Prevalence of foot diseases in outpatients attending the Institute of Dermatology, Bangkok, Thailand

Two thousand patients who visited the outpatient department at the Institute of Dermatology, Bangkok, were assessed for the presence of foot diseases by questionnaire and physical examination. Abnormalities were detected in 741 individuals (37.1%). Nonfungal conditions were more prevalent (31.4%), mainly consisting of eczema (254 cases, 12.7%) and psoriasis (176 cases, 8.8%). Fungal disease was observed in 119 cases (6.0%). There were 76 cases (3.8%) with tinea pedis and 33 cases (1.7%) with onychomycosis. The identified organisms causing tinea pedis were 57.9% nondermatophyte moulds, 36.8% dermatophytes, and 2.6%Candida spp. The corresponding organisms causing onychomycosis were 51.6% nondermatophyte moulds, 36.3% dermatophytes, and 6.0%Candida spp. Among nondermatophytes, Scytalidium dimidiatum was the leading pathogen while Trichophyton rubrum and T. mentagrophytes were the predominant dermatophytes identified. Diabetes mellitus, peripheral vascular disease and activities related to foot trauma were noted to be predisposing factors for onychomycosis. Footwear, particularly sandals and cut shoes, was the only factor relevant to individuals with tinea pedis (P < or = 0.05). In contrast with other published data on fungal foot infections, this study disclosed a higher prevalence of nondermatophyte organisms, predominantly S. dimidiatum, as the major cause of tinea pedis and onychomycosis. An increase in awareness is necessary to identify such cases, prevent misdiagnosis and initiate appropriate treatment.     

Onychomycosis and Trichosporon beigelii in Korea

BACKGROUND: Onychomycosis is a common superficial fungal infection. Causative organisms in onychomycosis have been extensively studied, but the role of nondermatophytes is controversial. Trichosporon beigelii is a soil and water inhabiting yeast and is occasionally found in the flora normally associated with human skin, mouth, and nails. Several reports in the literature have suggested that T. beigelii is one of the pathogens in onychomycosis. METHODS: We performed a survey of the mycologic laboratory records of patients clinically suspected of having onychomycosis from July 1996 to December 1998. RESULTS: Out of a total of 2591 nail samples examined, 1222 (47.2%) were culture positive, including 262 cases (10.1%) with T. beigelii. The overall positive rate for the KOH mount examination was 58.8%, and in the cases with T. beigelii was 89.1%. Among the age groups, the incidence rate was highest in the fifth decade (26.6%). The most common causative organism of microscopy-positive onychomycosis was Trichophyton rubrum (61.4%); the others in decreasing frequency were T. beigelii (20.4%), Candida spp. (7.3%), Trichophyton mentagrophytes (4.1%), and mixed infection (2.9%). T. beigelii was repeatedly isolated in successive nail cultures from 10 of 20 patients selected from those with T. beigelii nail infection. CONCLUSIONS: T. beigelii was the second most commonly isolated fungus in onychomycosis and had a high positive rate on KOH mount examination of the nails and successive repeated cultures. We suggest that T. beigelii might be a common pathogen of onychomycosis in Korea.     

Onychomycosis in Adana, Turkey: a 5-year study

BACKGROUND: Onychomycosis results from invasion of the nail plate by dermatophytes, yeasts or mould species of fungi. This report documents the etiological agents of onychomycosis in Adana, Turkey. METHODS: Results of mycological tests of nail clippings or subungal scrapings collected in the period between 1998 and 2002 were analyzed. Both the direct microscopy and the cultures of the nail material were performed to identify the causative agent. RESULTS: Out of a total of 388 cases examined, finger (12.4%) and toenail (87.6%) involvement, 155 (39.9%), were mycologically proven cases of onychomycosis (15 finger, 140 toenail). Among the 98 specimens from positive fungal cultures, dermatophytes were isolated in 74 (75.5%), and yeasts in 24 (24.5%). Trichophyton rubrum was the most common causative agent (48.0%), followed by T. mentagophytes var. interdigitale (26.6%), Candida tropicalis (11.2%), C. albicans (9.2%), C. glabrata (2.0%), C. krusei (2.0%) and Epidermophyton floccosum (1.0%). CONCLUSIONS: Dermatophyte fungi, especially T. rubrum and T. mentagrophytes var. interdigitale, were responsible for most of the infections.     

