Onychomycosis: clinical,mycological and in vitro susceptibility testing of isolates of Trichophyton rubrum

BACKGROUND

Onychomycosis or nail fungal infection is the most common nail disease. Despite the wide range of studies on this condition, it remains difficult to establish the correct diagnosis and effective treatment.

OBJECTIVES

To evaluate the efficacy of classical laboratory methods for the diagnosis of onychomycosis, and the in vitro susceptibility of the its main etiological agent to antifungals used in routine.

METHODS

Nail samples of 100 patients with clinically suspected feet onychomycosis were collected to confirm the diagnosis by direct mycological examination and fungal culture. In vitro antifungal susceptibility testing was performed against strains of the main dermatophyte isolated by microdilution, according to the standardized protocol (M38-A2 - CLSI)

RESULTS

Clinical diagnosis of onychomycosis was confirmed by laboratory analysis in 59% of patients. Of these, 54.2% were positive only in direct mycological examination, 44.1% in direct mycological examination and culture, and one case (1.7%) was positive only in culture, resulting in weak agreement between these tests (Kappa = 0.385; p <0.001) High minimum inhibitory concentration values of fluconazole and itraconazole were observed in 66.7% and 25.0% of isolates of T. rubrum tested. Additionally, high MIC values of terbinafine and ciclopirox was detected in only one isolate, and this was one of the strains in which in vitro activity of itraconazole and fluconazole has not been proven.

CONCLUSIONS

Poor agreement was observed between direct mycological examination and culture for the diagnosis of onychomycosis, with direct mycological examination being significantly more sensitive. Except for fluconazole, the other three antifungals tested showed good in vitro activity against clinical isolates of T. rubrum.     

Clinico-Mycological Study of Dermatophyte Toenail Onychomycosis in New Delhi,India

Introduction:

There is a constant need to define the epidemiological and mycological characteristics of onychomycosis (OM) for optimal management strategies.

Objectives:

To define the epidemiological and mycological characteristics of patients with dermatophyte toenail OM in a tertiary care hospital.

Materials and Methods:

Hundred consecutive patients of KOH and culture-positive dermatophyte toenail OM were subjected to detailed history, clinical examination and investigations.

Results:

Maximum number of patients (40%) belonged to 31-45 years age group and there was a male preponderance (M:F = 6.7:1). The mean duration of disease was 54 months. Thirty-three patients had fingernail involvement in addition to the toenail OM and 37% had co-existent cutaneous dermatophyte infection. Discoloration was the most common symptom (98%). Ninety-four (94%) patients had distal lateral subungual onychomycosis (DSLO) while two had superficial onychomycosis (SO) and only one had proximal superficial onychomycosis (PSO). Trichophyton interdigitale was the most common etiological agent (61%) followed by Trichophyton rubrum and Trichophyton verrucosum.

Conclusions:

Toenail OM is more common in males. DSLO was the most common clinical variant and T. interdigitale the most common etiological fungus responsible for toenail OM in our region. The importance of early diagnosis and treatment is highlighted as long-standing toenail OM predisposes to fingernail onychomycosis and recurrent tinea pedis.     

A META-ANALYSIS COMPARING EFFICACY OF CONTINUOUS TERBINAFINE WITH INTERMITTENT ITRACONAZOLE FOR TOENAIL ONYCHOMYCOSIS

Background:

Toenail onychomycosis is a challenge for clinicians to treat. While both Itraconazole and terbinafine have proven to be effective against onychomycosis, very little is known about their comparative efficacy in achieving mycological and clinical cure.

Aim:

The purpose of this meta-analysis is to compare the efficacy of continuous terbinafine with intermittent itraconazole in the treatment of toenail onychomycosis.

Material and Methods:

all RCTs comparing continuous terbinafine with intermittent itraconazole were identified from PUBMED and BIDS electronic database.

