A rationale for systemic treatment in onychomycosis with negative results on fungal examination.

BACKGROUND: Fungal infection of the nail affects millions of people worldwide, and has an estimated prevalence of about 10% of the general population. Laboratory confirmation of fungal infection is currently accepted as a requirement before initiation of antifungal treatment in clinical practice. AIM: To examine the rationale for systemic treatment in cases of clinical onychomycosis with negative results on fungal examination (potassium hydroxide test and fungal culture). METHODS: In total, 147 patients with suspected clinical toenail onychomycosis but with negative results on fungal examination underwent up to three consecutive fungal examinations of the affected nails. Patients who were negative after these examinations underwent a fourth set of investigations, including PCR. RESULTS: Of the 147 cases initially thought to be negative, 138 (94%) were rated as positive after up to four consecutive sets of laboratory mycological investigations including PCR. Trichophyton rubrum was by far the commonest dermatophyte cultured from all samples. CONCLUSIONS: In the majority of cases of initially negative examinations, consecutive laboratory fungal tests will eventually produce positive results. These findings suggest that systemic antifungal treatment should be started in patients with suspected fungal infections, even if they have negative laboratory fungal examinations.

A novel two-step kit for topical treatment of tinea pedis--an open study.

BACKGROUND: Tinea pedis is a common skin disease affecting most of the population during their lifetime. Topical and systemic treatments give only temporary relief. OBJECTIVE: To evaluate the efficacy and safety of a new topical treatment for moderate-to-severe tinea pedis. METHODS: Fifty patients suffering from tinea pedis were treated in two stages: the active stage--single use of the novel topical solution for 45 min and novel cream twice weekly for 4 weeks; the preventive stage--cream application once weekly for 10 months. RESULTS: Forty-five patients completed the active stage and achieved 76% cure rate. The medication was well tolerated; one patient dropped from the study because of very mild irritation. No other topical or systemic side effects were noted. Another five patients were lost to follow-up during the preventive stage. The total cure rate after the preventive stage was 70%. CONCLUSIONS: This novel treatment was found to be effective, well tolerated and safe in the treatment of moderate and severe tinea pedis during the active and the preventive stages.

A randomized, double-blind, placebo-controlled study to evaluate the efficacy in AD of liquid soap containing 12% ammonium lactate + 20% urea.

Atopic dermatitis (AD) is a common chronic skin disease, which mainly affects children. Xerosis is one of the most troublesome signs of the disease. The aim of this study was to evaluate the efficacy of liquid soap containing 12% ammonium lactate + 20% urea in patients with AD. In a randomized, double-blind study, 36 patients (both male and female patients; age range 3-40 years) with mild to moderate AD were enrolled. Patients were divided randomly into two groups, in a ratio of 2:1 (active:placebo). The prescribed soap was used on a daily basis during a shower for 3 weeks. All patients continued all other systemic or topical medication but avoided any other soap or emollients. After 3 weeks of treatment, efficacy was assessed both by clinician and patient. There were significant improvements in scaling (P < 0.0001), skin dryness (P < 0.0001) and redness (P = 0.03) as rated by the investigator, and subjective patient assessment of itch also improved (P < 0.001) in the study group compared with the control group. The liquid soap was found to be effective in patients with AD, as use of this soap in patients with stable mild to moderate AD improved the parameters studied.

New criteria for the laboratory diagnosis of nondermatophyte moulds in onychomycosis.

BACKGROUND: Nondermatophyte moulds (NDM) may be found as aetiological agents or as contaminants in onychomycosis. The classic and most used criteria for the diagnosis of NDM are those established by English in 1976. OBJECTIVES: The aim of this article is to re-evaluate the laboratory criteria for the diagnosis of NDM in onychomycosis. PATIENTS AND METHODS: Patients with suspected NDM of the nail underwent five consecutive examinations by both KOH and mycological culture; at the first visit, three samples from the affected nail were taken and were examined separately. Later those patients underwent four consecutive examinations; during this stage only a single sample for both KOH and culture was taken. We compared the culture results obtained from the three nail samples obtained at the first visit with the results from the four consecutive visits. RESULTS: We noted a clear trend showing that as the number of positive cultures increases (one to three cultures) during the first examination, the percentage of subsequent positive cultures, taken during the four consecutive visits, also increased. CONCLUSIONS: We suggest that when NDM infection is found in the first culture, the patient should be re-examined in a subsequent visit in which three separate samples are taken from the affected nail. If NDM is confirmed in all three cultures, the diagnosis of NDM is established. Treatment should be recommended in patients who show positive results in all three cultures.

