Growth inhibition of Trichophyton rubrum by laser irradiation: exploring further experimental aspects in an in vitro evaluation study.

BACKGROUND: According to the results of the clinical trials, laser therapy is effective for the treatment of onychomycosis, but the in vitro findings are inconsistent among studies. This study aimed to explore the experimental conditions of laser for the inhibition of Trichophyton rubrum growth in vitro. A 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser was used to irradiate colonies using a small (6-mm diameter) or large (13-mm diameter) area, and using 300, 408, or 600 J/cm2. The surface temperature of the colony was measured after irradiation and every 2 min. The growth area was calculated until the 7th or 10th day of incubation daily. RESULTS: For the small area group, at 300 J/cm2, the immediate surface temperature was 25.2 ± 0.2°C, but without effect on growth (P = 0.516). At 408 J/cm2, the immediate surface temperature was 32.0 ± 0.4°C; growth was inhibited for 7 days (P < 0.001). At 600 J/cm2, the immediate surface temperature was 38.1 ± 0.4°C; the growth was completely stopped for at least 10 days (P < 0.001). For the large area group, the temperature patterns were similar to those of the small area group, but the highest temperature was lower than in the small area groups, and no growth inhibition effect was observed (all P > 0.05). CONCLUSIONS: When the irradiation area is small, a 1064-nm Nd:YAG laser at 408 or 600 J/cm2 can be effective in suppressing T. rubrum growth in vitro.

Real-world effectiveness of a fractional CO2 laser with topical antifungal agents for the treatment of onychomycosis.

Current therapeutic agents for onychomycosis have limited efficacy or cause side effects. Recently, successful treatment using fractional CO2 lasers has been reported; however, the results are inconsistent. We analyzed the real-world effectiveness of a Fractional CO2 laser for the treatment of Onychomycosis A single-center retrospective chart review was conducted during January 2015-December 2018. Patients, diagnosed with onychomycosis through fungal culture and/or potassium hydroxide staining, underwent three or more fractional CO2 laser treatments and used topical antifungal agents. Treatment effects were assessed by using clinical images at 6, 12 months, and the last visit. Ninety-six patients were included; they underwent an average of 7.7 laser treatment sessions. Finally, 15 patients (15.6%) showed complete response (100% clearing of all nails), 24 patients (25%) showed partial response, and 57 patients (59.4%) showed no response (no 100% clearing of nails among all treated toenails per patient including mild improvement or temporary cosmetic improvement). Multivariable logistic regression analysis revealed longer disease duration (p = 0.006, OR = 1.16 [95% CI: 1.05-1.31]), patients with diabetes (p = 0.021, OR = 9.82 [95% CI: 1.75-94.01]) and fewer number of laser treatment sessions (p = 0.001, OR = 0.76 [95% CI: 0.64-0.89]) were significantly associated with non-response group. In conclusion, fractional CO2 laser with topical antifungal could be a safe alternative treatment in patients with onychomycosis, who are difficult to take oral antifungals.

Tinea pedis-An embarrassing problem for health and beauty-A narrative review.

Fungal infections present with a broad spectrum of diseases in humans (from relatively mild superficial infections of the skin and mucous membranes to the invasive or chronic infections of internal organs, which have a high mortality rate). Globally, up to 1.6 million people die each year as a result of various types of mycoses. Currently, many scientific studies focus on the best possible understanding of the aspects of the epidemiology and pathogenesis of invasive mycoses and effective methods to combat them. However, mycoses of the skin and its appendages remain a relatively less explored area. In some communities, superficial mycoses are a frequent problem as they affect nearly 70% of the population, an example of which is the athlete's foot. It involves the nails (onychomycosis) and skin (tinea pedis). It is mainly caused by keratin-decomposing dermatophyte fungi. Less often, infections are caused by non-dermatophyte moulds (Fusarium, Aspergillus, Scopulariopsis) or yeasts. Several factors have been listed as having substantial influence on the development of dermatophytosis, including those related to climate, season, geographical region, as well as to demography, socioeconomic and cultural customs, professions or contact with animals. In this review, we summarise the current knowledge about aetiology, epidemiology, diagnostics and therapy of tinea pedis with a special focus to the role of podologic management in spreading, prevention and therapy of mycoses. The article presents up-to-date knowledge on the management of the patient from the diagnosis, treatment and skincare, to counselling on how to prevent fungal skin infections in the long term.

