The descriptive epidemiology of tinea pedis in the community

Tinea pedis is a common inflammatory skin condition due to infection by dermatophyte fungi. A number of epidemiological studies have been completed on the frequency of tinea pedis in the community, particularly sporting and occupational groups and schools. Most studies have focused on small, high-risk populations. These include occupational groups involving manual labour, sporting groups such as swimmers, and those working or living in confined conditions with shared washing facilities, which favour the opportunity for crossinfection. Most studies show that the frequency of tinea pedis is higher in males than females. Tinea pedis infections appear to be least common among children, but do occur, and are commonly misdiagnosed. The difference between clinical disease and confirmed diagnosis by culture is not always clear when statistics of disease frequency have been presented. Clear diagnostic criteria indicating the level of mycologically confirmed diagnosis should be reported in future studies that include statistics on disease frequency. Future epidemiological studies should also aim to be population-based in order to obtain a more complete picture of disease frequency.     

Fast and sensitive detection of Trichophyton rubrum DNA from the nail samples of patients with onychomycosis by a double-round polymerase chain reaction-based assay

BACKGROUND: Trichophyton rubrum is one of the most frequently isolated pathogens in onychomycosis. Isolation of T. rubrum from nail samples by traditional methods is time-consuming and has a high false-negative rate of detection. OBJECTIVES: To investigate the detection of T. rubrum in nail samples using DNA detection methods. METHODS: A total of 62 nail samples from onychomycosis patients with T. rubrum infection were evaluated by culture on Sabouraud's dextrose agar plus chloramphenicol, cycloheximide and gentamicin and compared with genotyping methods utilizing DNA extracted directly from nails. Trichophyton rubrum DNA isolated directly from nails was amplified using two different conserved regions [actin gene and internal transcribed spacer 1 (ITS)] in double-round polymerase chain reaction (PCR) assays. RESULTS: Forty-eight of 62 (77.4%) samples were potassium hydroxide (KOH) positive, but T. rubrum culture was positive in only 14 of 62 (22.6%) samples. By contrast, direct T. rubrum DNA detection rate was 59.7% (37/62) by actin gene and 45.2% (28/62) by ITS1 region PCR assays corresponding to higher detection frequencies compared with culture with P < 0.001 and < 0.008, respectively. The combined detection of actin and ITS1 was 69.4% (43/62). Interestingly, T. rubrum DNA was detected in 9 out of 14 (64.3%) of KOH- and culture-negative samples. Importantly, 15 culture-negative samples collected from patients undergoing antifungal treatment tested PCR positive using the actin region. CONCLUSIONS: These results suggest that a direct DNA detection protocol is more sensitive, accurate and faster than traditional culture-based methods. It can be useful to detect T. rubrum in patients undergoing antifungal therapy and who have been reported mycologically cured on the basis of a culture-based method.     

Use of terbinafine for tinea in Australian Aboriginal communities in the Top End

Tinea of the skin and nails is a common problem in remote Aboriginal communities of the Top End of Australia. A retrospective study was performed on data collected from 104 patients from several indigenous communities. Worksheets were filled in by district medical officers and rural general practitioners, detailing the extent of the tinea. Patients were prescribed between 4 and 12 weeks of 250 mg daily oral terbinafine. Fifty-two patients were followed up, with 45 having a good response to treatment (87%) and with 22 of these patients having full clearance of tinea (42%). A prospective study with 44 subjects was performed. The extent of the tinea was documented and fungal scrapings/clippings were taken. Forty subjects were recruited and given oral terbinafine (2-12 weeks depending on skin/nail involvement) or topical terbinafine if oral treatment was contraindicated. Twenty-five of the 40 (63%) subjects were reviewed. Twenty-three (92%) subjects that were followed up improved clinically, with 8/25 (32%) clearing completely. Twenty (80%) of followed-up patients complied fully with treatment. Terbinafine was found to be a well-tolerated and effective treatment of tinea of the skin and nails.     

