Morphological and ultrastructural changes in fungal agents after LASER application.

BACKGROUND: Onychomycosis is a fungal nail infection of difficult treatment due to the fungal survival capacity and reduced number of effective therapies. The present study aimed to isolate fungal agents that cause onychomycosis in immunocompetent patients and evaluate how LASER treatments affect the growth and ultrastructure of isolates. METHODS: In total, 21 patients with positive direct microscopic examination (DME) for onychomycosis had nail samples collected for cultivation and phenotypic identification of microorganisms. From these patients, 12 underwent LASER treatment, divided in Group 1 (n = 5) treated with Nd: YAG 1,064 nm, and Group 2 (n = 7) treated with Nd: YAG 1,064 nm + Er: YAG 2,940 nm + topical isoconazole. Transmission Electron Microscopy (TEM) was performed to evaluate ultrastructural changes after treatment. RESULTS: DME, cultivation, and phenotypic identification showed that the most identified fungus was Trichophyton rubrum spp. After LASER therapy, sample cultivation showed alterations in the fungal morphology with reduction of hyphae, conidia, and reproductive structures. Alterations in fungal cell wall structure, cytoplasm density, and organelles were observed by TEM. CONCLUSION: LASER irradiation causes changes in the fungal cells, especially in the number of hyphae and the presence of conidia. In addition, it affects fungal growth and reproduction capacity, which interferes with their infection ability and virulence.

How Effective Are Devices in the Management of Onychomycosis?: A Systematic Review.

Onychomycosis is the most common nail disorder, with a global prevalence of approximately 5.5%. It is difficult to cure on both short-term and long-term bases. The most common treatments include the use of oral or topical antifungals. Recurrent infections are common, and the use of systemic oral antifungals raises concerns of hepatotoxicity and drug-drug interactions, particularly in patients with polypharmacy. A number of device-based treatments have been developed for onychomycosis treatment, to either directly treat fungal infection or act as adjuvants to increase the efficacy of topical and oral agents. These device-based treatments have been increasing in popularity over the past several years, and include photodynamic therapy, iontophoresis, plasma, microwaves, ultrasound, nail drilling, and lasers. Some, such as photodynamic therapy, provide more direct treatment, whereas others, such as ultrasound and nail drilling, aid the uptake of traditional antifungals. We conducted a systematic literature search investigating the efficacy of these device-based treatment methods. From an initial result of 841 studies, 26 were deemed relevant to the use of device-based treatments of onychomycosis. This review examines these methods and provides insight into the state of clinical research for each. Many device-based treatments show promising results, but require more research to assess their true impact on onychomycosis.

Urea versus fractional Er:YAG laser pretreatment of methylene blue photodynamic therapy in the treatment of moderate toenail onychomycosis: short- and medium-term effects.

Keratolytic properties of urea 40% have long time used for the treatment of onychomycosis. Fractional ablative lasers enhance the delivery of topically applied photosensitizers improving photodynamic therapy (PDT) efficacy. The aim of this study was to compare the short- and medium-term efficacy of a pretreatment with urea 40% and fractional Er:YAG (Fr Er:YAG) laser radiation before PDT mediated by methylene blue (MB) for moderate toenail onychomycosis. Twenty-first-toe toenails were randomized to receive either urea 40% (Group I) or Fr Er:YAG laser (Group II) pretreatment and 9 sessions of MB/PDT over the course of 16 weeks. At baseline, 28- and 40-week follow-ups, clinical efficacy was assessed by digital photographs [allowing determination of the onychomycosis severity index (OSI)], whereas mycological efficacy was assessed by histological examination and fungal culture. Details of the side effects and patients' satisfaction were also recorded. In both groups, a significant decrease in OSI values was observed at the 28-week follow-up and a slight rebound at the 40-week follow-up. The percentage of nail involvement decreased significantly in both groups at the 28-week follow-up, to continue declining gently in Group I at 40 weeks, in contrast to the rebound observed during this period in Group II. The mycological cure rate was 20% and 30% at 28-week follow-up and 70% and 40% at 40-week follow-up, in Group I and II, respectively. Patients reported being fairly satisfied, and no side effects were detected in any groups. Although both pretreatments favor the action of PDT for the treatment of onychomycosis, the use of urea at 40% is more effective in the medium term.

