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.

Clinical isolates of Trichophyton rubrum are completely inhibited by photochemical treatment with a γ-cyclodextrin formulation of curcuminoids.

INTRODUCTION: It was shown previously that dermatophytes can markedly be inhibited by a photochemical treatment with curcumin. This kind of photo-inactivation needs to be improved, however, because curcumin is poorly water-soluble. Therefore, a new water-soluble γ-cyclodextrin formulation of curcuminoids was tested for its photochemical inactivation of Trichophyton (T.) rubrum. MATERIALS AND METHODS: Conidia were harvested from 6 typical strains of T rubrum and used to inoculate wells of microtiter plates. These wells were also filled with a γ-cyclodextrin curcuminoid formulation with 0.1% DMSO and Sabouraud broth. The assays were then irradiated with visible light (wavelength 420 nm, 45 J/cm2 ). After 24 hours, curcuminoid was added once more, and irradiation was repeated. Fungal growth was monitored photometrically for 8 days and compared with controls. RESULTS: Growth of all 6 T rubrum strains was completely inhibited by the photochemical treatment with the γ-cyclodextrin formulation of curcuminoids. The same curcuminoid formulation applied without irradiation had only a minor inhibitory effect. DISCUSSION: Photo-inactivation of dermatophytes with a γ-cyclodextrin formulation of curcuminoids plus visible light is a very promising procedure with potential for a new treatment of patients with superficial tinea.

Impact on quality of life in patients with dermatophytosis.

BACKGROUND/OBJECTIVES: Dermatophytosis can have a significant effect on patient's psychosocial and economic life. Despite this, knowledge on the quality of life (QoL) in patients with dermatophytosis is limited. The objective of the present study was to assess the quality of life in patients with dermatophytosis. METHODS: This was a cross-sectional study conducted in the Department of Dermatology at a tertiary care hospital from August 2018 to December 2018. All the patients with dermatophytosis aged ≥16 years were included and evaluated for impact on quality of life. The association of Dermatology Life Quality Index (DLQI) scores with disease characteristics was assessed using t-test, ANOVA and Pearson's correlation test, as applicable. RESULTS: A total of 348 patients were analysed. The mean ± SD DLQI score in our study was 13.4 ± 7.3. Dermatophytosis was found to have a very large effect on the QoL in majority (44.8%) of our patients. DLQI questions pertaining to symptoms and feelings and daily activity had the highest impact on patients. The DLQI score was significantly affected by the number of sites involved (P < 0.001), body surface area (P < 0.001) and the severity of symptoms (P = 0.007). CONCLUSION: Dermatophytosis was found to have a significant impact on the QoL of affected patients. The DLQI score was influenced by the severity of the disease. This study also underscores the feasibility of DLQI score based QoL assessment in dermatophytosis.

The Oomycete Pythium oligandrum Can Suppress and Kill the Causative Agents of Dermatophytoses.

Pythium oligandrum (Oomycota) is known for its strong mycoparasitism against more than 50 fungal and oomycete species. However, the ability of this oomycete to suppress and kill the causal agents of dermatophytoses is yet to be studied. We provide a complex study of the interactions between P. oligandrum and dermatophytes representing all species dominating in the developed countries. We assessed its biocidal potential by performing growth tests, on both solid and liquid cultivation media and by conducting a pilot clinical study. In addition, we studied the molecular background of mycoparasitism using expression profiles of genes responsible for the attack on the side of P. oligandrum and the stress response on the side of Microsporum canis. We showed that dermatophytes are efficiently suppressed or killed by P. oligandrum in the artificial conditions of cultivations media between 48 and 72 h after first contact. Significant intra- and interspecies variability was noted. Of the 69 patients included in the acute regimen study, symptoms were completely eliminated in 79% of the patients suffering from foot odour, hyperhidrosis disappeared in 67% of cases, clinical signs of dermatomycoses could no longer be observed in 83% of patients, and 15% of persons were relieved of symptoms of onychomycosis. Our investigations provide clear evidence that the oomycete is able to recognize and kill dermatophytes using recognition mechanisms that resemble those described in oomycetes attacking fungi infecting plants, albeit with some notable differences.