Cold sub-atmospheric and atmospheric pressure plasma for the treatment of Trichophyton rubrum onychomycosis: An in-vitro study.

Previous studies have suggested the applicability of cold atmospheric pressure plasma for the treatment of onychomycosis. Whether delivering cold plasma in sub-atmospheric pressure would be beneficial for this purpose is yet to be established. The current study aimed to evaluate efficacy of cold sub-atmospheric and atmospheric pressure plasma in Trichophyton rubrum growth inhibition. Bovine nails infected with T. rubrum were treated by a cold air plasma device, which enables utilizing plasma in sub-atmospheric pressures (Low = 100 millibar; High = 300 millibar) or atmospheric pressure. The infected foci were exposed to the plasma source directly or indirectly. Treatment with high sub-atmospheric pressure setting achieved T. rubrum growth reduction of 94.0% and 73.0%, for direct and indirect exposure to the plasma source, respectively (P < .001). Low sub-atmospheric pressure setting achieved similar T. rubrum growth reduction of 86.2% for direct exposure to the plasma source (P < .001), but only marginally significant 58.8% reduction rate for indirect exposure to the plasma source (P = .056). None statistically significant fungal growth reduction was attained with the use of atmospheric pressure setting. Cold plasma was shown to effectively inhibit T. rubrum nail growth, with sub-atmospheric pressure setting achieving better outcome than atmospheric pressure.

Fractional CO2 laser plus topical antifungal versus fractional CO2 laser versus topical antifungal in the treatment of onychomycosis.

Onychomycosis is an important medical disorder affecting both health and quality of life of patients. This study was done to compare the efficacy of CO2 laser in combination with topical tioconazole versus CO2 laser only versus topical tioconazole alone in onychomycosis. A total of 120 patients with onychomycosis were randomly assigned to three groups. Group A patients were treated with fractional CO2 laser followed by topical tioconazole 28% for five sessions with 3 weeks interval. Group B patients were treated with only fractional CO2 laser for five sessions with 3 weeks interval. Group C patients were treated with only topical tioconazole 28% for 16 weeks. The clinical effect, KOH examination, and culture for the affected nails in the three groups were analyzed. One month after the last session, regarding clinical response, 55% showed complete clinical improvement in Group A versus 30% in Group B versus 25% in Group C with a significant difference in between. There was a significant difference between the three studied groups as regard KOH test and culture after treatment. Fractional CO2 laser combined with topical antifungal is a safe and effective treatment for onychomycosis.

Long-Pulsed Nd:YAG (1,064 nm) Laser Versus Q-Switched Nd:YAG (1,064 nm) Laser for Treatment of Onychomycosis.

BACKGROUND AND OBJECTIVES: To compare the efficacy of the long-pulsed Nd:YAG (1,064 nm) laser versus the Q-Switched Nd:YAG (1,064 nm) laser in treatment of onychomycosis. STUDY DESIGN/MATERIALS AND METHODS: This is a prospective cohort study. It was carried out on 20 patients with clinical and mycological evidence of onychomycosis who were randomly assigned into two groups; group I: included 10 patients treated with biweekly sessions of long-pulsed Nd:YAG (1064 nm) laser and group II; included 10 patients treated with monthly sessions of Q-Switched Nd:YAG (1064 nm) laser. The assessment was done using proximal nail measurement and microscopic examination using 10-20% potassium hydroxide solution and culture on Sabouraud's dextrose agar. All patients were followed up for 6 months after the last treatment session. RESULTS: Fungal isolates in the present study were grouped into yeast in 50%, non-dermatophyte moulds in 10%, while dermatophyte infection was detected in 40%. Each group showed a statistically significant improvement in proximal nail plate measurements with no statistically significant difference between both groups. Mycological cure was only achieved in 40% of group I and 30% of group II. Patient satisfaction was higher in group II. CONCLUSIONS: Both long-pulsed Nd:YAG (1064 nm) and Q-Switched Nd:YAG (1064 nm) laser systems can be used as a safe and effective modality in the treatment of onychomycosis, particularly in patients who refuse or have a contraindication to oral antifungal treatment. Lasers Surg. Med. 00:00-00, 2019. © 2019 Wiley Periodicals, Inc.

