Finger and toenail onycholysis.

Onycholysis - the separation of the nail plate from the nail bed occurs in fingers and toenails. It is diagnosed by the whitish appearance of the separated nail plate from the nail bed. In fingers, the majority is caused by trauma, manicuring, occupational or self-induced behavior. The most common disease producing fingernail onycholysis is psoriasis and pustular psoriasis. Phototoxic dermatitis, due to drugs can also produce finger onycholysis. Once the separation occurs, the environmental flora sets up temporary colonization in the available space. Finger onycholysis is most common in women. Candida albicans is often recovered from the onycholytic space. Many reports, want to associate the yeast as cause and effect, but the data are lacking and the treatment of the candida does not improve finger onycholysis. A reasonable explanation for the frequent isolation of Candida and Pseudomonas in fingernail onycholysis in women, is the close proximity the fingers have to the vaginal and gastrointestinal tract. Fifty per cent of humans harbour C. albicans in the GI tract and it is frequently carried to the vagina during hygienic practices. Finger onycholysis is best treated by drying the nail 'lytic' area with a hair blower, since all colonizing biota are moisture loving and perish in a dry environment. Toenail onycholysis has a very different etiology. It is mechanical, the result of pressure on the toes from the closed shoes, while walking, because of the ubiquitous uneven flat feet producing an asymmetric gait with more pressure on the foot with the flatter sole.

HYPONYCHIUM ABNORMALITIES Congenital Aberrant Hyponychium vs. Acquired Pterygium Inversum Unguis vs. Acquired Reversible Extended Hyponychium: a proposed classification based on origin, pathology and outcome.

BACKGROUND: Pterygium Inversum Unguis (PIU) is a wing-like extended hyponychium associated with the absence of the distal groove. Although a rare condition, it has been described with different names, confusing both the investigator and the reader. OBJECTIVE: We propose a new nomenclature based on tissue origin and pathology, to account for these conditions. 1) Congenital Aberrant Hyponychium 2) Acquired Pterygium Inversum Unguis 3) Acquired Reversible Extended Hyponychium. MAIN OBSERVATIONS: We report a case of a 19-year-old male, with epidermal pigmentation abnormalities, who had painful fingertips of both index fingers and thumbs since he was 13. He therefore let his finger nails grow very long, minimizing painful contact with the hyponychium. Removal of the aberrant hyponychium revealed glomus bodies aggregates with increased nerve fibers. Subsequently after excision of the hyponychium, his pain was resolved. SUMMARY: Congenital, transient or permanent changes in the hyponychium should be named and classified according to tissue origin to avoid nomenclature confusion.

Opportunistic toenail onychomycosis. The fungal colonization of an available nail unit space by non-dermatophytes is produced by the trauma of the closed shoe by an asymmetric gait or other trauma. A plausible theory.

Opportunistic onychomycosis is defined, when a non-dermatophyte mould is cultured from an abnormal nail unit in the absence of a dermatophyte. The presumption is that the mould has caused the abnormal clinical appearance of the nail unit, yet there are no data available to substantiate this claim. Reports have only identified the mould being recovered from the nail unit niche. A review of the published dermatologic literature describing toenail opportunistic onychomycosis by non-dermatophyte fungi has shown toenails with onycholysis, nail bed (NB) keratosis and nail plate surface abnormalities. The appearance of these clinical changes is indistinguishable from the diagnosis of the Asymmetric Gait Nail Unit Signs (AGNUS). AGNUS is produced by the friction of the closed shoe in patients with an asymmetric gait, resulting primarily from the ubiquitous uneven flat feet. Most commonly, species of Acremonium (Cephalosporium), Aspergillus, Fusarium, Scopulariopsis and rarely species of many different fungi genera are capable of surviving and reproducing in a keratinous environment and change the clinical appearance of the involved nail unit. AGNUS toenails predispose to the colonization by the non-dermatophyte opportunistic fungi but not by dermatophyte fungi.