Results:

analysis of total eight trials including 1181 patients state that treatment with continuous terbinafine is more likely to produce mycological and clinical cure compared to intermittent itraconazole with odds ratio 2.3(95% CI, 1.7 to 3.0 P<0.0001)

Conclusion:

though both itraconazole and terbinafine are well tolerated and highly effective drugs, continuous terbinafine is more effective than intermittent itraconazole at achieving mycological cure of toenail onychomycosis     

Onychomycosis Due to Nondermatophytic Molds

Background

Although there have been many studies about onychomycosis due to nondermatophytic molds (NDM), few studies about etiologic agents including NDM in onychomycosis have been reported in Korea. Objective: This study investigated onychomycosis due to NDM in the Gyeongju area of Korea.

Objective

This study investigated onychomycosis due to NDM in the Gyeongju area of Korea.

Methods

In the 10-year period from 1999~2009, we reviewed 59 patients with onychomycosis due to NDM. The etiologic agents were identified by cultures on Sabouraud''s Dextrose agar with and without cycloheximide. In some cases, internal transcribed spacer sequence analysis was done. NDM isolated considered pathogens when the presence of fungal elements was identified by direct microscopy observation and in follow-up cultures yielding the same fungi.

Results

Onychomycosis due to NDM comprised 2.3% of all onychomycosis. Of the 59 patients with onychomycosis due to NDM, 84.7% were toenail onychomycosis and 15.3% were fingernail onychomycosis. The incidence rate was highest in the fifth decade (27.1%). The ratio of male to female patients was 1:1.6. The frequency of associated diseases, in descending order, was hypertension, diabetes mellitus, and cerebral hematoma. Distal and lateral subungual onychomycosis (86.4%) was the most common clinical type of onychomycosis. Aspergillus spp. was the most frequently isolated etiologic agent of onychomycosis due to NDM (83.0%). Other causative agents were Scopulariopsis brevicaulis (10.2%), Acremonium spp. (3.4%), Fusarium solani (1.7%), and Chaetomium globosum (1.7%).

Conclusion

Because of the increase in onychomycosis due to NDM, we suggest the need of a careful mycological examination in patients with onychomycosis.     

Onychomycosis in Children: An Experience of 59 Cases

Background

Although tinea unguium in children has been studied in the past, no specific etiological agents of onychomycosis in children has been reported in Korea.

Objective

The purpose of this study was to investigate onychomycosis in Korean children.

Methods

We reviewed fifty nine patients with onychomycosis in children (0~18 years of age) who presented during the ten-year period between 1999 and 2009. Etiological agents were identified by cultures on Sabouraud''s dextrose agar with and without cycloheximide. An isolated colony of yeasts was considered as pathogens if the same fungal element was identified at initial direct microscopy and in specimen-yielding cultures at a follow-up visit.

Results

Onychomycosis in children represented 2.3% of all onychomycosis. Of the 59 pediatric patients with onychomycosis, 66.1% had toenail onychomycosis with the rest (33.9%) having fingernail onychomycosis. The male-to-female ratio was 1.95:1. Fourteen (23.7%) children had concomitant tinea pedis infection, and tinea pedis or onychomycosis was also found in eight of the parents (13.6%). Distal and lateral subungual onychomycosis was the most common (62.7%) clinical type. In toenails, Trichophyton rubrum was the most common etiological agent (51.3%), followed by Candida albicans (10.2%), C. parapsilosis (5.1%), C. tropicalis (2.6%), and C. guilliermondii (2.6%). In fingernails, C. albicans was the most common isolated pathogen (50.0%), followed by T. rubrum (10.0%), C. parapsilosis (10.0%), and C. glabrata (5.0%).

Conclusion

Because of the increase in pediatric onychomycosis, we suggest the need for a careful mycological examination of children who are diagnosed with onychomycosis.     

The association of fractional CO2 laser 10.600nm and photodynamic therapy in the treatment of onychomycosis

BACKGROUND

Onychomycosis is a fungal infection of the nails caused in most cases by dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes. Despite numerous available antifungal drugs for therapy of this infection, the cure rate is low, with high rates of relapse after treatment and side effects.

OBJECTIVES

To present a new option for the treatment of onychomycosis, in search of a more effective and rapid method than conventional ones.

METHODS

Patients underwent two sessions of CO₂ fractional laser 10.600nm associated with photodynamic therapy. Mycological and digital photography were performed before and after the treatment.

