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.

Onychopapilloma Presenting as Leukonychia: Case Report and Review of the Literature.

Onychopapilloma is a benign tumor of the nail bed and distal matrix and is the most common cause of localized longitudinal erythronychia. Here, we describe a case of onychopapilloma presenting as longitudinal leukonychia of the left 4th fingernail in a 71-year-old female. To date, this is only the ninth described case of onychopapilloma presenting as longitudinal leukonychia. We review the literature on the reported cases and provide evidence that longitudinal leukonychia as the presenting sign for onychopapilloma is becoming increasingly recognized in clinical practice.

Nail disorders: Kids are not just little people.

Nail disorders comprise an important subset of dermatologic conditions and often pose both diagnostic and therapeutic challenges to the clinician. Presentation and management can differ in adults and children. Proper understanding of these differences is important in delivering optimal patient care. This contribution discusses three common nail disorders in adults and children, onychomycosis, melanonychia striata, and trachyonychia, highlighting distinct features in the adult and pediatric populations.

Acquired Congenital Malalignment of the Great Toenails.

Congenital malalignment is the lateral deviation of the nail plate along the longitudinal axis due to the lateral rotation of the nail matrix. The nail plate grows out in ridges caused by repeated microtrauma to the nail. Common complications include onychomycosis, Pseudomonas infection and acute or chronic paronychia. Treatment options range from conservative management to surgical options including realignment and nail matrixectomy. Congenital malalignment usually presents in infancy or childhood, but we present two cases of acquired malalignment occurring in the teenage years.

Over-the-counter and natural remedies for onychomycosis: do they really work?

Onychomycosis is a fungal infection of the nail unit that may lead to dystrophy and disfigurement over time. It accounts for up to 50% of all nail conditions, with toenails affected more commonly than fingernails. Onychomycosis may affect quality of life and increase the prevalence and severity of foot ulcers in patients with diabetes. Available oral agents approved by the US Food and Drug Administration (FDA) for the treatment of onychomycosis include terbinafine and itraconazole, which have demonstrated good efficacy but are associated with the risk of systemic side effects and drug-drug interactions. Topical medications that are FDA approved for onychomycosis include ciclopirox, efinaconazole, and tavaborole. These therapies generally have incomplete efficacy compared to systemic agents as well as long treatment courses and possible local side effects such as erythema and/or blisters. Given the need for safe, effective, and cost-effective options for onychomycosis therapy, there has been a renewed interest in natural and over-the-counter (OTC) alternatives. This review will synthesize the laboratory data, known antifungal mechanisms, and clinical studies assessing the efficacy of OTC and natural products for onychomycosis treatment.

The epidemiology, etiology, and pathophysiology of onychomycosis.

The prevalence of onychomycosis in the United States is estimated to be at least 12%; prevalence increases with increasing age and is highest in individuals more than 65 years of age. Trichophyton rubrum, which also causes tinea pedis, is responsible for approximately 90% of cases of toenail onychomycosis. Risk factors include a family history of onychomycosis and previous injury to the nails, as well as advanced age and compromised peripheral circulation. Patients with compromised immune function may have an increased risk for onychomycosis and are susceptible to infection with less common dermatophytes and nondermatophyte organisms.

Diagnosis, clinical implications, and complications of onychomycosis.

The diagnosis of onychomycosis is suggested by the clinical presentation as well as the family history and patient age. The definitive diagnosis of onychomycosis is based on (1) establishing the presence or absence of fungal elements using laboratory methods and/or (2) identifying the fungus using fungal culture or, in the future, by polymerase chain reaction as new developments emerge in this technology, making more widespread application of this technique possible.

Current and emerging options in the treatment of onychomycosis.

Currently approved options for the treatment of onychomycosis include systemic therapy (the antifungal agents fluconazole, itraconazole, and terbinafine), topical agents (ciclopirox, which has been available since 1996, efinaconazole, currently pending approval), and laser systems. Phase III studies on another topical, tavaborole, have been completed and this medication also shows promise. Mechanical modalities are sometimes used but are seldom necessary. Recurrence of infection is common; the risk for recurrence may be reduced by adherence to preventive measures, especially avoiding (if possible) or promptly treating tinea pedis infections.

