Overall Prevalence and Prevalence Compared among Psoriasis Treatments of Onychomycosis in Patients with Nail Psoriasis and Fungal Involvement.

BACKGROUND: Whether nail psoriasis can increase the risk of onychomycosis is still being debated, and data relating to the prevalence of onychomycosis among psoriasis patients receiving different treatments is limited. OBJECTIVES: To investigate the overall prevalence and prevalence compared among psoriasis treatments of onychomycosis in patients with nail psoriasis and fungal involvement. METHODS: A prospective study of three groups of nail psoriasis being treated with only topical medication, methotrexate, or biologics (25 patients per group, 150 nails) was conducted at Siriraj Hospital (Bangkok, Thailand) during November 2018 to September 2020. Demographic data, psoriasis severity, and nail psoriasis severity were recorded. The nail most severely affected with psoriasis on each hand was selected for mycological testing. Potassium hydroxide, periodic acid-Schiff stain, and fungal culture were performed. RESULTS: The prevalence of onychomycosis in nail psoriasis was 35.3%. Among the treatment groups, the prevalence of onychomycosis was significantly higher in the methotrexate group than in the topical treatment and biologic treatment groups (p = 0.014). Candida spp. was the main causative organism, followed by Trichophyton rubrum. Thumb was most commonly affected (59.3%). The most common abnormality of the nail matrix and the nail bed was pitted nail (71.3%) and onycholysis (91.3%), respectively. Multivariate analysis revealed diabetes, wet-work exposure, and methotrexate treatment to be predictors of onychomycosis. CONCLUSIONS: Several factors, including psoriasis treatment, were shown to increase the risk of onychomycosis in nail psoriasis. Further research is needed to determine whether biologic agents, especially interleukin-17 inhibitors, can increase risk of onychomycosis and Candida infection/colonization of the nails.

Epidemiological analysis of nail aspergillosis and non-dermatophyte moulds. Criteria for the involvement of Aspergillus in 102 cases of onychomycosis at Montpellier University Hospital, France (1991-2019).

BACKGROUND: Moulds are often wrongly considered contaminants, not very sensitive to conventional antifungal treatments, but they may cause ungual hyphomycosis, particularly Aspergillus. Due to the lack of precise diagnostic criteria, their real impact is underestimated. OBJECTIVES: Retrospective descriptive analysis of all ungual hyphomycosis cases diagnosed at Montpellier Hospital from 1991 to 2019 to: (i) determine the incidence of onychomycosis by pseudo-dermatophytes and moulds; (ii) perform an epidemiological analysis of nail aspergillosis; and (iii) provide simple criteria for mould involvement in onychopathy. PATIENTS/METHODS: Data concerning 4053 patients were collected: age, sex, onychomycosis location, direct examination results, species(s) identified and fungal co-infections. Moreover, clinical data of patients with nail aspergillosis were analysed to identify potential contributing factors, and the classical criteria for mould involvement in onychopathy were critically reviewed. RESULTS: A pseudo-dermatophyte or a mould was involved in nail colonisation in 17.25% of patients (men/women ratio: 0.70; mean age: 53.1 years). The identified hyphomycetes belonged mainly to the genera Fusarium (45.68%), Scopulariopsis (30.23%) and Aspergillus (16.94%). Analysis of the clinical reports of 102 patients with ungual aspergillosis (men/women ratio: 0.67; mean age: 56.3 years) identified cardiovascular (43.9%), endocrine (25.8%), cancer (19.7%) and skin (18.2%) diseases as contributing factors. CONCLUSIONS: The adoption of simple and reliable criteria (ie, characteristic filaments on direct microscopic examination after periodic acid-Schiff staining, growth at seeding points in culture) allows determining the formal involvement of a mould in chronic onychopathies and avoiding possible side effects and costs of empirical or inappropriate and repetitive treatments.

Coexistence of onychomycosis and nail psoriasis and its correlation with systemic treatment.