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.

Dermatophytosis in northern Africa.

Infections caused by dermatophytes are a global problem and a major public health burden in the world today. In Africa, especially in the northern geographical zone, dermatophytic infections are being reported at an alarming rate. This is mostly because of some local but unique cultural practices, socioeconomic and environmental conditions, lack of reliable diagnostic personnel and facilities and ineffective treatment. Interestingly, the pathogen spectrum and the clinical manifestation are most times different from what is seen in other continents. Several epidemiological studies have been performed on the incidence and aetiology of dermatophytoses in northern Africa. However, there is currently no review article with up-to-date information on the relevant findings reported so far in this region. This information is necessary for clinicians who treat dermatophytic infections all over the world since agents of dermatophytes are no longer restricted because of the rapid mobility of humans from one part of the world to another. Moreover, the epidemiology of dermatophytoses is known to change over time, thus requiring the update of information from time to time. A review of relevant studies published on dermatophytoses in northern Africa is presented. This covers all of old Sudan, Algeria, Egypt, Libya, Tunisia and Morocco.

[Tinea in the genital area : A diagnostic and therapeutic challenge]. / Tinea im Genitalbereich : Eine diagnostische und therapeutische Herausforderung.

Pubogenital tinea or tinea genitalis represents a rare type of dermatophytosis which, however, is increasingly being diagnosed. The mons pubis is affected, but also the outer regions to the penis shaft and the labia together with the groins. Pubogenital tinea is a more superficial erythrosquamous type, but strong inflammatory dermatomycoses of the genital area as tinea genitalis profunda ranging to kerion celsi are observed. A total of 30 patients (14-63 years of age, 11 men and 19 women) with pubogenital tinea are described. Most patients originated from Graz, Austria, while 2 patients were from Germany (Saxony and Isle of Sylt). Causative agents were mainly zoophilic dermatophytes: Microsporum (M.) canis (11), Trichophyton (T.) interdigitale (9), T. anamorph of Arthroderma benhamiae (2), and T. verrucosum (1). Anthropophilic fungi were T. rubrum (6) and T. tonsurans (1). Anamnestic questions should include contact with pets, physical activities, and travel. Genital shaving and concurrent tinea pedis and onychomycosis are disposing factors. Treatment consisted of oral antifungals except in the three women who were pregnant. Preferably, itraconazole or terbinafine was used, while in a single case, fluconazole was administered. Griseofulvin was not used, because this classic systemic antifungal agent is not allowed any more in Austria. In one patient, oral antifungal therapy was changed from itraconazole to terbinafine due to inefficacy.

Common Skin Rashes in Children.

Because childhood rashes may be difficult to differentiate by appearance alone, it is important to consider the entire clinical presentation to help make the appropriate diagnosis. Considerations include the appearance and location of the rash; the clinical course; and associated symptoms, such as pruritus or fever. A fever is likely to occur with roseola, erythema infectiosum (fifth disease), and scarlet fever. Pruritus sometimes occurs with atopic dermatitis, pityriasis rosea, erythema infectiosum, molluscum contagiosum, and tinea infection. The key feature of roseola is a rash presenting after resolution of a high fever, whereas the distinguishing features in pityriasis rosea are a herald patch and a bilateral and symmetric rash in a Christmas tree pattern. The rash associated with scarlet fever usually develops on the upper trunk, then spreads throughout the body, sparing the palms and soles. Impetigo is a superficial bacterial infection that most commonly affects the face and extremities of children. Erythema infectiosum is characterized by a viral prodrome followed by the "slapped cheek" facial rash. Flesh-colored or pearly white papules with central umbilication occur with molluscum contagiosum, a highly contagious viral infection that usually resolves without intervention. Tinea is a common fungal skin infection in children that affects the scalp, body, groin, feet, hands, or nails. Atopic dermatitis is a chronic, relapsing inflammatory skin condition that may present with a variety of skin changes.

