Onychomycosis is a chronic fungal infection of the nail bed, matrix or plate. It accounts for roughly 50% of all nail disease. As the prevalence of onychomycosis is increasing, a critical review of ...diagnostic techniques and treatment options is required. Areas covered: This review discusses the current diagnostic techniques associated with diagnosing onychomycosis, such as microscopy, culture, periodic acid Schiff stain (PAS) and polymerase chain reaction (PCR). Oral and topical therapies are also discussed, as well as, the utility of device-based treatments and combination therapy. Expert commentary: Culture for the diagnosis of onychomycosis is the gold standard; however, PCR is more sensitive and should be considered. In general, topical treatments are recommended for mild to moderate disease and oral treatments should be considered for moderate to severe disease. Combination therapy and device-based treatments may enhance cure rates, further study is required.
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.
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.
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%.
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.
Background Laser treatment has emerged as a novel treatment modality for onychomycosis. Objective We sought to determine thermal response and optical effects of a submillisecond ...neodymium:yttrium-aluminum-garnet (Nd:YAG) 1064-nm laser on common fungal nail pathogens, and the clinical efficacy and safety of the Nd:YAG 1064-nm laser on onychomycotic toenails. Methods A 4-part in vitro and in vivo study was conducted using a Nd:YAG 1064-nm laser. The first portion evaluated 3 different nail pathogens in suspension at 7 heat and time exposures. The second and third parts of the study irradiated pure fungal colonies. The final portion involved an in vivo treatment of toenails over 5 treatment sessions. Results A fungicidal effect for Trichophyton rubrum was seen at 50°C after 15 minutes, and for Epidermophyton floccosum at 50°C after 10 minutes. Limited growth of Scytalidium was seen at 55°C after 5 minutes. No inhibition was observed after laser treatment of fungal colonies or suspensions. In vivo treatment of toenails showed no improvement in Onychomycosis Severity Index score. Limitations The Nd:YAG 1064-nm laser was the only laser tested. Conclusions Laser treatment of onychomycosis was not related to thermal damage or direct laser effects. In vivo treatment did not result in onychomycosis cure.
Onychomycosis is a nail fungal infection mainly caused by dermatophytes. Diagnostic confirmation is conventionally made by direct microscopy and culture, which suffer from low or moderate ...sensitivity. Several molecular methods have been used for dermatophytes detection and identification directly from nail samples. The aim of this study was the evaluation of the DermaGenius®(DG) multiplex kit in detecting and identifying dermatophytes from nail samples of untreated and treated patients with a clinical suspicion of onychomycosis.
All the patients underwent a nail scarification, performed with a sterile scalpel to collect small nail fragments from the suspected site of infection. All nail clippings were first analysed by microscopic and culture methods to define a diagnostic confirmation. DG PCR assays were retrospectively applied to the same samples.
A total of 109 toenails were collected for the microscopic, culture and DG PCR assays. The sensitivity, specificity, positive and negative predictive values of DG in the onychomycosis diagnosis in all 109 patients were respectively 78.5%, 100%, 100%, and 75.9%. Only for cultural exams the rate of positive results was significantly different in the two groups of patients with a percentage of 73.7% in untreated patients versus a 40.7% value in treated patients (P < 0.05).
Our results suggest that the use of DG kit could be useful to confirm the diagnosis of onychomycosis, implementing sensitivity especially in patients who underwent antifungal treatments without any clinical improvement.
Toenail onychomycosis is common in patients with diabetes and it can increase the risk of secondary infections and foot complications. Despite several studies investigating the prevalence and ...associated factors of toenail onychomycosis from different parts of the world, there are no data from Jordan.
To determine the prevalence and the associated factors of toenail onychomycosis among patients with diabetes in Jordan.
A cross-sectional study was conducted on 375 patients with diabetes at the National Centre for Diabetes, Endocrinology, and Genetics in Amman, Jordan. Several socio-demographic and health-independent variables including foot self-care practices were collected. Toenail onychomycosis was assessed by a specimen culture and microscopic examinations. Descriptive and inferential statistics were used for data analysis.
The prevalence of toenail onychomycosis was 57.6% (n=216). Multiple logistic regression revealed four significant associated factors; the presence of neuropathy (β=1.87, p=0.02), being an ex-smoker (β=2.69, p=0.01), being treated by both insulin and oral hypoglycemics drugs (β=1.32, p=0.03), and using antibiotics in the last year (β=1.78, p=0.02).