A prospective study using image analysis to assess the efficacy of a topical treatment kit for mild onychomycosis.

BACKGROUND: Onychomycosis is a fungal infection of the nails and is one of the most common dermatological infections worldwide. Infection occurs predominantly in the nails of the feet and if left untreated patients, particularly in at-risk populations, can develop more serious complications, including pain, fissuring and secondary infections. Fungal infections are also contagious and may spread to other nails or to family members. Topical treatments can be effective for mild cases of the disease and typically have fewer contraindications. However, generation of robust efficacy data for topical therapies is often hindered by the difficulties associated with monitoring progression of mild onychomycosis using the conventional methods of mycological culture to obtain confirmation of podiatrist assessments. OBJECTIVES: The aim of this study was to demonstrate image analysis as an effective method to monitor progression of fungal nail infections. METHODS: A novel digital image analysis technique was used to evaluate improvement in the visual signs of onychomycosis, when using a topical treatment kit for mild fungal nail infections in 60 participants over a 280-day period. RESULTS: Image analysis demonstrated a significant (P < .0001) reduction from baseline of the affected nail area throughout the study period, results which were also perceived by the subjects themselves. Use of the treatment kit also limited the deterioration of the infection and prevented transmission to other nails. CONCLUSIONS: Image analysis was established as a viable method to monitor the progression of fungal nail infections over long periods and demonstrate a clinical benefit following treatment.

Non-thermal atmospheric plasma treatment of onychomycosis in an in vitro human nail model.

BACKGROUND: Onychomycosis affects almost 6% of the world population. Topical azoles and systemic antifungal agents are of low efficacy and can have undesirable side effects. An effective, non-invasive therapy for onychomycosis is an unmet clinical need. OBJECTIVE: Determine the efficacy threshold of non-thermal atmospheric plasma (NTAP) to treat onychomycosis in an in vitro model. METHODS: A novel toe/nail-plate model using cadaver nails and agarose media inoculated with Candida albicans was exposed to a range of NTAP doses. RESULTS: Direct exposure of C albicans and Trichophyton mentagrophytes to 12 minutes of NTAP results in complete killing at doses of 39 and 15 kPulses, respectively. Onset of reduced viability of C albicans to NTAP treatment through the nail plate occurs at 64 kPulses with 10× and 100× reduction at 212 and 550 kPulses, respectively. CONCLUSIONS: NTAP is an effective, non-invasive therapeutic approach to onychomycosis that should be evaluated in a clinical setting.

[Mechanisms of action and clinical effectiveness of ultratonotherapy in the complex treatment of foot onychomycosis]. / Mekhanizmy deistviya i klinicheskaya effektivnost' ul'tratonoterapii v kompleksnom lechenii onikhomikozov stop.