Current therapeutic insights regarding problematic fingernails and toenails in the Republic of Korea.

BACKGROUND: Problematic nails and toenails are infected by germs and increasingly have many causes. AIMS: To investigate the types and treatment of problematic nails and toenails, we focused on bacteria that may appear in problematic nail toenail symptoms. METHODS: We have searched for PubMed and Google Scholar and correlated the words Onychomycosis, Tinea ungium, Melanonychia, and ingrown toenail related to symptoms. RESULTS: To measure onychomycosis, KOH tests and fungal culture tests will be used. Treatment can be treated with full-body treatment using anti-fungal agents and local treatment (laser therapy) that can minimize the side effects. A biopsy should be performed when Melanonychia is diagnosed with brown or black pigments on the patient's fingernail plate. Moreover, ingrown toenail surgical treatment can be improved by acquired lifestyle. CONCLUSIONS: There are many different types of treatments, but many studies show that problematic nail and toenail improvement periods are long and treatment success rates are low.

Síndrome de la uña verde: revisión actualizada de una patología emergente en la era COVID-19 / 19Green nail syndrome: updated review of an emerging disease in the era of COVID-19

El síndrome de la uña verde o cloroniquia corresponde a la infección por Pseudomonas aeruginosa de una lámina ungueal dañada en pacientes con algún factor de riesgo identificable, siendo los más frecuentes la inmunosupresión, el ambiente húmedo constante y la patología ungueal preexistente. Su diagnóstico es relativamente sencillo si se logra observar la tríada característica de coloración verdosa de la lámina ungueal, paroniquia proximal crónica y onicolisis distal; en casos de duda diagnóstica se puede enviar una muestra de la uña afectada para cultivos o estudio histopatológico. El pilar de su tratamiento corresponde al uso de antibióticos tópicos o sistémicos en conjunto con medidas generales que protejan de la humedad. Es muy importante enfatizar la prevención de esta patología en el personal de salud, especialmente en el contexto del lavado de manos frecuente y riguroso implementado durante la pandemia COVID-19, ya que existen reportes de transmisión nosocomial de P. aeruginosa por profesionales de la salud con infección ungueal.(AU)

Green nail syndrome or chloronychia is the infection of a damaged nail plate by Pseudomonas aeruginosa in a patient with an identifiable risk factor; the most frequently described are immunosuppression, a persistent moist environment and preexisting nail disease. Its diagnosis is relatively simple if the characteristic triad of green discoloration of the nail plate, chronic proximal paronychia and distal onycholysis can be observed, in cases of doubt a sample of the affected nail can be sent for cultures or histopathology. The cornerstone of treatment is the use of topical or systemic antibiotics along with measures to protect the nail from moisture. Prevention of this disease must be emphasized in health care personnel, especially in the context of frequent and rigorous handwashing practices implemented during the COVID-19 pandemic, since there are reports of nosocomial transmission of P. aeruginosaby health care professionals with nail infection.(AU)

Microbial Growth on the Nails of Direct Patient Care Nurses Wearing Nail Polish.

OBJECTIVES: To determine whether nurses wearing nail polish pose a greater infection risk to patients than nurses who are not wearing nail polish. SAMPLE & SETTING: 89 direct patient care oncology nurses at a large midwestern National Cancer Institute-designated comprehensive cancer center. METHODS & VARIABLES: The investigators assigned participants' three middle fingers of their dominant hand to three groups. RESULTS: Comparison of colony-forming units revealed that one-day-old polish exhibited fewer gram-positive microorganisms than the unpolished nail (p = 0.04). The four-day-old polish showed significantly more microorganisms than the one-day-old polish (p = 0.03). The same trend was demonstrated for gram-negative microorganisms, but the difference was not statistically significant (p = 0.3 and p = 0.17, respectively). IMPLICATIONS FOR NURSING: The results should be interpreted and applied to expert nursing practice in the care of vulnerable patient populations. Each institution and practitioner should make their own decisions and interpretation of evidence into practice.