Clinical evaluation of pediculicidal and ovicidal efficacy of two pyrethrin-piperonyl-butoxide formulations.

The pediculicidal and ovicidal efficacy of two pyrethrin-piperonyl-butoxide agents was evaluated in 40 children infested with head lice. Both commercial products, a lotion and a shampoo, had similar formulations. Specifically, the shampoo vehicle was tested to determine whether its surface-tension-lowering action made it more effective as an ovicidal agent than the lotion. Results of the study indicate that the shampoo is 49% more effective than the lotion as an ovicide.

Multicenter study comparing 0.05% gel formulations of desoximetasone and fluocinonide in patients with scalp psoriasis.

A double-blind, multicenter study was conducted to evaluate and compare the safety and efficacy of desoximetasone gel 0.05% and fluocinonide gel 0.05% in patients with scalp psoriasis. One hundred twenty-five patients were enrolled in this randomized, parallel-group trial. Responses based on clinical assessment in 123 patients showed that the desoximetasone gel formulation is a safe and effective treatment for psoriasis of the scalp. Although efficacy appears equivalent to that of fluocinonide gel 0.05% in treating psoriasis of the scalp, desoximetasone appears to be slightly better tolerated and better accepted cosmetically.

Superficial mycoses: treatment with a new, broad-spectrum antifungal agent: 1% clotrimazole solution.

A 1% clotrimazole solution was used as an antifungal for Tinea versicolor, Cutaneous Candidiasis and Dermatophytosis. All studies were double-blind and controlled, active vs vehicle. The final evaluation was made at a two-week follow-up after the treatment was stopped, which for most of the clinical conditions studied, was 28 days. The 1% clotrimazole solution was found to be effective with no local irritation noted.

Onychomycosis.

This article summarizes the diseases of the nail caused by fungi. The clinical appearance of the diseases are the key to understanding their causes. Therapy is updated. Specifically discussed are distal subungual onychomycosis, white superficial onychomycosis, proximal subungual onychomycosis, and onychomycosis in chronic mucocutaneous candidiasis.

Pigmentary abnormalities of the nails with emphasis on systemic diseases.

The nails can change colors for many reasons. White bands called leukonychia are especially common. The shape of the white band, that is, concave or convex, indicates the site of injury. Color changes in the nails may also be a sign of a variety of cutaneous or systemic disorders.

Comparison of an antifungal agent used alone with an antifungal used with a topical steroid in inflammatory tinea pedis.

The efficacy and safety of monotherapy with oxiconazole nitrate cream, 1 percent, a topical broadspectrum antifungal agent, were compared with those of combination therapy with oxiconazole nitrate cream, 1 percent, and fluticasone propionate cream, 0.05 percent, in a multicenter, randomized, double-blind, vehicle-controlled, parallel-group study of patients with inflammatory tinea pedis. Both combination therapy and monotherapy were associated with significantly greater proportions of mycologic and clinical cure, and a better global response than vehicle. An unexpected finding in this study was that more than 70 percent of patients with interdigital tinea pedis also had plantar or plantar plus vesiculobullous infection.

Vesicular scabies in an adult.

We describe an unusual vesicular eruption occurring secondary to scabies in an elderly patient receiving high-dose prednisone therapy.

Treatment of "tinea pedis" with griseofulvin and topical antifungal cream.

A protocol for determining the antifungal efficacy of systemic or topical drugs in tinea pedis is presented. In this study, (1) no patient had concomitant onychomycosis; (2) the clinical types were separated into (a) plantar scaling, (b) intertriginous, and (c) vesicular instep; (3) the soles were treated for three months (time related to the shedding of all stratum corneum); (4) the follow-up period for soles was three months (related to characteristics of the drug and its depot effect on the target area, the horny layer); (5) the final evaluation related to the percentage of patients "clinically and mycologically cured" at the end of the follow-up period. With this protocol, ultramicrosize griseofulvin (Gris-PEG) alone, topical clotrimazole (Lotrimin) alone, and a combination of the two were tested in seventy-three patients with tinea pedis. The results were as follows: for plantar scaling type of tinea pedis, the combination was not better than griseofulvin alone; for intertriginous tinea pedis, the combination was definitely better than griseofulvin alone; and topical 1 percent clotrimazole was much less effective than griseofulvin.