BACKGROUND: Epidemiological studies indicate that onychomycosis may affect up to 79% of psoriatic patients. Onychomycosis in psoriatic patients is more commonly caused by yeasts comparing with non-psoriatic. OBJECTIVES: Evaluate the prevalence of fungi in nail psoriasis. Evaluate the association between direct mycological examination (DME) and mycological culture, Nail Psoriasis Severity Index (NAPSI) and systemic treatment for psoriasis. METHODS: Of 133 nails from 20 patients with nail psoriasis were evaluated as follows: 9 patients were using topical treatment and 11 were on systemic treatment. The assessment of psoriasis severity using NAPSI was performed in all psoriatic nails. The presence of fungi was confirmed in DME and culture. RESULTS: DME showed the presence of fungal elements in 45 nails (33.83%) with a predominance of blastoconidia (95.5%) No septate hyphae were seen. Mycological culture was positive in 36 (27.06%) samples. Among them, Candida grew in 31 (86.1%): Candida parapsilosis in 15 (48.38%), Candida spp in 14 (45.16%). No growth of dermatophytes was observed. Patients with systemic treatment showed a higher frequency of positive test (DME and culture) for fungi when compared to topic treatment (p:.006). There was a positive correlation between NAPSI, mycological culture and systemic treatment (p:.0063); the risk was four times higher (OR:4.0). LIMITATION OF THE STUDY: Sample size. CONCLUSION: These results are consistent with some previous reports, Candida was the fungus with higher frequency on the psoriatic nails, however, the role of these fungi is controversial (contamination x colonisation x infection). The fact that the immunosuppressive treatment increases the chance of fungal infection leads us to a greater attention to this patient profile, to prevent the intensification of nail psoriasis (Köbner phenomenon).

Clinical significance of Candida isolation from dystrophic fingernails.

BACKGROUND: Candida onychomycosis mostly involves fingernails. Yet, in contrast to dermatophytes, Candida isolation from dystrophic fingernails does not prove casualty, as sample contamination and non-pathogenic Candida growth occur. Characterising treatment outcome of Candida-positive dystrophic nails is crucial to avoid unnecessary treatment. OBJECTIVE: To investigate predicators associated with treatment outcome among Candida-positive dystrophic fingernails. PATIENTS AND METHODS: A retrospective cohort study was carried out among 108 adults with Candida-positive dystrophic fingernails not cured with adequate systemic anti-fungal course. Diagnosis was based on a single mycological culture. Patients with treatment failure (n = 85; 78.7% of the cases) were compared to patients with partial response (mild to almost cure; n = 23; 21.3% of the cases) at 9 to 12 months following treatment initiation. RESULTS: Treatment failure was significantly associated with primary onycholysis (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.1-7.4) and prolonged dystrophy (12.8 vs. 3.7 years in average), compared to partial treatment response. Non-responders had lower odds to present with distal lateral subungual onychomycosis, compared to partial responders (OR 0.3; 95% CI 0.1-0.7). Demographic and mycological characteristics, as well as number of nails affected, co-presence of paronychia, and treatment regime were not found to be associated with treatment response. CONCLUSION: Candida-positive primary onycholysis was shown to be non-responsive to systemic anti-fungal treatment, suggesting that anti-fungal treatment is not indicated. For other clinical scenarios, high proportions of treatment non-response suggest that determining causality of Candida should not be based on a single positive mycological culture.

Assessment of the nail penetration of antifungal agents, with different physico-chemical properties.

Onychomycosis, or fungal nail infection, is a common fungal infection largely caused by dermatophyte fungi, such as Trichophyton rubrum or Trichophyton mentagrophytes, which affects a significant number of people. Treatment is either through oral antifungal medicines, which are efficacious but have significant safety concerns, or with topical antifungal treatments that require long treatment regimens and have only limited efficacy. Thus, an efficacious topical therapy remains an unmet medical need. Among the barriers to topical delivery through the nail are the physico-chemical properties of the antifungal drugs. Here, we explore the ability of a range of antifungal compounds with different hydrophilicities to penetrate the nail. Human nail discs were clamped within static diffusion (Franz) cells and dosed with equimolar concentrations of antifungal drugs. Using LC-MS/MS we quantified the amount of drug that passed through the nail disc and that which remained associated with the nail. Our data identified increased drug flux through the nail for the more hydrophilic compounds (caffeine as a hydrophilic control and fluconazole, with LogP -0.07 and 0.5, respectively), while less hydrophilic efinaconazole, amorolfine and terbinafine (LogP 2.7, 5.6 and 5.9 respectively) had much lower flux through the nail. On the other hand, hydrophilicity alone did not account for the amount of drug associated with/bound to the nail itself. While there are other factors that are likely to combine to dictate nail penetration, this work supports earlier studies that implicate compound hydrophilicity as a critical factor for nail penetration.

Efinaconazole topical solution 10%: Formulation and efficacy assessment in the treatment of toenail onychomycosis.