Onycomycosis due to artificial nails.

BACKGROUND: The use of artificial nails (ANs) as part of nail-care cosmetics is very popular. Several side effects and complications, such as contact dermatitis and bacterial and fungal infections, have been reported in patients using ANs. Objective The purpose of this study was to identify the fungal pathogens in nail abnormalities appearing in patients with ANs. METHODS: We evaluated 68 patients suffering from nail changes and paronychia, which appear after removal of ANs. Mycological samples were obtained from two sites: distal parts of the involved nail and the proximal nail fold. KOH examination and fungal culture were used for detection and identification of fungal infection. RESULTS: Mycological results from the distal part of the nail showed positive KOH test in 57 cases (83.8%), and culture was positive in 67 patients (98.5%). Mycological results obtained from the proximal nail fold showed positive KOH test in 36 patients (52.9%); in 36 of the cases, culture was positive. Candida spp. were the most common pathogen. Both KOH and culture results were significantly better while sampling from the distal part of the nail compared with sampling from the proximal nail fold (P = 0.0001). CONCLUSION: Onychomycosis was found to be very common in nail changes due to ANs, leading to an increased risk of transmitting microbial infections. Therefore, health care personnel and workers in the food industry should avoid using ANs.

Collection of fungi samples from nails: comparative study of curettage and drilling techniques.

BACKGROUND: Onychomycosis is a common problem. Obtaining a positive laboratory test before treatment is important in clinical practice because the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side-effects. OBJECTIVE: The purpose of this study was to compare curettage and subungual drilling techniques of nail sampling in the diagnosis of onychomycosis. METHODS: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and subungual drilling sampling techniques. Nail samples were obtained in each case from proximal, medial and distal parts of the nail. KOH examination and fungal culture were used for detection and identification of fungal infection. RESULTS: With each technique, the culture sensitivity improved as the location of the sample was more proximal (drilling proximal vs. distal, chi(2) = 5.15, P = 0.023; curettage proximal vs. distal, chi(2) = 4.2, P = 0.041). In each sample location, the drilling technique has a better culture sensitivity (drilling vs. curettage proximal, chi(2) = 11.9, P = 0.001; drill vs. curettage distal, chi(2) = 13.7, P < 0.0001). Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. CONCLUSION: The drilling technique was found to be statistically better than curettage at each site of sampling. With each technique, we found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken by both methods from proximal parts of the affected nails.

Lichen amyloidosus treated by hydrocolloid dressings.

We hereby report a case of lichen amyloidosus in a 69-year-old man unresponsive to various treatments. The patient was treated by occlusion with hydrocolloid dressings. Considerable subjective and objective improvement was observed with respect to the pruritus and cosmetic appearance. We suggest this convenient and efficacious treatment as first line therapy.

Multiple agminated superficial arteriovenous haemangioma on the scalp.

We describe a patient with an unusual presentation of multiple arteriovenous haemangioma (AVH) grouped in one area of the scalp. The diagnosis was confirmed by histological, X-ray and ultrasound studies. These lesion represent a rare, benign, acquired vascular hamartomatous formation that arises from the suprapapillary vascular plexus.

Subungual amelanotic melanoma.

We describe a 76-year-old white male with subungual amelanotic melanoma. The lack of pigmentation of the lesion may cause misdiagnosis and aggravate its poor prognosis.

Tungiasis.

A 24-year-old man developed slow-growing lesions on subungual and plantar areas that appeared a few weeks after returning from a trip to South America. The diagnosis of tungiasis was established by microscopic examination of a lesion. Tungiasis is rarely seen in non-endemic areas.

Follicular B-cell pseudolymphoma.

A 60-year-old woman presented with a 3-week history of a pruritic papulo-nodular eruption on the face and trunk after a bee sting. Histological examination showed a predominantly lymphocytic infiltrate with follicular centres and tingible body macrophages. Immunohistochemically, positive staining for both kappa and lambda light chains was noted. The eruption settled with oral antihistamine and topical corticosteroid. These findings support the diagnosis of follicular B-cell pseudolymphoma.