Descriptive epidemiology of acne vulgaris in the community

Acne is a common skin condition. No universally accepted standardized classification system for acne vulgaris exists, although there is a strong need for it Thus, the clinical definition of acne has been unclear in many studies. The reported prevalence of acne varies from 35 to over 90% of adolescents at some stage. In some studies the prevalence of comedones approaches 100% in both sexes during adolescence. The prevalence of acne varies between sexes and age groups, appearing earlier in females than in males, possibly reflecting the earlier onset of puberty. There is a greater severity of acne in males than in females in the late teens, which is compatible with androgens being a potent stimulus to sebum secretion. The prevalence of acne at a given age has been shown to be highly dependent on the degree of sexual maturity. Acne commonly shows a premenstrual increase in women. Some studies have detected seasonal variability in acne vulgaris, with the colder months associated with exacerbation and the warmer months showing improvement. Other studies have not confirmed these findings. Several studies that have investigated the psychosocial impact of acne have had conflicting results. The prevalence of severe acne has decreased over the past 20 years due to improved treatment. The general prevalence figure for acne may be confounded by treatment and this factor needs to be accounted for when collecting data.     

Observer agreement in recording the clinical signs of nail disease and the accuracy of a clinical diagnosis of fungal and non-fungal nail disease

BACKGROUND: Onychomycosis is increasing in incidence. To date, no studies have examined the detection of abnormalities of the nail apparatus, nor the accuracy of a clinical diagnosis of onychomycosis and non-fungal nail disease. OBJECTIVES: To assess the agreement between and within different groups of observers in detecting signs of nail disease, and to obtain information regarding clinical diagnostic skills. METHODS: An observational study was performed. Nine observers, including dermatologists, mycologists, general practitioners and a dermatology clinical assistant, completed a questionnaire containing 21 clinical signs of nail disease during examination of nine patients, five with onychomycosis and four with non-fungal nail disease. Observers were additionally requested to suggest the most likely underlying diagnosis for the nail dystrophy. Mean pair observer agreement values were calculated for each of the clinical signs, between all observers and within groups of observers. The chance-corrected agreement index, kappa, was determined. From the clinical diagnoses given, the positive predictive value of a diagnosis of fungal and non-fungal nail disease was calculated. RESULTS: There was substantial between-observer agreement on only three clinical signs: abnormal nails on both hands, abnormal toenails and abnormal fingernails. More specific signs of nail disease such as onycholysis elicited weaker agreement. All observers showed accuracy in making a clinical diagnosis of fungal nail disease, with a mean positive predictive value of 0.91, compared with 0.77 for non-fungal nail disease. CONCLUSIONS: Our results showed that agreement between observers, in recording signs of nail disease, was generally poor. The clinical diagnosis of onychomycosis was highly likely to be correct, suggesting that other criteria are being employed by individuals in reaching the diagnosis.     

The descriptive epidemiology of atopic dermatitis in the community

Atopic dermatitis (AD) is a common condition in the community, particularly amongst children. Although comparison of prevalence data between surveys is made difficult by differences in methodology, the available data suggest that there has been a substantial rise in the prevalence of AD, and that social, geographical and racial variation in disease frequency exists. There is a lack of quality data relating to the prognosis of AD. Recently a reliable set of diagnostic criteria has been developed and a number of severity scoring systems have been proposed for use in epidemiological studies.     

Is tinea unguium still widely incurable? A review three decades after the introduction of griseofulvin.