RESULTS

McNemar test with continuity correction and degrees of freedom = 1: for clinical cure rate, 13.06, with p=0.00005; for mycological cure, 17.05, with p=0.00005; 72% felt fully satisfied with the procedure.

CONCLUSIONS

The use of fractional CO₂ laser 10.600nm associated with photodynamic therapy can be effective in the treatment of onychomycosis, decreasing the risk of systemic lesions that may be triggered with prolonged use of oral antifungals.     

Study of dermatoses in kidney transplant patients

BACKGROUND

The increasing in the number of kidney transplant recipients has favored, more frequently than before, the emergence of dermatoses and warranted their study through subsequent publications.

OBJECTIVES

to evaluate the frequency of dermatoses in kidney transplant recipients.

METHODS

kidney transplant recipients with suspected dermatoses between March 1st 2009 and June 30th 2010.

RESULTS

53 patients (28 males and 25 females), aged between 22 and 69 (mean age = 45 years) were evaluated. Most of them came from the cities of Ceilândia, Samambaia and São Sebastião/DF, and had already been transplanted for 5 to 10 years before (37.7%); 62.3% were recipients of living donors and 83% were prednisone-treated. The most prevalent dermatoses were of fungal (45.3%) and viral (39.6%) etiologies. Among the non-melanoma malignant neoplasms, the basal cell carcinoma prevailed (six cases), in spite of the low incidence. Concerning fungal dermatoses, 12 cases of onychomycosis, five of pityriasis versicolor and four of pityrosporum folliculitis were reported. For diagnosis, in most cases (64.2%), laboratory examinations (mycological and histopathological) were performed.

CONCLUSION

cutaneous manifestations in kidney transplant recipients are generally secondary to immunosuppression. The infectious dermatoses, especially those of fungal origin, are frequently found in kidney transplant recipients and their occurrence increases progressively according to the time elapsed from the transplantation, which makes follow-up important.     

Topical Therapy for Toenail Onychomycosis: An Evidence-Based Review

Background

Managing toenail onychomycosis with topical treatments is challenging. It is difficult for topical medication to penetrate the nail plate, and this is reflected in lower cure rates with topical treatment than with oral treatment. However, oral medications may not be suitable for some patients, because of drug interactions; therefore, topical treatments are critical in managing the disease in certain patient populations.

Objective

This paper reviews the quality and content of the scientific literature on topical treatments for toenail onychomycosis.

Methods

PubMed, Ovid (Medline and Embase), Scopus, Cochrane library, and clinicaltrials.gov databases were searched for original clinical reports of topical monotherapy for microscopy and/or culture-confirmed toenail onychomycosis in adults. Studies were evaluated using an onychomycosis study quality scale, which was based on the CONSORT guidelines.

Results

Twenty-five publications (28 studies) were identified and met the inclusion criteria. Thirteen studies scored high ratings on the quality scale. These were randomized controlled trials or randomized comparative trials. Low-quality studies were nonrandomized, open studies that prevented statistical analysis. Most studies reported clinical and mycological cure. The most variation was observed with reporting outcomes of clinical improvement. Amorolfine, ciclopirox, tavaborole, and efinaconazole produced clinical and mycological cure in patients with mild to moderate toenail onychomycosis (<50–65 % nail involvement), with efinaconazole showing the highest rates. Treatments were generally applied daily for 24–48 weeks, with longer treatment and follow-up showing better outcomes.

Conclusion

Topical treatment with amorolfine, ciclopirox, tavaborole, or efinaconazole is appropriate for cases of mild to moderate toenail onychomycosis due to dermatophyte or mixed dermatophyte/Candida infection.     

Using 80% trichloroacetic acid in the treatment of ingrown toenails

BACKGROUND

Ingrown nails are a very common problem. There are different stages of disease and diverse therapeutic options. Phenol and sodium hydroxide are commonly used agents for chemical matricectomy but both frequently entail excessive healing times.

OBJECTIVE

This prospective study aimed mainly to evaluate the efficacy of partial nail avulsion and selective chemical cauterization of the matrix using 80% TCA in the treatment of the ingrowing nail.