Double-blind, randomized comparison of itraconazole capsules vs. placebo in the treatment of toenail onychomycosis.

Three multicenter, randomized, double-blind, placebo-controlled studies were conducted to determine whether twelve weeks of therapy with itraconazole, 200 mg, was effective in the treatment of dermatophyte infection of the toenail. Significantly more patients treated with itraconazole (110 patients) than with placebo (104 patients) achieved clinical (65 percent vs. 3 percent) and mycologic (54 percent vs. 6 percent) success. The mean percentage of affected reference nail before the initiation of therapy was 76 percent. Adverse events were comparable in the two treatment groups. These findings demonstrate that twelve weeks of continuous itraconazole, 200 mg once daily, is a highly effective, well-tolerated therapy for the management of toenail onychomycosis.

Naftifine cream in the treatment of cutaneous candidiasis.

Naftifine, a member of a new class of synthetic antifungal drugs, the allylamines, was evaluated for the treatment of cutaneous candidiasis. In a double-blind, parallel-group clinical trial, sixty patients with cutaneous candidiasis were randomly assigned to receive either naftifine cream 1 percent or its vehicle twice a day for three weeks. Two weeks after the end of therapy, 77 percent of the naftifine-treated patients were mycologically cured (negative results on potassium hydroxide preparations and culture) and had no clinically apparent disease, compared with 3 percent of the patients treated with vehicle (p less than 0.001). Side effects reported with naftifine cream were few and minor.

Multicentre double-blind clinical trials of ciclopirox olamine cream 1% in the treatment of tinea corporis and tinea cruris.

In separate multicentre, randomized, double-blind clinical trials, 1% ciclopirox olamine cream was compared with its cream vehicle and with 1% clotrimazole cream as treatment for tinea corporis and tinea cruris. Patients who demonstrated clinical and mycological findings consistent with the diagnoses of tinea corporis or tinea cruris were included in the study. Clinical and mycological evaluations were made pretreatment, at the end of each of the four weeks of treatment, and weekly for the two weeks immediately following cessation of treatment. In both studies, use of ciclopirox olamine cream resulted in demonstrable improvements after the first week of therapy and in complete clinical and mycological clearing in two thirds of the patients at the end of the treatment period. These results were maintained through the two-week drug-free observation period that followed the end of treatment. Statistically, the results with ciclopirox olamine cream were significantly better than those with the vehicle and were equivalent to those with clotrimazole cream. All treatments were well tolerated.

Diagnosing and treating onychomycosis.

Onychomycosis is a persistent fungal infection of the toenails or fingernails that is usually not painful but is unsightly and can affect a patient's quality of life by interfering with footwear. It may affect up to 30% of the population by age 60. In more that 99% of cases, it is caused by dermatophytes, the most common of which are Trichophyton rubrum and Trichophyton mentagrophytes. Each of the four clinical types of onychomycosis, as defined by the route of fungal invasion, has a characteristic appearance, but other diseases, particularly psoriasis, may have a similar appearance. Proper management, therefore, includes confirmation of fungal infection by potassium hydroxide slide preparation and culture. Traditionally, pharmacologic treatment has been less than optimal. In many cases, griseofulvin, the first oral agent approved for onychomycosis in the United States, must be given for 1 year or more to be effective. Low cure rates are related to poor bioavailability and the fungistatic rather than fungicidal effect of the drug. Newer agents, such as oral itraconazole and oral terbinafine, promise to substantially increase cure rates while shortening treatment duration. Oral terbinafine is potently fungicidal against dermatophytes and has proven efficacious with regimens as brief as 12 weeks when the nail is not 100% involved.