[Tropical and travel-related dermatomycoses: Part 1: Dermatophytoses]. / Tropen- und Reise-assoziierte Dermatomykosen : Teil 1: Dermatophytosen.

Today, tropical and travel-related dermatomycoses must be increasingly anticipated to present in dermatological offices and clinics. Skin infections due to dermatophytes or other fungi may occur after a journey in countries with a high prevalence for the respective causative fungal pathogen, e.g., tinea corporis due to Trichophyton soudanense. Otherwise, more frequently, single infections and even localized outbreaks due to "exotic" or "imported" pathogens of dermatophytoses occur. These epidemics are observed in childcare facilities in Germany and in other European countries. Source of infection are immigrants from Africa and sometimes from Asian countries. Furthermore, African children, and sometimes also adults, are often only asymptomatic carriers of such anthropophilic dermatophytes. Outbreaks of dermatophyte infections with one and more affected children and also adult staff and teachers due to Trichophyton violaceum or Microsporum audouinii in kindergartens and schools are not a rarity these days. Further tropical and travel-associated dermatophytes are Trichophyton tonsurans, Trichophyton schoenleinii, and Trichophyton concentricum. Tinea capitis should be treated in a species-specific manner. Griseofulvin is the treatment of choice for infections due to Microsporum species. In contrast, tinea capitis due to Trichophyton species has to be treated by terbinafine, however, because the agent is not approved for children in Germany, only after receiving written consent of parents. Alternatives are fluconazole and itraconazole. Onset and aggravation of tinea pedis during travel has its origin in a preexisting neglected fungal infection of the feet. In the tropics, exacerbations and secondary bacterial complications of tinea pedis develop under distinctly promoting conditions.

The Tinea Hospital in Granada, 1679-1923: an institution with a long history.

The Tinea hospital in Granada, Spain, was a charitable health facility founded in the 17th century and still treating patients well into the 20th century. The hospital accepted patients from anywhere, not only those residing in the surrounding area. We describe the hospital's founding and the characteristics of the patients and caregivers. We also discuss how tinea was considered at the time, including the typology and treatment protocols applied as well as diet and hygiene measures used. It is striking that a hospital so focused on treating a single disease did not produce studies on the condition or on the application of contemporary knowledge to guide treatment.

Diagnosis and management of tinea infections.

Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). The clinical diagnosis can be unreliable because tinea infections have many mimics, which can manifest identical lesions. For example, tinea corporis can be confused with eczema, tinea capitis can be confused with alopecia areata, and onychomycosis can be confused with dystrophic toenails from repeated low-level trauma. Physicians should confirm suspected onychomycosis and tinea capitis with a potassium hydroxide preparation or culture. Tinea corporis, tinea cruris, and tinea pedis generally respond to inexpensive topical agents such as terbinafine cream or butenafine cream, but oral antifungal agents may be indicated for extensive disease, failed topical treatment, immunocompromised patients, or severe moccasin-type tinea pedis. Oral terbinafine is first-line therapy for tinea capitis and onychomycosis because of its tolerability, high cure rate, and low cost. However, kerion should be treated with griseofulvin unless Trichophyton has been documented as the pathogen. Failure to treat kerion promptly can lead to scarring and permanent hair loss.

Treatment of a superficial mycosis by low-temperature plasma: a case report.

A case of dermatomycosis caused by zoophilic strain of Trichophyton interdigitale was treated by low-temperature plasma produced by direct current (DC) cometary discharge. The shortening of skin lesion persistence along with suppression of subjective discomfort and etiological agent was observed.

Common Skin Conditions in Children and Adolescents: Nonbacterial Infections.