METHODS

One-hundred-and-thirty-three patients with 197 ingrown toenails were included in this study. Preoperatively, we tried to find predisposing factors to the disease. In the postoperative period, patients were evaluated for potential complications at days 3, 30, 180, 270 and 360. Pain was measured before surgery, as well as 24 hours and 72 hours after surgery.

RESULTS

There were only 3 cases (out of 197) of ingrown nail recurrence. Preoperatively, we found the presence of drainage in 82% of patients, which, following the first visit after surgery, was reduced to 19%. Persistent granulation tissue was found in 3% of the patients (versus 75% prior to surgery). The most frequent predisposing factors for the ingrown nail were excessive trimming of the lateral nail plate (63%), plantar hyperhidrosis (58%) and heavy nail folds (39%). Pain was substantially reduced after surgery.

CONCLUSION

It is assumed that chemical procedures for the ingrown toenail are associated with delayed healing times but our results demonstrated quick recovery. Using 80% TCA for selective matricectomy in the ingrown toenail is an effective, quick and easy method.     

Evaluation of treatment with carboxymethylcellulose on chronic venous ulcers

BACKGROUND:

Among the chronic leg ulcers, venous ulcers are the most common and constitute a major burden to public health. Despite all technology available, some patients do not respond to established treatments. In our study, carboxymethylcellulose was tested in the treatment of refractory chronic venous ulcers.

OBJECTIVE:

To evaluate the efficacy of carboxymethylcellulose 20% on the healing of chronic venous ulcers refractory to conventional treatments.

METHODS:

This is an analytical, pre-experimental study. Thirty patients were included with refractory venous ulcers, and applied dressings with carboxymethylcellulose 20% for 20 weeks. The analysis was based on measurement of the area of ulcers, performed at the first visit and after the end of the treatment.

RESULTS:

There was a reduction of 3.9 cm² of lesion area (p=0.0001), corresponding to 38.8% (p=0.0001). There was no interruption of treatment and no increase in lesion area in any patient.

CONCLUSIONS:

Carboxymethylcellulose 20% represents a low cost and effective therapeutic alternative for the treatment of refractory chronic venous ulcers. However, controlled studies are necessary to prove its efficacy.     

Lack of compliance: a challenge for digital dermoscopy follow-up

BACKGROUND

Digital dermoscopy is the gold standard follow-up method for patients with high risk for developing cutaneous malignant melanoma. By comparing the same lesion at different moments, it allows early detection of subtle changes that could suggest the diagnosis of melanoma. Thus, it is clear that the test must be repeated after a period of time, according to time intervals determined by the evaluator.

OBJECTIVES

To evaluate adherence of patients to follow-up examinations using digital dermoscopy.

METHOD

Retrospective analysis of 36 patients who underwent digital dermoscopic examination and total-body photography in a private medical center between September 2010 and January 2013.

RESULTS

Only 25% of the patients returned for followup evaluations.

CONCLUSIONS

Low adherence to digital dermoscopy follow-up could compromise the efficacy of this valuable method. This lack of adherence represents a challenge for the evaluator.     

Factors that influence healing of chronic venous leg ulcers: a retrospective cohort

BACKGROUND

Venous ulcers have a significant impact on patient quality of life, and constitute a worldwide public health problem. Treatment is complex, with high failure rates.

OBJECTIVES

To identify clinical and therapeutic factors that influence healing of venous ulcers.

METHODS

Retrospective cohort study of patients with venous ulcers. Ulcer area was measured at the first visit (T0) and after 6 months (T6) and 1 year (T12). A reduction in ulcer area of 50% or more at T6 and T12 was the outcome of interest, weighted by clinical, demographic and treatment aspects.