BACKGROUND--Tinea unguium, especially of the feet, for ages has been looked on as an incurable disease. Today, therapeutic outcome is still controversial. To evaluate the present state of antifungal therapy of dermatophytoses of the nails, a survey of the pertinent literature has been performed. OBSERVATIONS--The introduction of griseofulvin three decades ago was first considered a major breakthrough. Today, however, conventional griseofulvin treatment regimens must be called disappointing in terms of clinical and microbiological cure to be achieved. Cure rates of 40% to 100% have been reported for fingernail infections, but only 3% to 38% for toenail tinea. Microbiological cure rates look only slightly better. Limited experience suggests that additional measures such as surgical nail avulsion or topical antifungal treatment might improve therapeutic outcome. Toenail avulsion increases cure rates to 47% to 82%. The lack of an adequate follow up, however, makes all statements questionable. CONCLUSIONS--Results are only limited with respect to newly developed oral antifungal agents. Whereas ketoconazole treatment had to be omitted due to its hepatotoxic effect, its congener, intraconazole, is under investigation. High cure rates have been obtained in a preliminary study with oral terbinafine, 0.25 g/d, for 12 months, which have cleared toenail tinea in 15 of 17 patients. The value of topical treatment alone has not yet been definitely established. The application of a topical azole (bifonazole) in combination with chemical nail avulsion, using urea paste under occlusion, has resulted in negative cultures in 62% of the patients 3 months after the end of treatment.     

Epidemiology of tinea pedis and toenail tinea unguium in worshippers in the mosques in Adana, Turkey

The aim of this study was to determine the prevalence of dermatomycosis and the risk factors in those who perform their prayers in the mosques in the city center of Adana Province. The diagnosis of dermatomycosis was made on the basis of direct microscopy and/or culture in addition to clinical findings. Among 461 subjects, 136 (29.5%) had tinea pedis, 23 (5.0%) had tinea unguium, and 21 (4.5%) had both infections simultaneously, with a resulting total of 180 (39.0%) cases of dermatomycosis. The causative agents by frequency were: Trichophyton rubrum (67.0%), T. mentagrophytes var. interdigitale (31.1%), and Candida albicans (1.9%). The prevalence of the foot dermatomycosis was found to be high among those who practiced ablution 3-5 times a day and did not dry their feet immediately, who used rubber shoes, and/or who shared their shoes. Pedal dermatophyte infection seems to be a major problem among the adult Muslim male population regularly attending mosques especially in 5th and 6th decades of life.     

Nail sampling in onychomycosis: comparative study of curettage from three sites of the infected nail

Background: Onychomycosis is a common problem.Obtaining accurate laboratory test results before treatment is important in clinical practice since the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side‐effects. The purpose of this study was to compare results of curettage technique of nail sampling in the diagnosis of onychomycosis from three different sites of the affected nail to establish the best location of sampling. Patients and Methods: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis (DLSO) and lateral subungual onychomycosis (LSO) using curettage technique. KOH examination and fungal culture were used for detection and identification of fungal infection. Results: The culture sensitivity improves significantly as the location of the sample is more proximal. Trichophyton rubrum was by far the most common pathogen detected from all sampling sites. Conclusions: We found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken from proximal parts of the affected nails.     

A review of the epidemiology of psoriasis vulgaris in the community

Standard diagnostic criteria for epidemiological studies of psoriasis are currently lacking. In their absence, clinical examination and diagnosis of psoriasis by dermatologists provides the gold standard to underpin epidemiological research in psoriasis. The methods of data collection used most frequently include cross-sectional studies, case-control studies, cohort studies, and surveys of hospital and private practice attendance. Estimates of psoriasis prevalence made in cross-sectional studies employing clinical examinations as the survey instrument have ranged from 0.3 to 2.5%. Psoriasis incidence has been estimated at 60.4 per 100 000 person years in one cohort study. Several factors have been identified as being associated either with causation of psoriasis or with triggering exacerbations or remissions, including genetic determinants, racial and regional variation, injury and infection, cigarette smoking, alcohol, diet and other diseases.     

