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Frontiers in Medicine 2023Onychomycoses are fungal infections that can be seen in any component of the nail unit, including the matrix, bed, and plate, and are caused by dermatophyte fungi,...
BACKGROUND
Onychomycoses are fungal infections that can be seen in any component of the nail unit, including the matrix, bed, and plate, and are caused by dermatophyte fungi, non-dermatophyte fungi, and yeasts. This disease affects approximately 1 to 8% of the general population and occurs in approximately 19 to 51.9% of the patients on hemodialysis. The high incidence of onychomycosis in patients on hemodialysis is associated, mainly, with immunologic deficits and histological changes caused by uremia.
METHODS
Adult patients of the São Francisco University Hospital Hemodialysis Center were included. The following characteristics were evaluated: age, sex, body mass index, comorbidity, and household location. All patients were clinically evaluated and those with suspected onychomycosis had subungual debris of the affected nail plate collected for the direct mycological examination and fungal culture. The onychomycosis severity for those patients with a positive result in the fungal culture examination was evaluated using the Onychomycosis Severity Index system.
RESULTS
The study included 151 patients, and 70 out of the 151 patients (46.4%) showed nail alteration, and among them, 31 out of the 70 patients (44.3%) had the onychomycosis diagnosis confirmed by direct mycological examination. The pathogens observed in the patients were [8 out of 31 (25.8%)], [7 out of 31 (22.6%)], S spp. [6 out of 31 (19.4%)], spp. [2 out of 31 (6.45%)], spp. [1 out of 31 (3.2%)], [1/31 (3.2%)], [1 out of 31 (3.22%)], and and spp. [1 out of 31 (3.2%)]. Three participants presented negative results in the culture examination, and one did not allow the collection of material for the examination. The nail involvement severity score for the majority of them was severe [23 out of 27 (85.2%)], and only 1 out of the 27 (3.7%) and 3 out of the 27 (1.1%) patients presented moderate and mild scores, respectively. The distal subungual onychomycosis occurred in 12 out of 27 (44.4%) patients, a mixed pattern occurred in 14 out of 27 (51.9%) patients, and, white superficial occurred in only 1 out of 27 (3.7%) patients. In the bivariate analysis, a higher risk of onychomycosis was associated with the male sex [23/31 (74.2%) vs. 56/120 (46.7%); OR = 3.286 (95%CI = 1.362 to 7.928)] and obesity [8/31 (25.8%) vs. 12/120 (10.0%); OR = 3.130 (95%CI = 1.150 to 8.521)]. Patients with diabetes mellitus were more susceptible to onychomycosis attacks (-value = 0.049; 16 out of 31 (51.6%) vs. 40 out of 120 (33.3%); however, OR was 2.133 (95%CI = 0.959 to 4.648). The patients with onychomycosis were older but without a significant difference between the groups (-value = 0.073; 66 years old vs. 58 years old). The multivariable model using the logistic regression (backward model) confirmed our results and was able to predict (81.5%) the onychomycosis-positive diagnosis (chi-square = 27.73; -value <0.001). The age [OR = 1.036; 95%CI = 1.004 to 1.069], male sex [OR = 5.746; 95%CI = 2.057 to 16.046], and presence of obesity [OR = 4.800; 95%CI = 1.435 to 16.055] were positive and significant in predicting the onychomycosis-positive diagnosis.
CONCLUSION
In our study, onychomycosis in patients on hemodialysis was associated with a great variety of microorganisms, mainly species. The nail involvement severity score for the majority of patients was severe, and distal subungual onychomycosis and mixed pattern onychomycosis were the most prevalent clinical types. The main risk factors associated with onychomycosis were male sex, older age, and the presence of obesity.
