Prevalence of onychomycosis in patients with diabetes mellitus: A cross-sectional study from a tertiary care hospital in North India.

Background Though diabetes mellitus (DM) is a well-recognised risk factor for onychomycosis (OM), the epidemiology of OM in diabetic patients remains largely unexplored, especially from the Indian subcontinent. Aims and objectives To estimate the prevalence of OM in diabetic patients, to identify and analyse risk factors, and correlate the severity of nail changes with glycemic control (HBA1c). Methods This cross-sectional, analytical study involved 300 diabetic patients. Patients with the clinical diagnosis of OM, supplanted by at least two of the four tests (KOH, culture, onychoscopy and nail histopathology) were considered cases of OM. Demographic and haematological profile was analysed using chi-square test/ Fischer's exact test. Logistic regression was applied to assess the independent risk factors. Results The prevalence of OM in DM patients was 34% (102/300) and significant risk factors included; age >60 years, male gender, closed shoes, disease duration >5 years, high BMI (>25) and lack of awareness about nail changes. Distal and lateral subungual OM (78%) was the commonest presentation followed by proximal subungual OM, superficial OM and total dystrophic OM. Correlation between HbA1c and the number of nails involved was found to be significant. Limitation As cases were recruited from a hospital setting, there could be chances of Berksonian bias. Conclusion The prevalence of OM in diabetic patients is high and the severity of nail changes correlates with HbA1C levels. It is important to diagnose OM early in order to treat and prevent complications.

Nail dermoscopy (onychoscopy) findings in the diagnosis of primary onychomycosis: A cross-sectional study.

BACKGROUND: Diagnosis of onychomycosis involves direct microscopic examination with potassium hydroxide, culture or histopathology with periodic acid-Schiff staining. Nail dermoscopy (onychoscopy) is a noninvasive, rapid and easily available diagnostic tool though its utility in onychomycosis remains unexplored. OBJECTIVE: To describe the various onychoscopic patterns and compare its percentage positivity with that of standard potassium hydroxide examination, culture and histopathology in patients with a clinical diagnosis of onychomycosis. METHODS: The study recruited 100 patients with a presumptive clinical diagnosis of onychomycosis. A detailed history, physical examination including that of nails and clinical photography was followed by onychoscopy with DermLite DL3. The nail clippings were sent for direct microscopic examination with potassium hydroxide, mycological culture and histopathology with periodic acid-Schiff stain. The patient was said to have onychomycosis if at least one of the three tests was positive. RESULTS: Onychomycosis was confirmed by potassium hydroxide and/or culture and/or histopathology in 88 patients. Onychoscopic features were identified and their association with different clinical variants of onychomycosis was attempted. Percentage positivity for diagnosing onychomycosis in decreasing order was: direct microscopic examination with potassium hydroxide followed by spiked pattern, subungual hyperkeratosis, distal irregular termination on onychoscopy, histopathology, mycological culture and ruins aspect again observed on onychoscopy. LIMITATIONS: Small sample size. CONCLUSIONS: Many onychoscopic features are highly specific for different variants of onychomycosis so onychoscopy may serve as an important and quick adjunct to diagnose onychomycosis until other time-consuming investigations, such as culture and periodic acid-Schiff become available. Studies on a larger population will help arrive at a logistic conclusion.

Comparative efficacy of continuous and pulse dose terbinafine regimes in toenail dermatophytosis: A randomized double-blind trial.

INTRODUCTION: Dermatophytes are the most frequently implicated agents in toenail onychomycosis and oral terbinafine has shown the best cure rates in this condition. The pharmacokinetics of terbinafine favors its efficacy in pulse dosing. OBJECTIVES: To compare the efficacy of terbinafine in continuous and pulse dosing schedules in the treatment of toenail dermatophytosis. METHODS: Seventy-six patients of potassium hydroxide (KOH) and culture positive dermatophyte toenail onychomycosis were randomly allocated to two treatment groups receiving either continuous terbinafine 250 mg daily for 12 weeks or 3 pulses of terbinafine (each of 500 mg daily for a week) repeated every 4 weeks. Patients were followed up at 4, 8 and 12 weeks during treatment and post-treatment at 24 weeks. At each visit, a KOH mount and culture were performed. In each patient, improvement in a target nail was assessed using a clinical score; total scores for all nails and global assessments by physician and patient were also recorded. Mycological, clinical and complete cure rates, clinical effectivity and treatment failure rates were then compared. RESULTS: The declines in target nail and total scores from baseline were significant at each follow-up visit in both the treatment groups. However, the inter-group difference was statistically insignificant. The same was true for global assessment indices, clinical effectivity as well as clinical, mycological, and complete cure rates. LIMITATIONS: The short follow-up in our study may have led to lower cure rates being recorded. CONCLUSION: Terbinafine in pulse dosing is as effective as continuous dosing in the treatment of dermatophyte toenail onychomycosis.