Onychomycosis infections in the Middle Black Sea Region, Turkey

Background  Onychomycosis, a fungal infection of the nail, is caused by dermatophytes, yeasts, and nondermatophyte molds. The causative pathogen and incidence of onychomycosis depend on age, gender, geographic and climatic conditions, living habits, and immune status of the host.
Aim  To determine the incidence and etiologic agents of onychomycosis in the Middle Black Sea Region, Turkey.
Methods  Two hundred and seventy-six specimens were collected from patients with suspected onychomycosis during January 2004 to May 2008.
Results  Culture positivity was obtained in 240 of the 276 samples. Dermatophytes were isolated in 225 samples. The most common causative agent of onychomycosis was Trichophyton rubrum (91) (38%), followed by Trichophyton mentagrophytes (49) (20.4%), Epidermophyton floccosum (41) (17%), and Trichophyton verrucosum (34) (14.2%). Seven isolates were identified as yeasts (2.9%). Nondermatophyte molds were isolated from eight samples (3.3%).
Conclusions  This survey reveals that the etiologic agents of onychomycosis in our area show large discrepancies from those in other regions of Turkey and Europe.     

Epidemiologic and clinicomycologic profile of onychomycosis from north India

Background  Onychomycosis is an important public health problem because of the increase in immunosuppressive states. Large-scale studies in India are scarce, and so the baseline incidence of onychomycosis is not firmly established.
Methods  Three hundred and two clinically suspected cases of onychomycosis were included in this study. Nail samples were collected for direct microscopic examination and culture. Clinical patterns and associated relevant factors were noted according to a predetermined protocol.
Results  The associated predisposing conditions included diabetes mellitus (3.9%) and systemic lupus erythematosus (2.3%). Distal and lateral subungual onychomycosis was the most common clinical pattern (62%), followed by total dystrophic onychomycosis (20.2%). The most common fungal isolates were dermatophytes (49.5%), followed by Candida spp. (40.4%) and nondermatophyte molds (10.1%). Of the dermatophytes, Trichophyton rubrum (47%) was the most common isolate, followed by Trichophyton tonsurans (20.4%). Of the Candida spp., Candida albicans was the most common (60%).
Conclusions  Until recently, yeasts and nondermatophyte molds were regarded as contaminants, but their emergence as a significant cause of onychomycosis in immunocompromised patients calls for mycologic diagnosis and antifungal susceptibility testing in onychomycosis. The recognition of the changing patterns of onychomycosis will aid in the therapeutic approach and the implementation of control measures.     

A nail drilling method suitable for the diagnosis of onychomycosis

We describe a nail drilling method suitable for the diagnosis of onychomycosis. Thirty-three patients with onychomycosis in which the big toenail had a white band or spike were enrolled in this study. We drilled a hole about 3-mm-wide in the most proximal part of the white band or spike using a ball-shaped metal file and then, through the hole, sampled the underlying nail material softened by fungi after removing the superficial hard nail plate. Fungi in 32 (97.0%) of the nail samples were detected by direct KOH examination. When incubated on Sabouraud's dextrose agar slant with chloramphenicol and cycloheximide, fungal cultures were obtained from 27 (81.8%) of the 33 nail samples. Fourteen of the fungal isolates were identified as T. rubrum, 11 as T. mentagrophytes, and 2 as Acremonium sp. The nail drilling method is suitable for diagnosing onychomycosis with a white band or spike, because it gives a high isolation rate and leaves the patients' nail relatively more intact compared with other methods.     