PubMed: 38076229
DOI: 10.3389/fmed.2023.1268324 -
Lasers in Medical Science Jun 2023Onychomycosis is a fungal infection of the nail unit caused by various species of dermatophytes, non-dermatophytic moulds or yeasts. They pose a therapeutic challenge to... (Randomized Controlled Trial)
Randomized Controlled Trial
Comparative study of safety and efficacy of combination therapy of fractional CO laser and topical amorolfine cream versus oral itraconazole in the treatment of onychomycosis.
Onychomycosis is a fungal infection of the nail unit caused by various species of dermatophytes, non-dermatophytic moulds or yeasts. They pose a therapeutic challenge to the treating dermatologist as the infection is often resistant to treatment and requires prolonged therapy. To evaluate the efficacy and safety profile of fractional CO laser and 0.25% Amorolfine hydrochloride cream in the treatment of onychomycosis. In this randomized controlled study on 50 patients with fingernail onychomycosis, one group (25 patients, 30 nails) were treated with fractional CO laser and 0.25% Amorolfine hydrochloride cream, and the second group (25 patients, 31 nails) with oral itraconazole pulse therapy. Four treatment sessions were carried out in the first group at an interval of two weeks each. Whereas, the second group received 2 doses of itraconazole pulse therapy with one month interval each. Both the groups were followed up for a period of 4 months. Results were assessed by Onychomycosis severity index(OSI), Physician global assessment scale, patient's subjective score and fungal microscopy. Complete resolution was seen in 14 out of 25(56%) patients and 6 out of 25(24%) patients in group 1 and group 2 respectively. There was statistically significant difference in the response between the two groups during 1 and 2 follow up (p value - 0.004 and 0.023 respectively). Fractional CO2 laser with amorolfine cream is proved to be a better modality in onychomycosis therapy compared to oral itraconazole pulse therapy, especially in distal lateral subungual and superficial white onychomycosis.
Topics: Humans; Itraconazole; Onychomycosis; Antifungal Agents; Carbon Dioxide; Lasers, Gas; Treatment Outcome
PubMed: 37354212
DOI: 10.1007/s10103-023-03804-3 -
Mycoses Jan 2022Onychomycosis (OM) is the most common infectious nail disease, and it occurs frequently in patients with psoriasis. Microbial community shifts have been suggested to...
BACKGROUND
Onychomycosis (OM) is the most common infectious nail disease, and it occurs frequently in patients with psoriasis. Microbial community shifts have been suggested to play a role in psoriasis and fungal infection occurrence.
OBJECTIVES
To investigate and compare nail microbial community compositions in psoriatic and nonpsoriatic patients with OM.
METHODS
Toenail samples were collected from nonpsoriatic patients with OM, psoriatic patients with nail psoriasis (NP) and OM, patients with only NP and healthy controls. Bacterial and fungal community compositions were analysed by amplicon sequencing of the V3-V4 regions of the 16S rDNA gene and the ITS1 region, respectively.
RESULTS
Psoriatic OM patients had higher bacterial and fungal alpha diversities. Taxonomic analysis revealed a significantly lower relative abundance of Trichophyton rubrum (32.88% vs 82.18%, p < .001) and an increased trend of the abundance of Candida in psoriatic patients with OM than in nonpsoriatic patients. Nonpsoriatic patients with OM had a higher abundance of Staphylococcus than healthy controls (59.66% vs 45.76%, p < .05). Trichophyton, Alternaria and Malassezia could accurately differentiate psoriatic and nonpsoriatic patients with OM, with an area under the curve (AUC) of 0.86. The severity of OM was positively correlated with the relative abundance of Trichophyton rubrum. Further, Trichophyton was positively correlated with Staphylococcus and negatively correlated with Corynebacterium, Anaerococcus, Malassezia and Alternaria.
CONCLUSIONS
The nail microbiome in psoriatic patients with OM has distinct bacterial and fungal signatures, suggesting that different dysbiosis is associated with the pathogenesis of OM in psoriatic and nonpsoriatic patients.