BACKGROUND: Efinaconazole is non-lacquer-based with a low surface tension that efficiently targets delivery of active ingredient into the nail and nail bed. OBJECTIVES: To develop an optimal, stable formulation of efinaconazole topical solution 10% (ETS10). METHODS: We evaluated the safety and efficacy of ETS10 on 10 Iranian participants in a pilot, single-group and before-after clinical study, for up to 8 weeks in onychomycosis. RESULTS: The study showed reasonable results concerning the short period of treatment. During the period of storage, the formulation showed no variation in colour, odour and pH. The average pH at initial, 1st, 6th and 12th months was 4.65, 4.64, 4.65 and 4.64, respectively. The assay of an active pharmaceutical ingredient in the formulation was desired over the whole period. This indicates that antimicrobial activity has been adequate and efficient. A significant decrease in Investigator Global Assessment (IGA) of the target toenails was also defined as the efficacy endpoint. The median score for IGA at baseline visit was 3 out of 5 which decreased to 2 out of 5 and the decrease was statistically significant. CONCLUSION: The study clarifies the new efficacy of ETS10 in subjects with onychomycosis and passed the safety study successfully. These properties may develop the potentiality of ETS10 as a good treatment option for patients with onychomycosis.

Prognostic factors influencing the treatment outcome of onychomycosis Candida.

Onychomycosis contributes as many as half of all nail disorder cases. In 2017, the incidence of onychomycosis was 15% of all dermatomycosis cases at our hospital, a tertiary hospital in Indonesia, with only 25% of the patients achieving mycological cure. This study aims to identify the prognostic factors influencing the treatment outcome of onychomycosis Candida. This is a retrospective study, using data obtained from outpatient registry at our hospital. Fifty-four onychomycosis patients were included in this study. Potential prognostic factors were analysed by STATA15.0. Retrospective analysis with cox proportional-hazard was used to measure the contribution of each variable to the treatment's outcome. Onset of disease, history of nail disorder, and site of infection were not associated with mycological cure (P > .05). Based on retrospective analysis, age[odds ratio (OR)1.46; 95% confidence interval (CI)1.07-2.03], onset of disease (OR 1.14; 95%CI 1.11-1.17), comorbidities (OR 1.07; 95%CI 1.03-1.11), type of onychomycosis (OR 1.08; 95%CI 1.05-1.16), site of infection (OR 1.12; 95%CI 1.04-1.22) and number of infected nails (OR 1.50; 95%CI 1.25-1.68) were significantly associated with poor treatment outcome, while type of treatment and type of systemic agents showed no significant association with the outcome. Kaplan-Meier curves showed that subjects elderly age and more than 3 infected nails had the lowest median survival. Elderly, longer onset, presence of comorbidities, multiple sites of infection, and high number of infected nails can affect the mycological cure negatively. Unstandardised treatment was associated with the mycological cure despite not affecting the prognosis. Therefore, the management's goal is to identify these specific prognostic features.

Cutaneous phaeohyphomycosis caused by Pyrenochaeta unguis-hominis in a diabetic patient: A case report.

Phaeohyphomycosis, caused by opportunistic rare fungi, has increasingly been reported in diabetic and immunosuppressed patients. Pyrenochaeta unguis-hominis (P. unguis-hominis), a member of the dematiaceae group, has been identified to cause human nail infection. We report a rare case of cutaneous phaeohyphomycosis in a diabetic female caused by P. unguis-hominis.

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

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.

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.

Diversity of phenotypically non-dermatophyte, non-Aspergillus filamentous fungi causing nail infections: importance of accurate identification and antifungal susceptibility testing.

Onychomycosis is most commonly caused by dermatophytes. In this study, we examined the spectrum of phenotypically non-dermatophyte and non-Aspergillus fungal isolates recovered over a 10-year period from nails of patients with onychomycosis in Hong Kong. A total of 24 non-duplicated isolates recovered from 24 patients were included. The median age of the patients was 51 years, and two-thirds of them were males. One-third and two-thirds had finger and toe nail infections respectively. Among these 24 nail isolates, 17 were confidently identified as 13 different known fungal species, using a polyphasic approach. These 13 species belonged to 11 genera and ≥9 families. For the remaining seven isolates, multilocus sequencing did not reveal their definite species identities. These seven potentially novel species belonged to four different known and three potentially novel genera of seven families. 33.3%, 41.7% and 95.8% of the 24 fungal isolates possessed minimum inhibitory concentrations of >1 µg/mL to terbinafine, itraconazole and fluconazole, respectively, the first line treatment of onychomycosis. A high diversity of moulds was associated with onychomycosis. A significant proportion of the isolates were potentially novel fungal species. To guide proper treatment, molecular identification and antifungal susceptibility testing should be performed for these uncommonly isolated fungal species.