Prevalence of dermatological disorders in Japan: a nationwide, cross-sectional, seasonal, multicenter, hospital-based study

To clarify the prevalence of skin disorders among dermatology patients in Japan, a nationwide, cross-sectional, seasonal, multicenter study was conducted in 69 university hospitals, 45 district-based pivotal hospitals, and 56 private clinics (170 clinics in total). In each clinic, information was collected on the diagnosis, age, and gender of all outpatients and inpatients who visited the clinic on any one day of the second week in each of May, August, and November 2007 and February 2008. Among 67,448 cases, the top twenty skin disorders were, in descending order of incidence, miscellaneous eczema, atopic dermatitis, tinea pedis, urticaria/angioedema, tinea unguium, viral warts, psoriasis, contact dermatitis, acne, seborrheic dermatitis, hand eczema, miscellaneous benign skin tumors, alopecia areata, herpes zoster/postherpetic neuralgia, skin ulcers (nondiabetic), prurigo, epidermal cysts, vitiligo vulgaris, seborrheic keratosis, and drug eruption/toxicoderma. Atopic dermatitis, impetigo, molluscum, warts, acne, and miscellaneous eczema shared their top-ranking position in the pediatric population, whereas the most common disorders among the geriatric population were tinea pedis, tinea unguium, psoriasis, seborrheic dermatitis, and miscellaneous eczema. For some disorders, such as atopic dermatitis, contact dermatitis, urticaria/angioedema, prurigo, insect bites, and tinea pedis, the number of patients correlated with the average high and low monthly temperatures. Males showed a greater susceptibility to some diseases (psoriasis, erythroderma, diabetic dermatoses, inter alia), whereas females were more susceptible to others (erythema nodosum, collagen diseases, livedo reticularis/racemosa, hand eczema, inter alia). In conclusion, this hospital-based study highlights the present situation regarding dermatological patients in the early 21st century in Japan.     

An innovative water-soluble biopolymer improves efficacy of ciclopirox nail lacquer in the management of onychomycosis

Background  A new 8% ciclopirox-medicated nail lacquer (P-3051), based on a new technology, revealed superior properties in terms of affinity to keratin, nail permeation, and ease of use.
Objective  This study aims to assess the efficacy and safety of P-3051 vs. the market 8% ciclopirox nail lacquer.
Methods  This is a multicentre, randomized, three-arm, placebo-controlled, parallel groups, evaluator-blinded study. Overall, 467 patients with onychomycosis of at least one big toenail were randomized to receive P-3051, the reference drug or placebo in a 2 : 2 : 1 ratio for a 48-week treatment by daily application, followed by a 12-week follow-up.
Results  The study satisfied its objective by demonstrating that P-3051 was both superior to placebo and non-inferior to reference in the complete cure rate after a 48-week active treatment period. Switching the non-inferiority to superiority hypothesis, the superiority of P-3051 vs. reference was nearly significant at week 48 (confirmed at week 52), and it was significant at week 60 (cure rate for P-3051 is 119% higher than reference; P  < 0.05). Altogether, the results on primary endpoint exceed expectations; superiority test was performed also on secondary endpoints to confirm the superiority trend of the study. At the end of follow-up, percentages of patients who achieved the endpoint 'responder' in the P-3051 group were 66% higher than reference ( P  < 0.05), and those who achieved the endpoint 'decrease of diseased nail' were 40% higher ( P  < 0.05).
Conclusion  Ciclopirox 8% hydrolacquer is more active than reference ciclopirox nail lacquer in the treatment of onychomycosis.

Conflicts of interest

None declared.     

Prevalence of superficial fungal infections among sports-active individuals: results from the Achilles survey, a review of the literature

OBJECTIVE: To examine the effect of sport activities on the prevalence of foot disease in the Achilles survey, conducted during the spring of 1997 and 1998 in several European countries. SUBJECT: Foot diseases, especially fungal infections (tinea pedis and onychomycosis). METHODS: A questionnaire and a clinical examination regarding individuals presenting to a general practitioner for disorders irrespective of possible foot problems. RESULTS: More than 50% of subjects visiting a general practitioner had clinical evidence of foot disease, and approximately two-thirds of these had clinical evidence of a superficial fungal infection. The survey evidenced a significant age-dependent association between sporting activities and the prevalence of foot diseases and superficial fungal infection, especially in children. CONCLUSIONS: The results of this pan-European survey indicate that sporting activities can have an unfavourable effect on the individual regarding the occurrence of foot disease and superficial fungal infection. The results indicate a need to pay more attention to foot disease, to predict and prevent future diseases and further complications.     