Topics: Alternaria; Arthrodermataceae; Case-Control Studies; Humans; Malassezia; Microbiota; Nail Diseases; Nails; Onychomycosis; Psoriasis; Trichophyton
PubMed: 34549836
DOI: 10.1111/myc.13372 -
Microbial Pathogenesis Aug 2022Onychomycosis (OM) is a fungal infection, responsible for about 50% of nail diseases. OM has been attributed to the ability of fungi to naturally organize themselves... (Review)
Review
Onychomycosis (OM) is a fungal infection, responsible for about 50% of nail diseases. OM has been attributed to the ability of fungi to naturally organize themselves into biofilms on nail surfaces. However, little is known about the exact role of the biofilm in the etiopathogenesis of OM, as well as its influence in the permeation of a topical treatment. The objectives of this study were to review the literature for topical OM treatments in clinical trials, assess the efficiency of these treatments, and discuss factors that could affect the success of these treatments. First, a systematic search of articles published in the MEDLINE database (PubMed) between January 2010 and December 2019 was conducted, focusing on drugs under clinical trials for the topical treatment of OM. Of the publications selected, it was clear that none of them had considered the fungi organized in biofilm. Therefore, we reflected on some important variables involved in OM, such as the nail structure and the mechanism of fungal invasion. Some methods, such as histopathologic analysis and spectroscopy techniques, were found to be effective in the detection of nail biofilm, and could be used in future drug permeation studies. This review allowed us to conclude that novel antifungals for the topical treatment of OM must consider the drug to permeate through biofilm. Natural products, such as propolis, seem strong candidates in this respect.
Topics: Administration, Topical; Antifungal Agents; Humans; Nail Diseases; Nails; Onychomycosis
PubMed: 35716926
DOI: 10.1016/j.micpath.2022.105640 -
Scientific Reports May 2022Onychomycosis (OM) is a common fungal nail infection. Based on the rich mycobial diversity in healthy toenails, we speculated that this is lost in OM due to the...
Onychomycosis (OM) is a common fungal nail infection. Based on the rich mycobial diversity in healthy toenails, we speculated that this is lost in OM due to the predominance of a single pathogen. We used next generation sequencing to obtain insights into the biodiversity of fungal communities in both healthy individuals and OM patients. By sequencing, a total of 338 operational-taxonomic units were found in OM patients and healthy controls. Interestingly, a classifier distinguished three distinct subsets: healthy controls and two groups within OM patients with either a low or high abundance of Trichophyton. Diversity per sample was decreased in controls compared to cases with low Trichophyton abundance (LTA), while cases with a high Trichophyton abundance (HTA) showed a lower diversity. Variation of mycobial communities between the samples showed shifts in the community structure between cases and controls-mainly driven by HTA cases. Indeed, LTA cases had a fungal β-diversity undistinguishable from that of healthy controls. Collectively, our data provides an in-depth characterization of fungal diversity in health and OM. Our findings also suggest that onychomycosis develops either through pathogen-driven mechanisms, i.e., in HTA cases, or through host and/or environmental factors, i.e., in cases with a low Trichophyton abundance.
Topics: Biodiversity; High-Throughput Nucleotide Sequencing; Humans; Nails; Onychomycosis; Trichophyton
PubMed: 35614121
DOI: 10.1038/s41598-022-13074-8 -
Skin Appendage Disorders Jul 2022Onychomycosis is notoriously difficult to treat. While oral antifungals are the most efficacious treatment for onychomycosis, they are contraindicated in certain patient...
INTRODUCTION
Onychomycosis is notoriously difficult to treat. While oral antifungals are the most efficacious treatment for onychomycosis, they are contraindicated in certain patient populations, and patients may desire lower risk and accessible alternatives to systemic agents. In this study, we examine the clinical evidence supporting the use of complementary and alternative therapies in the treatment of onychomycosis.
METHODS
PubMed, Embase, and Cochrane Library were searched for clinical trials, observational studies, and case reports/case series, examining the efficacy of a complementary or alternative therapy for the treatment of onychomycosis.