INTRUDUCTION: A long course of onychomycosis, severe hyperkeratosis, slow growth of the nails of the feet, somatic burden, as well as an increase in the resistance of pathogens often lead to a decrease in the effectiveness of traditional antimycotics, dictating the need to create new methods of therapy. A promising direction of treatment is the use of alternating current of supratonal frequency of high voltage and low power - ultratonotherapy (UT) in combination with antifungal drugs. The article presents data on the mechanisms of action and clinical effectiveness of this method in the complex treatment of foot onychomycosis. AIM OF STUDY: To study the mechanisms of action and evaluate the clinical effectiveness of UT in the complex treatment of foot onychomycosis. MATERIAL AND METHODS: The antifungal effect of UT was studied in the colonies of Trichophyton rubrum and Candida albicans. The distribution of ozone released during the procedure on the affected nail plate was evaluated in vitro using a qualitative chemical reaction and photodermatoscopy. The state of tissue blood flow in the periungual tissues under the influence of UT was studied in vivo by means of ultrasound dopplerographic scanning (USDGS). The clinical effectiveness of the method was evaluated according to the results of complex treatment of patients with foot onychomycosis in comparison with traditional methods of therapy. RESULTS: UT has both fungicidal and fungistatic effects. With a qualitative reaction to ozone, coloring of the surface and small structures of the nail plate was noted. According to the USDGS, after the use of UT, a significant increase in blood supply to the periungual tissues was recorded. The combined use of alternating current of a high voltage ultrasonic frequency with antifungal drugs in patients with foot onychomycosis contributes to the rapid growth of the nail and shorten the duration of mycological cure. CONCLUSION: UT has an antifungal effect and improves microcirculation in the area of the nail bed. In the complex treatment of patients with foot onychomycosis, the method accelerates clinical and mycological cure, stimulates nail growth, which reduces the rate of systemic and local antifungal therapy.

Onychomycosis: Treatment and prevention of recurrence.

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.

Efficacy of combination therapy with efinaconazole 10% solution and 1064 nm Nd:YAG laser for treatment of toenail onychomycosis.

BACKGROUND: Onychomycosis is a common but difficult to treat nail disorder. Treatment strategies thus far have included oral and topical antifungals, surgical treatment and recently lasers have emerged as a therapeutic modality. OBJECTIVE: The objective of this study was to assess whether efinaconazole together with laser would result in greater clinical and mycologic cure and lower rate of relapse compared to efinaconazole alone. METHODS: Thirty subjects were randomized to either self-apply efinaconazole 10% once daily for 48 weeks, or follow the same treatment plan but also receive six treatments with a 1064 nm Nd: YAG laser every 4 weeks. The primary endpoint was to assess the proportion of subjects who achieved complete cure at week 52. RESULTS: The combination therapy group showed significantly quicker mycological cure at the 48- and 52-week follow-up. CONCLUSION: Both efinaconazole and combination with laser were efficacious treatment, but the combination therapy leads to quicker resolution with fewer rate of relapse.

Onychomycosis: Diagnosis, Treatment, and Prevention.

Toenail disorders account for the majority of foot complaints for which adults seek medical care. Onychomycosis, a fungal nail infection, is the most prevalent. Dermatophytes are responsible for the majority of nail infections and cause varying degrees of nail deformities. While several treatment strategies are available, no one approach (topical, systemic, or mechanical) is highly curative. This article reviews causes, diagnosis, and treatment options for onychomycosis and provides patient education tips to prevent and limit the spread of the disease.

Common Foot Problems: Over-the-Counter Treatments and Home Care.

Most foot disorders do not require podiatry referral or complex interventions. After the clinical diagnosis is made, these conditions can typically be managed with over-the-counter (OTC) and home remedies, with guidance from the primary care physician. Stretching and strengthening exercises, along with the use of heel cups, resolve most plantar fasciitis cases and are at least as effective as nonsteroidal anti-inflammatory drugs or steroid injections. Hallux rigidus is best managed with a hard-soled shoe or rigid insert that relieves pain by restricting motion across the metatarsophalangeal joint. Hallux valgus responds to use of wide toe box shoes, and surgery is not clearly beneficial beyond one year. Plantar warts can be treated effectively at home with OTC salicylic acid and cryotherapy topical agents, which have equal effectiveness to liquid nitrogen. In patients with corns and calluses, OTC topical salicylic acid has short-term benefits, and pads and inserts that more evenly redistribute contact forces have long-term benefits. Inserts are commonly recommended to redistribute forefoot pressure and relieve pain. Several OTC preparations are available for the treatment of tinea pedis, with topical allylamines being the most effective. Although OTC topical treatments have been widely used for onychomycosis, they have poor long-term cure rates compared with prescription oral medications.