Onychomycosis in Lahore, Pakistan

BACKGROUND: Onychomycosis, a common nail disorder, is caused by yeasts, dermatophytes, and nondermatophyte molds. These fungi give rise to diverse clinical presentations. The present study aimed to isolate the causative pathogens and to determine the various clinical patterns of onychomycosis in the population in Lahore, Pakistan. PATIENTS: In 100 clinically suspected cases, the diagnosis was confirmed by mycologic culture. Different clinical patterns were noted and correlated with causative pathogens. RESULTS: Seventy-two women (mean age, 32.6 +/- 14.8 years) and 28 men (mean age, 40.6 +/- 15.8 years) were studied. Fingernails were involved in 50%, toenails in 23%, and both fingernails and toenails in 27% of patients. The various clinical types noted were distolateral subungual onychomycosis (47%), candidal onychomycosis (36%), total dystrophic onychomycosis (12%), superficial white onychomycosis (3%), and proximal subungual onychomycosis (2%). Candida was the most common pathogen (46%), followed by dermatophytes (43%) (Trichophyton rubrum (31%), T. violaceum (5%), T. mentagrophytes (4%), T. tonsurans (2%), and Epidermophyton floccosum (1%) and nondermatophyte molds (11%) (Fusarium (4%), Scopulariopsis brevicaulis (2%), Aspergillus (2%), Acremonium (1%), Scytalidium dimidiatum (1%), and Alternaria (1%). CONCLUSIONS: Onychomycosis is more common in women of 20-40 years of age. Distolateral subungual onychomycosis and candidal onychomycosis are the most common clinical presentations, and Candida and T. rubrum are the major pathogens in Pakistan.     

Fungal nail infections - an update. Part 2 - From the causative agent to diagnosis - conventional and molecular procedures

Trichophyton (T.) rubrum is the most frequently isolated dermatophyte in onychomycosis, both in Germany and worldwide. T. interdigitale (formerly T. mentagrophytes var. interdigitale) follows in second place. A further however rarely isolated dermatophyte in onychomycosis is Epidermophyton floccosum. Candida parapsilosis, Candida guilliermondii, and Candida albicans, followed by Trichosporon spp. are the most important yeasts which are found in onychomycosis. The molds most often responsible include Scopulariopsis brevicaulis, and several Aspergillus species, e.?g. Aspergillus versicolor, and Fusarium spp. These so called non-dermatophyte molds (NDM) are increasingly isolated as emerging pathogens in onychomycosis. The diagnosis of onychomycosis should be verified in the mycology laboratory. Conventional diagnostic methods include the direct examination, ideally using fluorescence staining with Calcofluor? or Blancophor?, and culture. However, new molecular biological methods primarily employing the polymerase chain reaction (PCR) for direct detection of dermatophyte DNA in skin scrapings and nail samples have been introduced into routine mycological diagnostics. The diagnostic sensitivity is higher when both conventional and molecular procedures are combined.     

Evaluation of a polymerase chain reaction-restriction fragment length polymorphism assay for dermatophyte and nondermatophyte identification in onychomycosis

Background  Dermatophytes are the main cause of onychomycoses, but various nondermatophyte filamentous fungi are often isolated from abnormal nails. The correct identification of the aetiological agent of nail infections is necessary in order to recommend appropriate treatment.
Objective  To evaluate a rapid polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay based on 28S rDNA for fungal identification in nails on a large number of samples in comparison with cultures.
Methods  Infectious fungi were analysed using PCR-RFLP in 410 nail samples in which fungal elements were observed in situ by direct mycological examination (positive samples). The results were compared with those previously obtained by culture of fungi on Sabouraud agar from the same nail samples.
Results  PCR-RFLP identification of fungi in nails allowed validation of the results obtained in culture when Trichophyton spp . grew from infected samples. In addition, nondermatophyte filamentous fungi could be identified with certainty as the infectious agents in onychomycosis, and discriminated from dermatophytes as well as from transient contaminants. The specificity of the culture results relative to PCR-RFLP appeared to be 81%, 71%, 52% and 63% when Fusarium spp., Scopulariopsis brevicaulis , Aspergillus spp. and Candida spp., respectively, grew on Sabouraud agar. It was also possible to identify the infectious agent when direct nail mycological examination showed fungal elements, but negative results were obtained from fungal culture.
Conclusions  Improved sensitivity for the detection of fungi in nails was obtained using the PCR-RFLP assay. Rapid and reliable molecular identification of the infectious fungus can be used routinely and presents several important advantages compared with culture in expediting the choice of appropriate antifungal therapy.     