Promoting and maintaining or restoring healthy nails: practical recommendations for clinicians and patients.

The American Academy of Dermatology guidelines for managing patients with onychomycosis, published almost 2 decades ago, provide sound, basic recommendations for clinicians. This article provides a quick reference for clinicians and includes a handout for patients to support the health care provider's educational efforts.

Longitudinal melanonychia: when to biopsy and is dermoscopy helpful?

Longitudinal melanonychia (LM) is a common presenting problem in general dermatology, and represents a diagnostic challenge to clinicians given its broad differential diagnosis that includes both benign and malignant entities. The decision of when a biopsy is required is incredibly challenging for dermatologists. Dermoscopy is a noninvasive technique that enhances the clinical evaluation of LM, and has demonstrated potential in improving the clinical decision making as to whether or not to biopsy LM. However, it is critical for clinicians to understand the limitations of dermoscopy, and that although it is able to add new criteria for the diagnosis of ungual pigmentation, it does not replace histopathologic diagnosis. Biopsy of the nail unit should be performed in any case where doubt based on the clinical evaluation exists.

Recurrent digital glomus tumor: analysis of 75 cases.

BACKGROUND: Glomus tumors are rare, benign, cutaneous neoplasms that must be excised completely to prevent recurrence. OBJECTIVE: To investigate factors associated with recurrence of glomus tumors after surgery. METHODS AND MATERIALS: Fifty-eight women and 17 men with digital glomus tumors underwent surgery between 1990 and 2008 at our hospital. These cases were retrospectively analyzed. RESULTS Mean age at diagnosis was 41.8, with an average diagnostic delay of 3.9 years. The tumor was located on a finger in 70 cases (right, 29; left, 41) and a toe in five (right, 3; left, 2). The tumor recurred in 13 (17%) patients. Recurrence was more likely if the tumor was skin-colored (odds ratio (OR)=31.67, 95% confidence interval (CI)=2.68-373.74, p=.006) or located within the nail matrix (OR=5.79, 95% CI=1.03-32.49, p=.046). No recurrence occurred in patients who had had preoperative magnetic resonance imaging or ultrasound studies. CONCLUSION: Skin-colored tumors or those in the nail matrix are at higher risk of recurrence. The authors have indicated no significant interest with commercial supporters.

Dermatologic findings of ankyloblepharon-ectodermal defects-cleft lip/palate (AEC) syndrome.

Hay-Wells syndrome, caused by mutations in the p63 gene, is an autosomal dominant ectodermal dysplasia with the main features of ankyloblepharon filiforme adnatum, ectodermal defects, and cleft lip/palate, from which the disorder's other name, AEC syndrome, is derived. The National Foundation for Ectodermal Dysplasias convened the International Research Symposium for AEC Syndrome on November 8-10, 2006, at Texas Children's Hospital/Baylor College of Medicine, Houston, TX with appropriate IRB approval. This multidisciplinary conference was the largest gathering of such patients to date and allowed us to further characterize dermatologic features of AEC syndrome, which included: sparse and wiry hair, nail changes, past or present scalp erosions, decreased sweat production, palmar/plantar changes, and unique pigmentary anomalies. Early recognition of the features of AEC syndrome and subsequent early diagnosis is important in minimizing invasive diagnostic studies, improving morbidity and mortality, and providing genetic counseling. Skin erosions, especially those of the scalp, were identified as the most challenging cutaneous aspect of this syndrome. Although the reasons for the skin erosions and poor healing are not known, mutations of p63 may lead to a diminished store of basal cells capable of replenishing the disrupted barrier. Therapeutic strategies currently under exploration include gene therapy, as well as epidermal stem cell therapy. Until then, gentle wound care and limiting further trauma seem to be the most prudent treatment modalities.