Distal Lateral Subungual Onychomycosis Owing to Tritirachium oryzae: A Bystander or Invader?

The genus Tritirachium is a mitosporic fungus which inhabits in soil and decaying plant material and also a notable insect pathogen. Human infections with Tritirachium species though rare were previously reported to cause corneal ulcers, otomycosis, onychomycosis, and dermatomycosis of the scalp and hence may be considered as a potential pathogen. Here we report a case of distal lateral subungual onychomycosis involving right great toenail in a 22-year-old female, wherein direct potassium hydroxide preparations, fungal cultures, and molecular sequencing of the isolate established Tritirachium oryzae as the etiological agent. Antifungal susceptibility performed by the microbroth technique of CLSI revealed increased MICs to amphotericin B and low MICs to azoles and echinocandins. The case was managed with surgical nail avulsion followed by topical application of 2% ketoconazole cream resulting regrowth of normal nail. To the best of our knowledge, this is the first report of non-dermatophytic mold T. oryzae causing onychomycosis in India.

[Onychomycosis: Practical treatment strategies]. / Onychomykose: Konzepte für die Praxis.

BACKGROUND: Onychomycosis is one of the most common nail diseases with an increasing number of cases. There is always a need for therapy because fungal nail infection never shows a tendency to spontaneous self-healing. Thus, the disease belongs to core competency of dermatologists. CONCLUSION: Successful treatment requires a correct diagnosis based on meticulous anamnesis, the clinical findings as well as the identification of the pathogen fungus. Dermatoscopy and histological examination play an important role in this context. The algorithm as presented gives a concise overview of treatment.

THE PREVALENCE OF ONYCHOMYCOSIS IN THE ZAGREB AREA - THE ROLE OF SABOURAUD AGAR WITHOUT CYCLOHEXIMIDE IN DIAGNOSIS AND THERAPY.

- Mycological analysis is considered the gold standard in the diagnosis of very common fungal diseases of nails. The purpose of the article is to present the prevalence of onychomycosis obtained by using direct microscopic examination (DME) and cultivation on Sabouraud media without cycloheximide. The quantitative retrospective research was conducted on 2706 patients of both sexes (mostly middle-aged to elderly) with various toenail lesions, who had undergone mycological analyses in the Mycological Laboratory of our Department of Dermatovenereology in 2013 and 2014. Analysis of the results obtained revealed that there were 35.4% of positive DME results; of these, there were 39.2% of dermatophytes, 59.1% of yeasts and 1.7% of molds. The percentage of dermatophytes (Trichophyton spp.) was twice as high in men as in women. A considerable percentage (12%) of mixed isolates was also observed. Particularly worrisome was the high percentage (one-third) of suppressed and insufficiently developed dermatophytes (a possible indicator of inappropriate preparation of patients for mycological analysis). Cultivation on culture media without cycloheximide requires frequent inspections because of the fast-growing molds while not allowing sporulation for a great number of dermatophytes. However, it has certain advantages, i.e. it offers an insight into the wide range of the present fungi. As part of the biofilm, they can be potentially pathogenic in dystrophic nails under certain circumstances because, according to our results, the percentage of dermatophytes does not change substantially with aging; however, what does change is the percentage of molds, yeasts and mixed isolates.

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.

A Clinical Review of Laser and Light Therapy for Nail Psoriasis and Onychomycosis.