临床疑诊甲真菌病1036例真菌学分析

目的　了解近 5年本院甲真菌病病原菌的种类和构成 ,观察流行病学特点。方法　对近 5年临床疑诊的10 3 6例甲真菌病患者的真菌学实验室检查情况进行系统分析、总结。结果　共培养出真菌 63 1株 ,其中酵母菌占49.60 % ,以克柔念珠菌、红酵母、近平滑念珠菌为主 ;皮肤癣菌占 2 1.71% ,主要菌种为须癣毛癣菌和红色毛癣菌 ;其他丝状真菌占 19.81% ,主要菌种为曲霉和青霉 ;污染真菌占 8.87%。结论　本院近 5年甲真菌病患者病原菌依次为酵母菌、皮肤癣菌、其他丝状真菌 ,排前 5位的真菌分别是须癣毛癣菌 (11.2 5 % ) ,克柔念珠菌 (10 .14 % ) ,红酵母 (9.98% ) ,红色毛癣菌 (9.5 1% ) ,曲霉 (8.87% )。     

某社区医院甲真菌病临床类型和致病真菌的研究

目的分离和调查某社区医院甲真菌病的致病真菌和临床类型。方法自2005年1月～2007年8月,对306例甲真菌病患者的病甲进行致病真菌分离,将取材物进行KOH显微镜检查和真菌培养。记录每位患者的病史资料,分析致病真菌分布与各因素之间的关系,临床类型与致病真菌之间的关系。结果306例中足趾甲感染占62.1%,手指甲感染占9.5%,手足指趾甲混合感染占28.4%。远端侧缘甲下型(DLSO)是最常见的一种临床类型,有195例患者(63.7%),其次是全甲破坏型(TDO)(82例;26.8%),无甲沟炎的近端甲下型(PSO)(18例;5.9%),合并甲沟炎的近端甲下型(PSO)(8例;2.6%),浅表白甲型(SWO)(3例;0.98%)。DLSO与其他临床类型相比显著增多(P<0.001)。306株致病真菌中主要为皮肤癣菌(68.0%),其中80.3%为红色毛癣菌;酵母菌22.5%,其中73.9%为白念珠菌;第三位是霉菌(9.5%),主要为曲霉。结论发现该社区医院甲真菌病常见的临床类型为DLSO和TDO,而PSO和SWO不常见。致病病原菌以红色毛癣菌和白念珠菌为主。临床类型和病原学关系显示单一致病真菌可以引发一种以上类型的甲真菌病。     

2002-2003年中国部分地区甲真菌病致病菌流行病学调查报告

目的：调查2002-2003年我国甲真菌病致病菌流行情况。方法：在全国进行多中心开放性研究，自2002年5月-2003年11月，采用统一培养基，多点接种法进行研究。结果：从1084例患者965个培养基中分离出739株致病菌．其中皮癣菌占首位，而皮癣菌中红色毛癣菌占56．4％，须癣毛癣菌占5．5％，犬小孢子菌占0．3％，石膏样小孢子菌占2．6％．絮状表皮癣菌占1．5％，紫色毛癣菌占0．1％等；酵母菌居第2位，其中白念珠菌占10．0％，光滑念珠菌占5．1％，热带念珠菌占4．5％．近平滑念珠菌占5．8％，克柔念珠菌占1．9％等；霉菌居第3位。结论：甲真菌病致病菌中酵母菌类日益增多，故治疗应个体化．宜选用广谱抗真菌药物治疗。     

GMS is superior to PAS for diagnosis of onychomycosis

Background:  Onychomycosis is a common cause of deformed nails. Periodic acid-Schiff (PAS) stains are more sensitive than fungal cultures for diagnosing onychomycosis. We performed a retrospective study comparing the use of PAS and Gomori methenamine silver (GMS) stains for histopathologic diagnosis of onychomycosis.
Methods:  GMS stains were performed on 20 PAS-positive and 51 PAS-negative cases from nail biopsies with a clinical diagnosis of onychomycosis. The PAS stained slides and GMS stained slides were evaluated for the presence of fungal hyphae. The results were analyzed with McNemar's test.
Results:  All 20 PAS-positive cases were also positive with GMS stains. Of the 51 PAS-negative cases, GMS stains detected an additional five cases with fungal hyphae. GMS stains were quantitatively superior (p < 0.0253). GMS stains were also qualitatively superior. More fungal hyphae were highlighted and fungal hyphae were more easily recognized on low or medium power magnification.
Conclusions:  GMS stains are superior to PAS stains for the routine diagnosis of onychomycosis.     

