长脉宽Nd:YAG激光治疗甲真菌病疗效观察

目的 探讨长脉宽Nd:YAG激光治疗甲真菌病的疗效及安全性。 方法 对35例甲真菌病患者使用长脉宽Nd:YAG激光进行治疗,治疗参数：波长1064 nm,能量30 ～ 40 J/cm2,脉宽35 ms,光斑4 mm。观察疗效及不良反应,并根据不同感染菌种、临床类型、病甲位置对病例进行分组,采用SPSS17.0统计软件进行卡方检验比较不同分组间疗效、复发情况的差异。结果 共治疗79甲,随访至初次治疗后9个月,临床有效率为67.1%,真菌学有效率为73.4%,复发或再感染率为19.0%。红色毛癣菌组的临床疗效（χ2 = 10.913,P < 0.05）及真菌学疗效（χ2 = 13.532,P < 0.05）均优于其他真菌组,复发或再感染率低于其他真菌组（χ2 = 10.980,P < 0.05）,但与白念珠菌组比较这三方面的差异均无统计学意义。白色浅表甲真菌病（WSO）组的临床疗效优于远侧甲下真菌病（DLSO）组（χ2 = 11.935,P < 0.05）,而DLSO组的临床疗效又优于近端甲下真菌病（PSO）及全甲营养不良甲真菌病（TDO）组（χ2 = 17.515,P < 0.05）。根据病甲位置不同分类,第2 ～ 5指甲组的临床疗效优于拇指甲/第2 ～ 5趾甲组（χ2 = 13.437,P < 0.05）及拇趾甲组（χ2 = 10.595,P < 0.05）,而拇指甲/第2 ～ 5趾甲组与拇趾甲组相比临床疗效差异无统计学意义（χ2 = 3.030,P > 0.05）,它们的真菌学疗效及治疗后的复发或再感染率差异无统计学意义。治疗过程中除疼痛外未发生其他不良反应。结论 长脉宽Nd:YAG激光是治疗甲真菌病的一种安全有效的方法,其疗效受到感染菌种、临床类型、病甲位置的影响。     

Epidemiology of onychomycosis in southern Greece

Background Onychomycosis appears to be a variable entity: it presents in different forms in different parts of the world. It is probable that every country has its own particularities of presentation and it is also probable that different regions of the same country, with either different or equivalent environmental conditions, present with different levels of incidence. Large-scale epidemiological studies performed worldwide have demonstrated different epidemiological results. Objective This study was undertaken to determine the epidemiology of onychomycosis in the population of southern Greece. Methods Direct microscopic examination and culture were performed on samples from patients with clinical suspected onychomycosis. Results The most frequently isolated fungus was Candida (52.44%), followed by dermatophytes (41.04%) and saprophytic molds (6.51%). Finger nails were infected more than toe nails in both sexes. The most frequently isolated fungus in finger nails was Candida (76%), followed by dermatophytes (23%), and molds (1%); toe nails were most often infected by dermatophytes (71%), Candida (13%) and molds (16%). Among the infected women patients, the most frequently isolated fungus was Candida (64%), followed by dermatophytes (30.58%); 5.33% were infected by saprophytic molds. Of the 101 men infected, dermatophytes were most frequently isolated (62.37%), followed by Candida (28.71%) and saprophytic molds (8.91%). Conclusions Comparison of the results of epidemiological studies of onychomycosis worldwide show great differences, not only between different countries and different climate zones, but also between studies performed in the same country. In our opinion such epidemiological studies should be performed in every country in order to determine the major fungal species responsible; such information is extremely useful in the treatment of nail onychomycosis.     

Onychomycosis: a significant medical problem

The importance of onychomycosis is often underestimated. Far more than being a simple cosmetic problem, infected nails serve as a chronic reservoir of infection which can give rise to repeated mycotic infections of the skin. 448 patients with nail abnormalities attending Skin O. P. D of King George Hospital, Visakhapatnam during a 1 (one) year period between November'98-October'99, were subjected to detailed clinical, epidemiological study. Diagnosis was confirmed in 204 cases by direct microscopy or culture or by both. Females (51.96%) were slightly more than the males (48.04%). Majority of the cases were between 21-40 years age group. Housewives (33.33%) were most frequently affected. Trauma was a predisposing factor in 11.27% of the cases. The duration of lesions varied from 3 months to 15 years. In the majority (38.23%) it was less than one year. Candidal onychomycosis was the most prevalent clinical type (58.82%) followed by distal subungual onychomycosis (38.72%). Disease was limited only to finger nails in 57.35% and toe nails in 32.35%. Predominant isolates obtained were candida spp. (56.7%), followed by dermatophytes (38.2%) and non-dermatophyte molds (3.37%). 26.96% of the patients had experienced physical, psychosocial and occupational problems.     

Trichophyton rubrum onychomycosis in an 8-week-old infant

An 8-week-old infant presented with 7 weeks history of nail involvement and discoloration. Lesions started over the middle fingernail of right hand at 1 week of age, spreading over to other nails within 2 weeks. Only two nails of the feet were spared. On KOH examination, fungal hyphae were seen and culture showed growth of Trichophyton rubrum. The purpose is to report the earliest case of onychomycosis having multiple nail involvement of fingers and toes (18 nails).     

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.     