Relationship between antifungal susceptibility profile and virulence factors in Candida albicans isolated from nail specimens

Abstract INTRODUCTION: The aim of this study was to evaluate some virulence factors in Candida albicans isolates from patients with onychomycosis and determine the correlation between these factors and the antifungal resistance profile. METHODS: Seventy species of C. albicans were confirmed using polymerase chain reaction amplification of the HWP1 gene. According to the Clinical & Laboratory Standards Institute guidelines, the susceptibility profile of four antifungal agents was investigated, and the production of aspartyl protease, phospholipase, haemolysin, and biofilm was determined. The correlation between these profiles was also investigated. RESULTS: The isolates indicated different levels of resistance and production of virulence factors. Significant correlations were observed between the minimum inhibitory concentration (MIC) of fluconazole/itraconazole and biofilm production, between phospholipase production and fluconazole/itraconazole MIC, and between fluconazole MIC and hemolytic activity in C. albicans isolates. The results also showed significant correlations between phospholipase activity and biofilm production. CONCLUSIONS: Our findings will contribute to a better understanding of the pathogenesis of C. albicans and characterize the relationship between virulence factors and antifungal resistance, which may suggest new therapeutic strategies considering the possible involvement of the virulence mechanism in the effectiveness of treatment.

Simultaneous dermatophytosis and keratomycosis caused by Trichophyton interdigitale infection: a case report and literature review.

BACKGROUND: Dermatophytosis is a fungal infectious disease caused by dermatophytes, which produce protease and keratinase to digest keratin, leading to the colonization, invasion, and infection of the stratum corneum of the skin, hair shafts, and nails. Trichophyton interdigitale belongs to Trichophyton mentagrophytes complex, which is the common pathogen causing dermatophytosis. Fungal keratitis, also called keratomycosis, is an infectious disease of cornea. CASE PRESENTATION: Here, we report a case of simultaneous dermatophytosis and keratomycosis caused by Trichophyton interdigitale. A 67-year-old man presented with extensive erythema all over the body since 4 years ago, fungal infection of left eye for 2 years, and loss of vision in the eye. These symptoms had become aggravated in the last month. Dermatological examinations showed extensive erythematous plaques with clear borders and scales, scattered red papules with ulceration, and scabs throughout the body. Onychomycosis was observed on the nails of left hand, conjunctival infection with secretion and loss of vision were noted in left eye. Hyaline septate hyphae were observed under direct microscopic examination, fungal culture and internal transcribed spacer sequencing revealed T. interdigitale. Histopathological examination suggested infectious granuloma. A diagnosis of dermatophytosis and keratomycosis caused by T. interdigitale with loss of vision in left eye was made. The patient was treated with luliconazole cream (two applications per day) and itraconazole (100 mg, BID, PO). Complete clinical remission was achieved after 1 month. Subsequently, the patient underwent left eye enucleation in the ophthalmology department. CONCLUSIONS: In the present study, we reported a case of simultaneous dermatophytosis and keratomycosis caused by T. interdigitale, and reviewed the literature on corneal infection caused by Trichophyton. A total of 10 articles with 45 patients were published between 1973 and 2018. The pathogen of 27 patient were identified to species level. There were T. schoenleinii (17), T. mentagrophytes (4), T. verrucosum (3), T. rubrum (1), T. erinacei (1), and T. interdigitale (1). Five patients had corneal trauma, one had contact lens use history. Direct microscopic examination, fungal culture, and analysis of physiological characteristics were the main methods of identification. Early diagnosis and prompt treatment may help improve the management and outcomes.

Occurrence of dermatophytoses in patients from the Sistema Único de Saúde.