Liquid chromatography-tandem mass spectrometry is effective for analysis of ergosterol in fungal-infected nails.

BACKGROUND: Identification of onychomycosis is mainly based on clinical diagnosis with auxiliary diagnostic methods such as potassium hydroxide (KOH) microscopy, periodic acid-Schiff staining or fungal culture. However, each method is limited by its sensitivity and specificity. AIM: To develop a new test method using the common fungal end product, ergosterol, and investigate if it can be used as a new diagnostic tool. METHODS: We collected consecutive data from 20 participants with nail problems. Following clinical diagnosis, samples were taken for KOH microscopy and for mass spectrometry (MS) to check for the presence of ergosterol. RESULTS: Of the 20 cases collected, 7 were positive for fungal infection by MS. Four of these were already suspected to have onychomycosis, whereas one of the remaining three subjects was presumed to have dry nail and the other two to have onycholysis. The MS test seemed to be better at detecting combinations of nail conditions. Conversely, of the five patients clinically diagnosed as having onychomycosis, four had a positive MS result, whereas the fifth had negative results on both KOH and MS. Two other participants had a positive KOH test and were also found to have positive MS results. CONCLUSION: Detection of the presence of ergosterol by MS seems to be a useful tool for confirming onychomycosis. However, further studies are needed to verify the sensitivity and specificity of this MS method.

Fusarium oxysporum is an onychomycosis etiopathogenic agent.

AIM: To evaluate and characterize the etiopathogenesis of the fusarial onychomycosis in an ex vivo study through fragments of sterile human nail, without the addition of any nutritional source. MATERIALS & METHODS: The infection and invasion of Fusarium oxysporum in the nail were evaluated by scanning electron microscopy (SEM), CFU, matrix, histopathology and Fourier Transform Infrared Spectrometer coupled to an equipment with diamond accessory (FTIR-ATR). RESULTS: F. oxysporum infected and invaded across the nail, regardless of application face. However, the dorsal nail surface was the strongest barrier, while the ventral was more vulnerable to infection and invasion process. The fungal-nail interaction resulted in the formation of a dense biofilm. CONCLUSION: F. oxysporum infect and invade the healthy human nail, resulting in biofilm formation. Therefore, F. oxysporum is likely a primary onychomycosis agent.

Distrofia ungueal hiperqueratósica / Hyperkeratotic nail dystrophy

No disponible

Documented vancomycin-induced severe immune-mediated thrombocytopaenia.

A 69-year-old man developed Propionibacterium acnes left knee hardware infection after suffering from an infected ingrown toenail. The hardware was removed and he was treated with intravenous vancomycin. Ten days after initiation of vancomycin, he developed severe thrombocytopaenia, epistaxis and petechiae. Vancomycin was discontinued, and platelets rapidly recovered. Serum vancomycin IgG were positive. Patient completed a 6-week course of ceftriaxone with no further complications.

Pitted keratolysis - a study of various clinical manifestations.

BACKGROUND: Pitted keratolysis (PK) is a common bacterial infection of skin characterized by noninflammatory superficial pits. Very few studies have focused on variations in clinical manifestations of PK. We conducted this study so that diagnosis of this treatable condition is not missed when it presents in an uncommonly perceived way. AIMS AND OBJECTIVES: Assessment of PK patients for various sites and morphologies. MATERIALS AND METHODS: A total of 30 patients with PK were assessed for various sites and morphologies. Bacterial and fungal cultures along with histopathology were performed. RESULTS: Of 30 patients, 24 were females. Hyperhidrosis and malodour were the most common symptoms. Interdigital interface skin of the toes was the first site affected in most patients. Plantar skin was affected in all patients with involvement of interface skin of the toes in 29 patients. Other sites affected were palms, finger web spaces, nonglabrous skin, paronychium, and nail. Other than classical pits, scaly crusted inflammatory lesions with post-inflammatory hyperpigmentation (PIH) were noted. Associated keratoderma was also reported in some patients. DISCUSSION: The presence of hyperhidrosis, malodour, and plantar lesions is consistent with previous studies. Interface skin between toes as the first site affected, involvement of toe web spaces, and associated keratoderma have been reported rarely. However, female preponderance, involvement of finger web spaces, nonglabrous skin, paronychium, nail changes, the presence of inflammation with crusting, and PIH have never been reported previously. CONCLUSION: PK can involve web spaces, nonglabrous skin, and paronychium, and can cause nail changes. The lesions can be inflammatory with crusting and PIH.