RESULTS

Ninety-four patients were included (137 ulcers). A reduction in ulcer area of 50% or more was seen in 40.1% of patients (95%CI 31.9 to 48.4%) at T6 and 49.6% (95%CI 41.2 to 58.1%) at T12. Complete healing occurred in 16.8% (95%CI 10.5 to 23.1%) at T6 and 27% (95%CI 19.5 to 39.5%) at T12. The lowest ulcer area reductions at T6 were associated with longstanding ulcer (RR=0.95; 95%CI 0.91 to 0.98), poor adherence to compression therapy (RR=4.04; 95%CI 1.31 to 12.41), and infection episodes (RR= 0.42; 95%CI 0.23 to 0.76). At T12, lower reductions were associated with longstanding ulcer (RR=0.95; 95%CI 0.92 to 0.98), longer topical antibiotic use (RR=0.93; 95%CI 0.87 to 0.99), and systemic antibiotic use (RR=0.63; 95%CI 0.40 to 0.99).

CONCLUSIONS

Longstanding ulcer, infection, poor adherence to compression therapy, and longer topical and systemic antibiotic use were independently correlated with worse healing rates.     

Clinical,epidemiological, and therapeutic profile of dermatophytosis

BACKGROUND

The cutaneous mycoses, mainly caused by dermatophyte fungi, are among the most common fungal infections worldwide. It is estimated that 10% to 15% of the population will be infected by a dermatophyte at some point in their lives, thus making this a group of diseases with great public health importance.

OBJECTIVE

To analyze the clinical, epidemiological, and therapeutic profile of dermatophytosis in patients enrolled at the Dermatology service of Universidade do Estado do Pará, Brazil, from July 2010 to September 2012.

METHOD

A total of 145 medical records of patients diagnosed with dermatophytosis were surveyed. Data were collected and subsequently recorded according to a protocol developed by the researchers. This protocol consisted of information regarding epidemiological and clinical aspects of the disease and the therapy employed.

RESULTS

The main clinical form of dermatophyte infection was onychomycosis, followed by tinea corporis, tinea pedis, and tinea capitis. Furthermore, the female population and the age group of 51 to 60 years were the most affected. Regarding therapy, there was a preference for treatments that combine topical and systemic drugs, and the most widely used drugs were fluconazole (systemic) and ciclopirox olamine (topical).

CONCLUSION

This study showed the importance of recurrent analysis of the epidemiological profile of dermatophytosis to enable correct therapeutic and preventive management of these conditions, which have significant clinical consequences, with chronic, difficult-totreat lesions that can decrease patient quality of life and cause disfigurement.     

Dermoscopic and Clinical Features of Pigmented Skin Lesions of the Genital Area

BACKGROUND

The dermoscopic features of vulvar melanosis lesions are well known. To our knowledge, there are only a few case reports about dermoscopic features of pigmented genital lesions in male patients.

OBJECTIVE

To evaluate dermoscopic and clinical characteristics of benign lesions of the genital area in both males and females, and to assess the distinguishing dermoscopic criteria of vulvar melanosis and atypical melanocytic nevi of the genital type.

METHODS

68 patients with pigmented genital lesions were included in this observational study (28 male and 40 female). A punch biopsy was taken from all pigmented lesions and histopathological examination was performed on all specimens.

RESULTS

We histopathologically diagnosed: genital melanosis in 40 lesions, atypical melanocytic nevi of the genital type in 15 lesions, melanocytic nevi in 9 lesions, seborrheic keratosis in 4 lesions. The most frequent locations were the glans penis (19 patients, 67.9%) in males and the labia minora (19 patients, 47.5%) in females. The mean age of patients with atypical nevi (28,6 ± 11,36) was significantly lower than the mean age of patients with genital melanosis (47,07 ± 15,33).

CONCLUSIONS

Parallel pattern is prominent in genital melanosis, ring-like pattern is only observed in genital melanosis. Most pigmented lesions on the genital area are solitary. Blue-white veil and irregular dots are only observed in AMNGT. According to these results, we propose that histopathological examination is performed, especially if blue-white veil and irregular dots are found by dermoscopy.     

Evaluating the effectiveness of the customized Unna boot when treating patients with venous ulcers

BACKGROUND

Lower limb ulcers are a serious medical and socioeconomic problem throughout the world. One type of chronic wound of the lower extremities is the venous ulcer. Therapeutic methods for treating venous ulcer include the use of the Unna boot.

OBJECTIVES

To evaluate the effectiveness of the customized Unna boot in the treatment of venous ulcers and to monitor the subsequent development and healing of the lesions.