甲真菌病分离菌株体外角蛋白酶活性的测定

目的对甲真菌病常见分离菌株进行体外降解角蛋白能力的比较,以初步探讨该病的临床表现与角蛋白酶的相关性。方法角蛋白酶的诱导培养基为含甲培养基,测定的底物为keratin-azure,以A595nm值衡量角蛋白酶的活性。结果①皮肤癣菌与非皮肤癣菌的角蛋白酶活性无显著性差异(P=0.12);②红色毛癣菌角蛋白酶活性显著高于其他受试真菌(P<0.001);③不同SCIO积分段的甲真菌病红色毛癣菌临床分离株角蛋白酶活性的差异无显著性(P=0.68)。结论甲真菌病的发病与角蛋白酶有一定相关性,但仅用角蛋白酶尚不能完全解释该病的发病机制。     

Foliculitis por Trichophyton rubrum (granuloma de Majocchi)

—Majocchi's granuloma (granulomatous folicular tinea) is a well known but uncommon infection of dermal and subcutaneous tissue by dermatophytes, being the most common organism associated Trichophyton rubrum. Commonly affecting the legs of middle age women, often following a physical trauma. We describe a 48 year old womanwith toe nail onychomycosis, presenting a plaque on the leg contracted 4 years earlier. A deep fungal infection by Trichophyton rubrum was detected, responding successfully to terbinafine.     

Causative agents of onychomycosis — a retrospective study

Background: Dermatophytes, yeasts and moulds all are potential causative agents of onychomycosis.The aim of this study was to determine the percentage of cases of onychomycoses caused by each group. In addition, the responsible genus and species was identified for each nail infection. Patients and Methods: In a retrospective study performed at the Department of Dermatology of the Leipzig University, 5 077 nail samples from 4 177 patients – 2 240 women and 1 937 men – with a variety of nail changes – not just onychomycosis – were investigated. 75% were toenails, 23% fingernails, and 2% from both sites. Results: Both microscopic and/or cultural detection of fungi (dermatophytes, yeasts and moulds) were successful in 54% of samples.Causative fungal agents were: 68% dermatophytes, 29% yeast, and 3% moulds. The most frequently detected dermatophyte species were T. rubrum (91%), and T. mentagrophytes (7.7%).Among yeasts, C. parapsilosis (42%) was most common,followed by C. guilliermondii (20.1%), C. albicans (14.2%), and Trichosporon spp. (10%).Scopulariopsis brevicaularis (43%) was the most frequent mould. The percentage of mixed fungal infections was 22%. Conclusions: Dermatophytes, in particular T.rubrum, but also T. mentagrophytes, are the most frequently isolated causative agents in onychomycosis. In addition, yeasts may be isolated relatively frequently, while moulds are uncommon.     

Characteristics of superficial fungal infections in the Riyadh region of Saudi Arabia

Background The prevalence and characteristics of superficial fungal infections (SFIs) vary with climatic conditions, lifestyle, and population migration patterns. This study was undertaken to determine the characteristics of SFIs amongst patients visiting the dermatology clinic of Riyadh Military Hospital, Riyadh, Saudi Arabia, during the period 2003–2005. Methods One hundred and nineteen patients with confirmed SFI (37 males and 82 females), aged between 5 months and 67 years, were included in this study. The diagnosis of SFI was based on clinical presentation confirmed by laboratory analysis. The type of mycotic pathogen and the site of infection were recorded as a function of age and sex. Results Onychomycosis (40.3%) was the most frequent infection, followed by tinea capitis (21.9%), tinea pedis (16%), tinea cruris (15.1%), and tinea corporis (6.7%). Tinea capitis was most prevalent (15.1%) in children (male to female ratio, 1 : 1.57), whereas tinea pedis was most common (11.8%) in adults (male to female ratio, 1 : 2.5). Trichophyton mentagrophytes and Microsporum canis were the most common dermatophytes responsible for tinea infections, and T. mentagrophytes, Candida spp., and Aspergillus spp. were mainly responsible for onychomycosis. Conclusion The prevalence of SFI was twofold greater in females than males. Children were most commonly affected by tinea capitis, whereas adults generally suffered from tinea pedis. The frequency of onychomycosis was nearly three times higher in adults. This study clearly shows that SFIs are of concern in both genders and in all age groups.     