BACKGROUND: There are considerable emerging data in the use of lasers and lights to treat onychomycosis and psoriasis of the nail subunit. OBJECTIVE: We aimed to review all of the medical literature on laser therapy of nail psoriasis and onychomycosis published since 1992. METHODS AND MATERIALS: We performed a PubMed literature search using the search terms "nail," "laser therapy," "laser surgery," "light," with search terms "psoriasis" and "onychomycosis." In addition, we performed extensive MeSH and bibliographic searches as delineated in the manuscript. Because of the poor quality of evidence, we were not able to complete a quantitative review and thus present our findings qualitatively. RESULTS: Although the trials are small, PDL (595 nm) and IPL with a 550-nm filter demonstrate compelling data in treating nail psoriasis. Laser studies of onychomycosis fall short on many levels. Q-switched Nd:YAG lasers with very short pulse durations and fractionated CO2 demonstrate the most promise for the treatment of onychomycosis. CONCLUSION: The data for treating nail psoriasis and onychomycosis with laser and light therapy are rapidly emerging. With increased subject data, improved study methodology, and more precise output parameters, lasers may become an important modality in the treatment of nail psoriasis and onychomycosis.

A critical review of improvement rates for laser therapy used to treat toenail onychomycosis.

Onychomycosis is a nail infection that is primary caused by dermatophytes. Alternative treatments are needed as current therapies (oral and topical antifungals) have limited effectiveness. Lasers are currently approved by the FDA to temporarily increase the amount of clear nail in onychomycosis patients. Lasers can theoretically elicit fungicidal effects but in practice produce mixed results. This review compared laser-induced improvement rates to FDA-approved indications and traditional onychomycosis treatments. A review of the literature (PubMed, Clinicaltrials.gov, Medline and Embase) was used to locate articles for this review. RCTs, non-randomized, uncontrolled and retrospective studies that included at least one of the following measures were eligible; complete cure, mycological cure, clinical improvement and clinical cure. Mycological cure (negative culture and negative microscopy) was evaluated in two studies using patients as the unit of analysis with an average rate of 11%, increasing to 63% when nails were used as the unit of analysis (three studies). Clinical cure (100% clear nail) was evaluated in six studies with a rate of 13% using nails as the unit of analysis and 13% when patients were used as the unit of analysis (two studies). Clinical improvement (at any time point) was found in 36% of patients (five studies) and 67% of nails (nine studies). Nail clarity as measured by clear nail growth and/or nail plate/bed clearance at 12 weeks was found to be 2.6 mm across onychomycotic nails. Laser studies, to date, provide preliminary evidence of clinical improvement and clear nail growth in toenail onychomycosis, consistent with the FDA clearance for aesthetic endpoints. Laser studies however do not provide efficacy rates for medical endpoints that equate or exceed those found with traditional therapies (oral and topical treatments).

Treating onychomycosis with the short-pulsed 1064-nm-Nd:YAG laser: results of a prospective randomized controlled trial.

BACKGROUND: The role of the short-pulsed 1064-nm-Nd:YAG laser in treating onychomycosis has been the subject of controversial discussion ever since it received FDA approval in 2010. Research to date provides no valid conclusions supporting its use from an evidence-based perspective. OBJECTIVE: In this prospective randomized controlled pilot study, we analysed the effect of the short-pulsed 1064-nm-Nd:YAG laser on the rate of mycological remission and clinical improvement after excluding relevant confounders with regard to our previous studies. PATIENTS AND METHODS: Twenty patients with a total of 82 mycotic toenails were randomized to the treatment group (short-pulsed 1064-nm-Nd:YAG laser) or control group (no laser treatment). We conducted four laser treatments at 4- to 6-week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12 months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events. RESULTS: Mycological remission was not achieved in either study group. A comparison of both groups yielded no difference in the OSI score, both at the beginning of the trial (P = 0.9873) and after 12 months (P = 0.4317). In the treatment group, the OSI score worsened by a mean 2.0 points, and in the control group, by a mean 3.5 points. On a visual analogue scale (0 = 'no pain' to 10 = 'most intense pain'), pain in the treatment group was indicated at a mean score of five. Other adverse events were not reported. CONCLUSIONS: The short-pulsed 1064-nm-Nd:YAG laser shows no long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.