METHODS

Prospective exploratory and quantitative longitudinal study, conducted at the "Outpatients Department (Wound Care) of the Grupo da Fraternidade Espírita Irmão Alexandre" in the city of Pouso Alegre (MG), Brazil, in 2008. The sample consisted of 32 patients with venous ulcers who underwent treatment with the Unna boot and 11 patients (control group), who used a simple bandage application. The patients''lesions were monitored over a three month period.

RESULTS

The average age of the predominently female (65.1%) patients was 61.88. From observing the differences in healing times at the three evaluation stages, it was clear that after the initial evaluation the wound area decreased in Groups 1 and 2 (p>0.05).

CONCLUSION

The use of the customized Unna boot contributes to quicker healing. However, over a period of three months the simple bandage applications were seen to be just as effective as the Unna boot method.     

Comorbidities and cardiovascular risk factors in patients with psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease and its pathogenesis involves an interaction between genetic, environmental, and immunological factors. Recent studies have suggested that the chronic inflammatory nature of psoriasis may predispose to an association with other inflammatory diseases, especially cardiovascular diseases and metabolic disorders.

OBJECTIVES

To describe the demographic, clinical, epidemiological, and laboratory characteristics of a sample of psoriasis patients; to assess the prevalence of cardiovascular comorbidities in this group of patients; and to identify the cardiovascular risk profile using the Framingham risk score.

METHODS

We conducted a cross-sectional study involving the assessment of 190 patients. Participants underwent history and physical examination. They also completed a specific questionnaire about epidemiological data, past medical history, and comorbidities. The cardiovascular risk profile was calculated using the Framingham risk score.

RESULTS

Patients'' mean age was 51.5 ± 14 years, and the predominant clinical presentation was plaque psoriasis (78.4%). We found an increased prevalence of systemic hypertension, type 2 diabetes, metabolic syndrome, and obesity. Increased waist circumference was also found in addition to a considerable prevalence of depression, smoking, and regular alcohol intake. Patients'' cardiovascular risk was high according to the Framingham risk score, and 47.2% of patients had moderate or high risk of fatal and non-fatal coronary events in 10 years.

CONCLUSIONS

Patients had high prevalence of cardiovascular comorbidities, and high cardiovascular risk according to the Framingham risk score. Further epidemiological studies are needed in Brazil for validation of our results.     

Observational descriptive study of cutaneous manifestations in patients from Mato Grosso with viral chronic hepatitis

BACKGROUND

Extrahepatic manifestations are seen in association with chronic infection by hepatitis B or C virus including cutaneous disorders. The frequency of these findings seems to vary among different places and reports. There is a lack of information about this issue in Brazil.

OBJECTIVES

To estimate the prevalence of cutaneous findings affecting HBV or HCV carriers from a reference outpatient unit in Mato Grosso.

METHODS

A cross-sectional observational study.

RESULTS

108 patients were studied. 88.9% presented some cutaneous findings but must of them were nonrelated to chronic viral infection. Four patients had cutaneous or autoimmune syndromes that may be HBV or HCV related.

CONCLUSION

In our study we found no statistical association between viral hepatitis and skin diseases.     

Variants of CARD14 gene and psoriasis vulgaris in southern Chinese cohort

BACKGROUND:

Recent mutation analysis identified several missense mutations in CARD14 in psoriasis.

OBJECTIVES:

We performed the genomic sequence analysis on CARD14 in southern Chinese Han Cantonese with Psoriasis Vulgaris (PsV) to reveal more causative missense mutations.

METHODS:

A total of 131 patients with PsV and 207 matched controls were included. We conducted sequence analysis of all the exon and exon-intron boundaries of CARD14 in the group of PsV patients and subsequent case control analysis of potential sequence variants of significance.

RESULTS:

We found five rare mutations and four of them are annotated or reported. Only the variant (c.1291C>G) has not been reported and annotated, but the variant was also found in controls. No significant difference was detected among all rare variant allele frequencies of patients and controls.

CONCLUSION:

None of the new definite variants were pathogenic. The other pathogenic mutations for PsV are still elusive in our cohort.