儿童、青少年甲真菌病临床特点及致病菌分析

目的:确定儿童、青少年甲真菌病的主要临床特征和致病菌的种类。方法:回顾性分析220例(年龄18岁)甲真菌病患者的临床特征和致病菌种类。结果:220例患者中男110例,女100例,年龄3个月~17岁,儿童、青少年甲真菌病最常见的感染类型是远端侧缘甲下型(50.45%)和白色浅表型(42.27%)。趾甲较指甲感染常见,共分离出病原菌228株(混合感染8例),其中皮肤癣菌199株(87.28%)、念珠菌属27株(11.84%)、曲霉菌属2株(0.88%)。在199株皮肤癣菌属中红色毛癣菌192株(96.48%),趾甲真菌病多为红色毛癣菌,指甲多为念珠菌属。结论:儿童、青少年甲真菌病中最常见的病原菌为红色毛癣菌,其次为念珠菌属。     

Combined distal and lateral subungual and white superficial onychomycosis in the toenails

BACKGROUND: The 5 main types of onychomycosis are distal and lateral subungual onychomycosis (DLSO), white superficial onychomycosis (WSO), proximal subungual onychomycosis (PSO), Candida onychomycosis, and total dystrophic onychomycosis (TDO) (primary or secondary type). In the literature there is infrequent discussion about 2 types of onychomycosis present in the toenails of the same individual. OBJECTIVE: We attempted to determine the prevalence and etiologic organisms of DLSO and WSO occurring in the same individual. METHODS: We surveyed 4411 subjects presenting to dermatology offices for causes other than the management of onychomycosis. In each patient the toenails were examined. If they appeared abnormal, nail material was obtained for mycologic evaluation; partitioned sampling was performed when more than one type of onychomycosis was present. RESULTS: In our series, 39 (0.9%) of 4411 patients had the combination DLSO and WSO, compared with 417 (9.4%) and 111 (2.5%) who had DLSO and WSO, respectively. After controlling for age and sex in the general population, the projected prevalence rates of DLSO, WSO, and combined DLSO and WSO in the province of Ontario, Canada were 7.1%, 1.5%, and 0.5%, respectively. The combination of DLSO and WSO in the toenails of an individual occurred more frequently than that predicted by chance alone (P <.0001). Nine (0. 2%) of 4411 subjects had DLSO and WSO on the same nail. In 23 (59%) of 39 subjects both the DLSO and WSO were associated with Trichophyton mentagrophytes. In the remaining 16 subjects other organisms cultured were T rubrum, Acremonium spp, Aspergillus spp, Fusarium oxysporum, and Onychocola canadensis. In 33 (84.6%) of 39 subjects with the combination of DLSO and WSO on the toenails, the same fungal organism was associated with both the DLSO and WSO. CONCLUSION: When both DLSO and WSO are concurrently present in the toenails of an individual, partitioned sampling (ie, sampling for each of the two types of onychomycosis) may provide us with a better understanding of the different organisms associated with the onychomycosis and the relationship between the two types of onychomycosis.     

White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients

OBJECTIVE: To analyze the epidemiology, responsible agents, clinical features, and outcome of white superficial onychomycosis (WSO). DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: A total of 79 patients with WSO seen at the Department of Dermatology of Bologna University from 1994 to 2002. Responsible agents included Trichophyton interdigitale in 58 cases (73%), Trichophyton rubrum in 4 (5%), Fusarium species in 9 (11%), Aspergillus species in 5 (6%), and Acremonium strictum in 3 (3%). RESULTS: White superficial onychomycosis may have different clinical and epidemiological features. "Classic" WSO, characterized by superficial nail plate involvement, is usually due to Trichophyton mentagrophytes (var interdigitale), although Acremonium strictum or Onychocola canadiensis can sometimes be responsible. A deep and diffuse WSO, characterized by massive penetration of the nail plate by fungi, can be seen in nail infections by molds such as Fusarium species and Aspergillus species, or in nail infections by Trichophyton rubrum in healthy children and in patients infected with human immunodeficiency virus. CONCLUSIONS: Severity and spread of WSO is the result of complex host-parasite relationships. When dealing with a patient with WSO, we should always consider the causative organism and the host characteristics to choose the best therapeutic approach.