The prevalence of toenail onychomycosis among patients with diabetes in Jordan is high. Regular foot screening and podiatric care are recommended especially among patients with diabetic neuropathy, current treatment by insulin and oral hypoglycemics drugs, previous history of smoking, and previous use of antibiotics.
Onychomycosis is a fungal infection of nails caused by dermatophytes,
yeasts or nondermatophyte molds and represents about 30% of mycotic
cutaneous infections. Increasingly onychomychosis is being ...viewed as
more than a mere cosmetic problem. In spite of improved personal
hygiene and living environment, onychomycosis continues to spread and
persist. The prevalence rate of onychomycosis is determined by age,
predisposing factor, social class, occupation, climate, living
environment and frequency of travel. Onychomycosis in immunocompromised
patients can pose a more serious health problem. Dermatophytes are the
most frequently implicated causative agents in onychomycosis.
Previously regarded as contaminants, yeasts are now increasingly
recognised as pathogens in fingernail infections, as are some moulds.
Clinical diagnosis of onychomycosis is based on the patients′
history; a physical examination, microscopy and culture of nail
specimens. The treatment of onychomycosis has been attempted throughout
the ages, but only in the last two decades have safe, effective
systemic treatments been available for this chronic superficial fungal
disease. Oral Griseofulvin and Ketoconazole; once the agents of choice
for the treatment of onychomycosis, have been superseded by newer
systemic compounds that have a higher cure and lower relapse rates,
cause fewer side effects and are suitable for short-term dosing.
Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% ...solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112. doi:10.36849/JDD.7676.
Onychomycosis is caused by dermatophytes, yeasts or non-dermatophyte molds; when caused by dermatophytes, it is called tinea unguium. The main etiological agents are
Trichophyton rubrum
and
...Trichophyton interdigitale
. The most frequent types are distal and lateral subungual onychomycosis. Diagnosis usually requires mycological laboratory confirmation. Dermoscopy can be helpful and also biopsy is an excellent diagnostic method in uncommon cases or when mycological test is negative. Treatment must be chosen according to clinical type, number of affected nails and severity. The goal for antifungal therapy is the clearing of clinical signs or mycological cure.
Difficulties in obtaining human nails that are large enough for examining the penetration of drug formulations led us to produce keratin films regenerated from human hair. We assume that these films ...can simulate human nail plates in drug penetration and permeation tests and can serve as a biological model for studying onychomycosis. The films were formed from keratin extracted from human hair using dithiothreitol, urea and thiourea. The obtained keratin extract was dispensed into Teflon rings and dried at 40 °C and then cured at 110 °C. The structure, surface morphology, chemical characterization and thermal stability of the films were characterized and were compared to those of human nail, hair and bovine hoof samples using SDS-electrophoresis, scanning electron microscopy (SEM), X-ray diffraction analysis (XRD), Fourier transform infrared spectroscopy (FTIR) and thermogravimetric analysis (TGA). The structure of the obtained films was found to be closer to human nails than to hair or bovine hooves. The keratin films were infected with
and were proven to be appropriate for serving as a model for studying onychomycosis.
Summary
Background
Photodynamic therapy (PDT) or intense pulsed light (IPL) are efficient therapeutic methods in the treatment of superficial skin infections, and thus, they could be good options for ...onychomycosis treatment, the most common nail disorder.
Methods
Forty patients, affected with different diagnosed types of onychomycosis in nails of the first toe, were randomly divided into two groups of 20 patients to be treated by PDT or IPL. Nail plates were softened with urea 40% by occlusive dressing for 12 hours during 3‐7 days before treatments. Then, eight sessions separated by an interval of 2 weeks of a PDT protocol mediated by methylene blue (MB) and red laser diode (Periowave®, λ = 670 nm, 200 mW) or an IPL protocol based on 10 pulses/cm2 (Dye‐VL‐F module, Alma Lasers, λ = 500‐600 nm, 10 J) were applied.
Results
Both treatments reduced significantly the Onychomycosis Severity Index (OSI) (P < 0.05). In terms of complete cure: 70% (PDT) and 80% (IPL) of the patients reached it after 12 weeks post‐treatment. No patient reported any adverse effects or complications, although in the IPL Group, some referred pain sensation during light irradiation and hematomas apparition.
Conclusions
Photodynamic therapy and IPL were effective for onychomycosis cure of any etiology.
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