儿童头癣致病真菌调查及分子流行病学研究

目的调查分析儿童头癣患者生活环境中致病真菌存在情况,探索其流行病学规律,为儿童头癣的防治提供依据。方法收集儿童头癣患者临床资料,并进行病发真菌镜检和培养,收集每例儿童头癣患者生活环境中密切接触物品及亲属头发进行真菌培养,培养结果与相应患者真菌培养结果对比分析。鉴定为相同菌株者采用真菌通用引物ITS1和ITS4对rDNA的ITS区进行扩增,并采用（GACA）4单引物进行分子鉴定,用随机引物扩增DNA多态性（RAPD）方法对相同菌株者进行株间差异性分析。结果调查91例儿童头癣患者,年龄从1岁至12岁,病程1周至3月;患者病发的真菌培养结果：犬小孢子菌44株（48．35％）,铁锈色小孢子菌41株（45．05％）,须癣毛癣菌4株（4．40％）,红色毛癣菌1株（1．10％）,石膏样小孢子菌1株（1．10％）;患者亲属头发及枕巾等接触物品真菌培养结果均未分离到致病真菌：2例儿童的伙伴病发中分离到与对应惠儿相同的致病菌;有宠物接触者28例（30．77％）中有7例（7．69％）分离到与头癣患者病发相同的致病菌种。RAPD分析发现从患者分别与其对应环境中分离的犬小孢子菌的基因组DNA随机引物扩增后产生的产物片断长度多态性一致,显示无株间差异性。结论儿童头癣患者生活环境中有致病真菌存在．致病真菌主要来源于宠物及密切接触伙伴。     

Metal allergen of the 21st century--a review on exposure, epidemiology and clinical manifestations of palladium allergy

Consumers are mainly exposed to palladium from jewellery and dental restorations. Palladium contact allergy is nearly always seen together with nickel allergy, as palladium and nickel tend to cross-react. We aimed to analyse the available palladium patch test data and case reports to determine whether the prevalence of palladium mono-sensitization has increased. Based on available patch test data from the period 1986-2008, a total of 10 778 patients were patch tested with palladium chloride. The median prevalence of palladium allergy was 7.8% (range <1.0-19.0%) in dermatitis patients and 7.4% (range 1.3-13.9%) in dental patients. The median prevalence of palladium mono-sensitization (defined as the presence of palladium allergy and the absence of nickel allergy) was 0.2% (range 0-1.6%) in dermatitis patients and 0.5% (range 0-7.2%) in dental patients. A slight increase in the prevalence of palladium mono-sensitization was observed over the study period. We conclude that clinically relevant palladium allergy should mainly be suspected in patients who present with allergic contact granulomas at sites of piercing, but also in patients who have clinical disease and palladium patch test reactivity without concomitant nickel reactivity. Palladium salts should be included in dental screening patch test series. Palladium use in jewellery should be limited until we know more about the risk of sensitization.     

荧光染色法和KOH湿片法在不同类型足癣诊断中的应用比较

目的:对比荧光染色法和KOH湿片法检测不同类型足癣的阳性率和平均阅片时间.方法:对118例拟诊为水疱鳞屑型足癣、104例拟诊为角化过度型足癣及78例拟诊为浸渍糜烂型足癣标本分别采用荧光染色法和KOH湿片法直接镜检,比较阳性检出率和平均阅片时间.结果:荧光染色法背景相对干净,真菌清晰可见;KOH湿片法背景杂乱,真菌形态较...