BACKGROUND: Dermatophytosis is a cutaneous disease caused by filamentous keratinophilic fungi belonging to the genera Trichophyton, Microsporum and Epidermophyton, which present a high prevalence in the general population, being among the most common mycoses affecting about 20% of the world's population. OBJECTIVE: To carry out the epidemiological survey of cases of dermatophytosis in patients from the Sistema Único de Saúde in a regional Laboratory in the period of 5 years (2009 to 2013). METHODS: A retrospective study (January 2009 to December 2013) was carried out with a qualitative and quantitative design, through the registry book of the laboratory, Mycology Sector, where cases of patients with suspected dermatomycosis were analyzed. RESULTS: In a 5-year period, a total of 4467 cases were suspected of having a fungal infection. Of these, 68.74% (3071) cases were of dermatomycosis. In relation to cultures with fungal growth, 12.54% (385 cases) were dermatophyte fungi and 7.97% (245 cases) non-dermatophyte fungi were isolated. Among the species identified, there was a higher prevalence of T. rubrum complex (75%), T. mentagrophytes complex (11.68%) and M. canis (7.01%). Regarding the sites analyzed, nail involvement was the most frequent in 75% of the cases. STUDY LIMITATIONS: This work is representative in the studied region. CONCLUSIONS: Dermatomycosis samples are the most frequent among all samples of fungal infections from these patients, with the nail being the most affected area and the fungi T. rubrum complex and T. mentagrophytes complex the most frequent.

[Evaluation of the usefulness of nail biopsy in the diagnosis of onychomycosis]. / Evaluación de la utilidad diagnóstica de la biopsia ungueal en las onicomicosis.

BACKGROUND: Onychomycosis affects between 2% to 30% of the world population. Nail biopsy may help in making a diagnosis and can distinguish between invasion and colonisation. AIMS: To evaluate the diagnostic usefulness of nail biopsy with Periodic acid-Schiff (PAS) staining for onychomycosis, compared to direct KOH examination, culture and its combination in a reference laboratory in Colombia. METHODS: The study included 66 patients in whom a blind and independent reading of the three tests was performed. The usefulness was defined based on the validity (sensitivity, specificity, Youden's index, likelihood ratios), performance (predictive values) efficiency (proportion of correctly diagnosed patients), and reproducibility (kappa coefficient). RESULTS: The mean age of the patients was 55±16 years, and included 76% women. The direct tests with KOH were positive in 66.7% (n=44), 62.1% (n=41) were positive with culture, and 56.1% (n=37) with the biopsy. The main causal agents were non-dermatophytes moulds in 36.4% (n=24). The most frequent species were Neoscytalidium dimidiatum (n=11), Trichophyton rubrum (n=11), and Candida parapsilosis (n=13). The sensitivity of nail biopsy, when compared to the standard (KOH and/or culture), was 71%, specificity 83%, Youden's index 0.54, positive likelihood ratio 4.25, negative likelihood ratio 0.35, positive predictive value 92%, negative predictive value 52%, efficiency 74% and kappa coefficient 0.45. When biopsy was evaluated only in patients with onycholysis of the nail plate greater than 50%, all the parameters of diagnostic usefulness increased. CONCLUSIONS: The overall usefulness of the biopsy was moderate for patients with more severe symptomatology, which makes its use advisable in cases of extensive onycholysis, and when discriminating colonisation from invasion is required.

Occurrence of dermatophytoses in patients from the Sistema Único de Saúde

Abstract: Background: Dermatophytosis is a cutaneous disease caused by filamentous keratinophilic fungi belonging to the genera Trichophyton, Microsporum and Epidermophyton, which present a high prevalence in the general population, being among the most common mycoses affecting about 20% of the world's population. Objective: To carry out the epidemiological survey of cases of dermatophytosis in patients from the Sistema Único de Saúde in a regional Laboratory in the period of 5 years (2009 to 2013). Methods: A retrospective study (January 2009 to December 2013) was carried out with a qualitative and quantitative design, through the registry book of the laboratory, Mycology Sector, where cases of patients with suspected dermatomycosis were analyzed. Results: In a 5-year period, a total of 4467 cases were suspected of having a fungal infection. Of these, 68.74% (3071) cases were of dermatomycosis. In relation to cultures with fungal growth, 12.54% (385 cases) were dermatophyte fungi and 7.97% (245 cases) non-dermatophyte fungi were isolated. Among the species identified, there was a higher prevalence of T. rubrum complex (75%), T. mentagrophytes complex (11.68%) and M. canis (7.01%). Regarding the sites analyzed, nail involvement was the most frequent in 75% of the cases. Study Limitations: This work is representative in the studied region. Conclusions: Dermatomycosis samples are the most frequent among all samples of fungal infections from these patients, with the nail being the most affected area and the fungi T. rubrum complex and T. mentagrophytes complex the most frequent.