RESULTS
We identified 17 articles studying a complementary and alternative therapy for onychomycosis, including tea tree oil ( = 5), ( = 3), ( = 2), natural coniferous resin lacquer ( = 2), Vicks VapoRub ( = 2), propolis extract ( = 2), and ozonized sunflower oil ( = 1).
CONCLUSION
Given the rise of antifungal resistance, complementary and alternative therapies should continue to be studied as adjunctive or alternative therapy for onychomycosis. While preliminary evidence exists for several complementary and alternative therapies in the treatment of onychomycosis, large-scale, randomized, placebo-controlled trials are needed prior to endorsing their use to patients.
PubMed: 35983465
DOI: 10.1159/000521703 -
Mycoses Apr 2022Onychomycosis represents a therapeutic challenge. The complete cure rate with itraconazole pulse therapy remains unsatisfactory implying the need for an effective...
BACKGROUND
Onychomycosis represents a therapeutic challenge. The complete cure rate with itraconazole pulse therapy remains unsatisfactory implying the need for an effective therapeutic regimen. Given the successful treatment of recurrent dermatophytosis with isotretinoin and itraconazole, we investigated the therapeutic use of acitretin in onychomycosis.
AIM
To evaluate and compare the efficacy of combined itraconazole and acitretin versus monotherapy with each in onychomycosis.
PATIENTS AND METHODS
The study included 135 adult patients with finger- and/or toenail onychomycosis. They were equally subdivided into 3 groups: itraconazole pulse therapy, acitretin and combined itraconazole/acitretin therapy. The drugs were administered for 3 months. Evaluation of severity was done by onychomycosis severity index score. Potassium hydroxide microscopy and culture were performed at baseline and at the end of the study.
RESULTS
Mycological and complete cure of onychomycosis was observed in 51.1% and 20% of the itraconazole group, 28.9% and 28.9% of the acitretin group, and 80% and 53.3% of the combined group. There was a statistically significant difference between groups in favour of the combined itraconazole/acitretin therapy (P ≤ .05).
LIMITATIONS
Small sample and short therapy duration.
CONCLUSIONS
Acitretin could be a powerful therapeutic player in the field of onychomycosis, with greater efficacy when combined with itraconazole.
Topics: Acitretin; Adult; Antifungal Agents; Foot Dermatoses; Humans; Itraconazole; Onychomycosis; Treatment Outcome
PubMed: 35103343
DOI: 10.1111/myc.13424 -
AAPS PharmSciTech Jul 2023The humanoid nail is considered an exceptional protective barrier that is formed mainly from keratin. Onychomycosis is the cause of 50% of nail infections that is... (Review)
Review
The humanoid nail is considered an exceptional protective barrier that is formed mainly from keratin. Onychomycosis is the cause of 50% of nail infections that is generally caused by dermatophytes. Firstly, the infection was regarded as a cosmetic problem but because of the tenacious nature of onychomycosis and its relapses, these infections have attracted medical attention. The first line of therapy was the oral antifungal agents which were proven to be effective; nevertheless, they exhibited hepato-toxic side effects, alongside drug interactions. Following, the opportunity was shifted to the topical remedies, as onychomycosis is rather superficial, yet this route is hindered by the keratinized layers in the nail plate. A potential alternative to overcome the obstacle was applying different mechanical, physical, and chemical methods to boost the penetration of drugs through the nail plate. Unfortunately, these methods might be expensive, require an expert to be completed, or even be followed by pain or more serious side effects. Furthermore, topical formulations such as nail lacquers and patches do not provide enough sustaining effects. Recently, newer therapies such as nanovesicles, nanoparticles, and nanoemulsions have emerged for the treatment of onychomycosis that provided effective treatment with possibly no side effects. This review states the treatment strategies such as mechanical, physical, and chemical methods, and highlights various innovative dosage forms and nanosystems developed in the last 10 years with a focus on advanced findings regarding formulation systems. Furthermore, it demonstrates the natural bioactives and their formulation as nanosystems, and the most relevant clinical outcomes.