Tinea infections are caused by dermatophytes, except for tinea versicolor, which is caused by yeasts in the Malassezia genus. If available, potassium hydroxide preparation should be performed to confirm diagnosis of tinea capitis or onychomycosis. In some cases, fungal culture, UV light examination, or periodic acid-Schiff stain can be helpful. Topical drugs are effective for tinea corporis, tinea cruris, and tinea pedis. Tinea incognito is an atypical presentation that usually requires systemic treatment. Management of tinea capitis always requires oral drugs. Oral drugs are preferred for onychomycosis treatment but should not be prescribed without confirmation of fungal infection. Localized cases of tinea versicolor can be managed with topical drugs, but oral drugs might be needed for severe, widespread, or recurrent cases. Warts are superficial human papillomavirus infections. Common treatments include irritant, destructive (eg, cryotherapy), immune stimulant (eg, intralesional Candida antigen), and debridement and excision methods. Scabies infestation results in intensely itchy papules, nodules, or vesicles. Mites and burrows on the skin are pathognomonic but difficult to identify. Dermoscopy, particularly with UV light, can make identification easier. Topical permethrin and oral ivermectin are two of the most commonly used treatments. All household and close contacts should be treated regardless of the presence or absence of symptoms.

Dermatophytomas in Onychomycosis: A Scoping Review of Prevalence, Diagnosis, and Treatment.

BACKGROUND: Dermatophytoma, also described as a longitudinal streak/spike, is a form of onychomycosis that presents as yellow/white streaks or patches in the subungual space, with dense fungal masses encased in biofilm. This scoping review of the literature was conducted to address a general lack of information about the epidemiology, pathophysiology, and treatment of dermatophytomas in onychomycosis. METHODS: A search was performed in the PubMed and Embase databases for the terms "longitudinal spike" or "dermatophytoma." Outcomes of interest were definition, prevalence, methods used for diagnosis, treatments, and treatment efficacy. Inclusion and exclusion of search results required agreement between two independent reviewers. RESULTS: Of a total of 51 records, 37 were included. Two reports provided the first unique definitions/clinical features of dermatophytomas. Overall, many descriptions were found, but one conclusive definition was lacking. Prevalence data were limited and inconsistent. The most frequently mentioned diagnostic techniques were clinical assessment, potassium hydroxide/microscopy, and fungal culture/mycology. Oral terbinafine and topical efinaconazole 10% were the most frequently mentioned treatments, followed by topical luliconazole 5% and other oral treatments (itraconazole, fluconazole, fosravuconazole). In studies with five or more patients without nail excision, cure rates were highest with efinaconazole 10%, which ranged from 41% to 100% depending on the clinical and/or mycologic assessment evaluated. Other drugs with greater than or equal to 50% cure rates were topical luliconazole 5% (50%), oral fosravuconazole (57%), and oral terbinafine (67%). In studies that combined oral terbinafine treatment with nail excision using surgical or chemical (40% urea) methods, cure rates ranged from 50% to 100%. CONCLUSIONS: There is little published information regarding dermatophytomas in onychomycosis. More clinical research and physician education are needed. Although dermatophytomas have historically been considered difficult to treat, the efficacy data gathered in this scoping review have demonstrated that newer topical treatments are effective, as are oral antifungals in combination with chemical or surgical methods.

[Onychomycosis. Successful treatment with a 1064 nm Nd:YAG-Laser]. / Onychomykose. Erfolgreiche Behandlung mit dem 1064-nm-Nd:YAG-Laser.

A 58-year-old man presented with a two-year history of progressive onychodystrophy of the nails of both great toes. Clinical inspection as well as KOH examination and culture confirmed the diagnosis of disto-lateral onychomycosis of both nails caused by Trichophyton rubrum). The diseased nail materially was mechanically débrided. In addition both nails were treated with a 1064 nm Nd:YAG laser (spot-diameter: 5 mm; pulse-width: 0.3 ms; fluence: 12 J/cm(2); frequency: 5 Hz; impulses: 200 per toenail). The laser therapy was repeated four times at intervals of 2 months. Seven months later the patient showed complete clearance of both nails. We here demonstrate the efficacy of the Nd:YAG laser in the treatment of onychomycosis. Non-ablative laser therapy may present a promising, effective, well-tolerated and cost-efficient option for the treatment of onychomycosis. Controlled studies with relevant patient collectives are urgently needed.