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

Abstract: 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.

Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients.

BACKGROUND: Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser. METHODS: We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013-December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2-6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy. RESULTS: Clinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed. CONCLUSIONS: The 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.

Microbial counts in hands with and without nail varnish after surgical skin preparation: a randomized control trial.

Nail varnish is commonly removed from fingernails prior to surgical procedures. We report the results of a randomized controlled trial comparing the microbial counts in hands with and without nail varnish applied, following surgical skin preparation. Forty-three patients were randomized; three patients were lost to follow-up. Each patient had one hand painted with nail varnish and had both hands tested 1 week later. There was no significant difference in terms of positive microbial growth between the nail plates or hyponichia with or without nail varnish applied. Our results demonstrate that the presence of nail varnish does not have an effect on the microbial counts of hands following surgical skin preparation. LEVEL OF EVIDENCE: I.

Nail Raman spectroscopy: A promising method for the diagnosis of onychomycosis. An ex vivo pilot study.

Trichophyton rubrum and Candida species comprise the majority of onychomycosis pathogens. The aim of this study was to evaluate Raman spectroscopy for the differentiation between healthy and either T. rubrum or Candida infected nails. Raman measurements were performed on clippings (N = 52) infected either by T. rubrum (N = 12) or Candida species (N = 14; C. parapsilosis (sensu lato): N = 11, C. glabrata: N = 1, C. albicans: N = 2) with healthy nails (N = 26) used as controls. Systematic spectral differences were observed in the 500-520 cm-1 band region, attributable to a diverting imprint of the disulfide stretching of cystine and cysteine residues among samples. Particularly, Candida infected nails demonstrated a shoulder at 519 cm-1, corresponding to the signal of the less stable gauche-gauche-trans conformation of the disulfide bond. Two additional bands at 619 and 648 cm-1, corresponding to the C-S stretching vibration, were more evident in the T. rubrum infected nails. Finally, a Raman band at 1550 cm-1, attributable to amide II and tryptophan (Trp) content, was undetectable in Candida infected nails. Using principal component analysis (PCA), efficient differentiation of healthy, T. rubrum and Candida species infected nails was achieved. Soft independent modeling of class analogy (SIMCA) and partial least squares-discriminant analysis (PLS-DA) were further applied to generate diagnostic algorithms for the classification of Raman spectra. Both techniques succeeded in modeling clinical nail samples in three groups according to their mycological categories. Raman spectroscopy is a promising method for the differentiation of healthy vs. diseased nails, including efficient differentiation between onychomycosis caused by T. rubrum and Candida species.

Emergence of non-Candida albicans species: Epidemiology, phylogeny and fluconazole susceptibility profile.

OBJECTIVE: Non-Candida albicans (NCA) species now account for a significant part of clinical candidiasis worldwide. In the present study, epidemiology and antifungal susceptibility profile of NCA isolated from various forms of candidiasis were studied with special focus on their phylogenetic relationship by ITS sequencing. PATIENTS AND METHODS: Seventy-nine NCA isolates were isolated from skin and nail scrapings (67.0%), vaginal discharges (8.8%), blood (8.8%), sputa (5.0%), urine (5.0%), oral swabs (2.6%), biopsy and eye tumor, each (1.4%). These isolates were identified by morphological, biochemical and molecular (ITS sequencing) techniques. In vitro antifungal susceptibility of the isolates to fluconazole (FCZ) was tested according to the CLSI method (M27-S4). RESULTS: Among a total number of 79 cases of proven NCA infections, C. parapsilosis (36.8%) was the most prevalent species followed by C. glabrata (32.9%), C. orthopsilosis (11.4%), C. tropicalis (8.9%), C. krusei (5.0%) and C. guilliermondii (5.0%). The susceptibility to FCZ was assessed for C. parapsilosis (96.5%), C. orthopsilosis (88.9%), C. tropicalis (85.7%) and C. guilliermondii (50.0%). C. glabrata and C. krusei isolates were not susceptible to FCZ. NCA species were distributed in various phylogenetic clades including C. glabrata (1), C. tropicalis (3), C. parapsilosis (6) and C. orthopsilosis, C. krusei and C. guilliermondii (each 2). CONCLUSION: C. parapsilosis and C. glabrata were the most predominant NCA species involve in the etiology of candidiasis. C. orthopsilosis was reported from superficial candidiasis. Taken together, our results further substantiate the increasing importance of the involvement of NCA species in the etiology of candidiasis.

