharmacokinetics has led to the development of safer, more effective systemic therapies for onychomycosis, such as itraconazole, fluconazole, and terbinafine. These new oral antifungal agents allow shorter periods of treatment, provide rapid efficacy, and may improve patient compliance and attitudes regarding therapy. Treatment selection will depend on several factors, including appropriate spectrum of activity, adverse effects, and potential drug interactions plus patient preferences for specific dosing regimens.

Managing common nail disorders in active patients and athletes.

Sports-related acute nail trauma can cause subungual hematoma and pain, which can be alleviated by fluid evacuation; the differential diagnosis includes subungual melanoma. A careful history will help distinguish splinter hemorrhages related to systemic disease from those caused by trauma. Chronic trauma can damage the nail matrix, leading to longitudinal splits or ridging, pigmentary changes, pterygium, or dystrophy. Mildly ingrown toenails can be treated with cotton placed under the lateral nail edges and proper trimming; severe cases may require surgery. Treatment of acute paronychia includes systemic antibiotics, while chronic paronychia may require topical or systemic antifungal agents.