Topics: Humans; Onychomycosis; Administration, Topical; Nails; Nail Diseases; Drug Delivery Systems; Antifungal Agents
PubMed: 37421509
DOI: 10.1208/s12249-023-02603-x -
Journal of Cosmetic Dermatology May 2020Onychomycosis is a dermatophyte fungal infection of the nail plate, bed, and the matrix, leading to the gradual damage which often considered a cosmetic problem. Several...
BACKGROUND
Onychomycosis is a dermatophyte fungal infection of the nail plate, bed, and the matrix, leading to the gradual damage which often considered a cosmetic problem. Several presentations of onychomycosis: distolateral subungual (DLSOM), superficial white, proximal subungual, endonyx, and total dystrophic (TDOM). Although the diagnosis relies on mycological results, there are three specific dermoscopic findings for onychomycosis: a jagged edge of the onycholytic area, with spikes directed to the proximal fold, white-yellow longitudinal striae in the onycholytic nail plate, and colored parallel bands.
AIMS
The objective of this diagnostic cross-sectional study was to evaluate the diagnostic accuracy of dermoscopy as a low-cost tool compared with fungal culture in patients with onychomycosis.
PATIENTS/METHODS
This study was carried out on 40 patients with a clinical diagnosis of onychomycosis collected from dermatology outpatient clinic of Alzahraa University Hospital after approval from the research ethics committee of Al-Azhar University. For each patient, dermoscopic imaging of nail was done. And nail scrapings, culture on sabouraud's dextrose agar medium, and dermatophyte test agar medium. Informed written consent was taken from all patients, and the data collected from dermoscopic and laboratory results were statistically evaluated.
RESULTS
Concerning the dermoscopic features, longitudinal white striae, jagged proximal edge with spikes, were the most commonly detected in DLSOM and TDOM. Linear edge was exclusive to traumatic onycholysis. Laboratory results: Aspergillus species was the most common detected fungus (45%) followed by Candida (32.5%).
CONCLUSION
Dermoscopy could facilitate the diagnosis of onychomycosis and differentiate it from mycologically negative onycholysis.
Topics: Adult; Aspergillus; Candida; Cross-Sectional Studies; Dermoscopy; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Mycological Typing Techniques; Nails; Onycholysis; Onychomycosis
PubMed: 31502751
DOI: 10.1111/jocd.13144 -
Acta Dermato-venereologica Sep 2021Nail dermoscopy (onychoscopy) is a valuable diagnostic tool for evaluating diseases in the nail apparatus. It is non-invasive, allowing clinicians to prioritize... (Review)
Review
Nail dermoscopy (onychoscopy) is a valuable diagnostic tool for evaluating diseases in the nail apparatus. It is non-invasive, allowing clinicians to prioritize particular nails for biopsy. Thus, it can improve diagnostic accuracy and expedite treatment. Evaluating inflammatory nail disorders using onychoscopy is a relatively new approach to clinical assessment and has the potential to augment clinical care. This review highlights key dermoscopic features of major inflammatory nail disorders, including trachyonychia, nail psoriasis, nail lichen planus, onychotillomania, nail lichen striatus and allergic contact dermatitis due to artificial nails. It also illustrates their management and differential diagnoses, including onychomycosis, onycholysis, nail dystrophy due to systemic amyloidosis and malignant nail tumours. Limitations of this review included the low amount of literature on this topic and non-standardized terminology used among research-ers. As onychoscopy is a relatively new technique, further studies and standardization of terminology are warranted to consolidate the role of dermoscopy in evaluating inflammatory nail disorders.
Topics: Humans; Lichen Planus; Nail Diseases; Nails; Onychomycosis; Psoriasis
PubMed: 34490472
DOI: 10.2340/00015555-3917