Examining the importance of laboratory and diagnostic testing when treating and diagnosing onychomycosis.

Onychomycosis is a fungal nail infection caused primarily by dermatophytes. Several other nail disorders, including psoriasis, can simulate onychomycosis. Accurate diagnosis is therefore vital for the ongoing treatment and management of onychomycosis and to avoid misdiagnosis and treatment delay, which can be both lengthy and costly. Often, a combination of histologic and laboratory techniques is used to obtain an accurate diagnosis. The potential diagnostic challenges associated with the differential diagnosis of onychomycosis caused by dermatophytes and the most common techniques used to confirm the diagnosis are discussed.

Clinical laser treatment of toenail onychomycoses.

Onychomycoses are fungal infections of the fingernails or toenails having a prevalence of 3% among adults and accounts for 50% of nail infections. It is caused by dermatophytes, non-dermatophyte filamentous fungi, and yeasts. Compressions and microtraumas significantly contribute to onychomycosis. Laser and photodynamic therapies are being proposed to treat onychomycosis. Laser light (1064 nm) was used to treat onychomycosis in 156 affected toenails. Patients were clinically followed up for 9 months after treatment. Microbiological detection of fungal presence in lesions was accomplished. A total of 116 samples allowed the isolation of at least a fungus. Most of nails were affected in more than two thirds surface (some of them in the full surface). In 85% of cases, after 18 months of the onset of treatment, culture turned negative. After 3 months months, only five patients were completely symptom-free with negative culture. In 25 patients, only after 6 months, the absence of symptoms was achieved and the cultures negativized; in 29 patients, 9 months were required. No noticeable adverse effects were reported. This study reinforces previous works suggesting the applicability of laser therapies to treat toenail onychomycosis.

Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective.

BACKGROUND: Onychomycosis can be investigated by sampling. Information gleaned includes nail bed involvement, nail plate penetration, fungal viability, and species identification. Testing samples can confirm a diagnosis. While diagnostic testing is considered useful in directing therapy, a substantial number of clinicians do not confirm diagnosis prior to treatment. OBJECTIVES: The aim of this study is to quantify the benefit of confirmatory testing prior to treating toenail onychomycosis. METHODS: The cost of mycological cure (negative potassium hydroxide and negative culture) and the cost-effectiveness of confirmatory testing were determined using the average cost of potassium hydroxide (KOH), culture, periodic acid-Schiff (PAS), efinaconazole, ciclopirox, terbinafine, and itraconazole. Costs were obtained through literature searches, public domain websites, and telephone surveys to local pharmacies and laboratories. To represent the potential risks of prescribing onychomycosis treatment, the costs associated with liver monitoring, potential life-threatening adverse events, and drug-drug interactions were obtained through public domain websites, published studies, and product inserts. RESULTS: PAS was determined to be the most sensitive confirmatory test and KOH the least expensive. The overall cost of an incorrect diagnosis (no confirmatory test used) ranged between $350 and $1175 CAD per patient for treatment of 3 infected toenails. Comparatively, performing confirmatory testing prior to treatment decreases the overall cost to $320 to $930, depending on the therapy, physician, and test. CONCLUSIONS: It is preferred to diagnose onychomycosis prior to treatment. Furthermore, there are cost savings when confirmatory testing is performed before initiating treatment with both topical and oral antifungals in Canada.