Itraconazole pulse therapy for the treatment of Candida onychomycosis

In this open label, multicentre trial, 44 patients with clinical and mycological evidence of Candida onychomycosis were treated with itraconazole pulse therapy. Onychomycosis of the toes alone and concomitant disease involving the fingers and toes was treated with three pulses, and onychomycosis of the fingers alone with two pulses. Final evaluation for patients with finger and toe onychomycosis was at 6-9 months and 9-12 months, respectively. There were 29 patients with toe onychomycosis (C. albicans, 27; C. glabrata, one; Candida species, one), 12 patients with finger onychomycosis (C. albicans, two; C. glabrata, one) and three patients had combined toe and finger onychomycosis (C. albicans, two; C. guillermondii, one). In the patients with toe onychomycosis mycological cure was observed in 29 of 32 patients (90.6%). There was complete cure [mycological cure (negative culture and KOH at endpoint evaluation) with clinical cure] or marked improvement (mycological cure with 75% or greater decrease in area of involvement of target nail compared with pretherapy) in 24 of 32 patients (75.0%). All 12 patients with finger onychomycosis alone due to Candida species achieved a mycological cure (100%). In this group of patients complete cure or marked improvement was observed in 11 of 12 patients (91.7%). Itraconazole pulse therapy was well tolerated and no serious adverse events were reported in the patients treated with this triazole. In conclusion, itraconazole pulse therapy is an effective and safe treatment for both finger and toe onychomycosis associated with Candida.     

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.     

Tioconazole nail solution—an open study of its efficacy in onychomycosis

In view of the problems encountered in the treatment of onychomycosis with orally administered antifungal drugs, alternative forms of therapy arc needed. Tioconazole (28%) nail solution is a new topical preparation for use on infected nails. In this study 27 patients received treatment with tioconazole (28%) for up to 12 months. Six patients (22%) achieved complete clinical remission and were free of infection at follow-up, 3 months after therapy. They included infections caused by Trichophyton rubruni (4), Hendersonula toruloidea (1) and Acremonium (1). Apart from the latter, all infections responding to treatment were in the finger nails, even though three patients had active infection in the toe nails as well which did not respond to therapy. Significant improvements were recorded in a further 11 patients. They did not, however, achieve complete clinical and mycological recovery. The results indicate that cures of onychomycosis are possible after topical therapy, and further methods of using this form of treatment such as combined surgical and topical therapy are discussed.     

A large-scale North American study of fungal isolates from nails: the frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns

BACKGROUND: Onychomycosis, a fungal infection of the nail bed, is responsible for up to 50% of nail disorders. Although several surveys have been conducted in different parts of the world, there have been no multicenter epidemiologic surveys of onychomycosis in North America. OBJECTIVE: A 12-center study was undertaken to (1) determine the frequency of onychomycosis, (2) identify organisms recovered from the nails, and (3) determine the antifungal susceptibility of isolates. METHODS: A total of 1832 subjects participated in this study and completed a comprehensive questionnaire, and nail clippings were collected for potassium hydroxide examination and culturing. RESULTS: The frequency of onychomycosis, as defined by the presence of septate hyphae on direct microscopy and/or the recovery of a dermatophyte, was found to be 13.8%. In general, the dermatophyte isolates were susceptible to the antifungals tested. CONCLUSION: Because of the limited number of large-scale studies, the baseline incidence is not firmly established. However, the higher frequency of onychomycosis in this study may confirm the suspected increase in incidence of disease in North America.     

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.     

Histopathological periodic acid-schiff stains of nail clippings as a second-line diagnostic tool in onychomycosis

The diagnosis of onychomycosis, using direct microscopy and fungal cultures, is often negative despite the presence of disease. Periodic acid-Schiff (PAS) staining of nail clippings, using histopathological processing, may be positive in these cases. It is not always clear, however, whether the fungal elements detected by PAS staining are pathogenic fungi or some are saprophytes. We aimed to study the efficacy of histopathological PAS staining of nail clippings as a second-line diagnostic tool in onychomycosis. The study included 100 consecutive cases in which direct microscopy and fungal cultures from suspected onychomycosis were negative on one occasion or more. The obtained nail clippings were processed for routine histology, stained with hematoxylin and eosin and PAS, and examined microscopically. Of the 100 cases, 38 (38%) showed positive fungal elements. As a result, 9 patients had sought and received oral antifungal therapy and all achieved complete clinical cure. The histological examination also revealed parakeratosis and globules of plasma, which were statistically significantly more common in the fungal infected nail samples. This may indicate an ongoing inflammatory process associated with onychomycosis. Neutrophils and bacteria were not statistically and significantly more common in the fungal infected nails. We conclude that as a second-line diagnostic tool, PAS stain of nail clippings increases markedly the diagnostic yield of onychomycosis and, consequently, the outcome of therapy.     

伊曲康唑间歇冲击治疗趾甲真菌病疗效和血清及甲中药物水平临床研究

目的:研究伊曲康唑间歇冲击疗法治疗趾甲真菌病(甲母质未受累)的疗效和在血清及甲中药物水平的变化。方法:41例趾甲真菌病患者应用伊曲康唑连续3个冲击治疗,第52周进行最终疗效评价;采用高压液相色谱仪(HPLC)法对其中15例趾甲真菌病患者进行了血清及甲中药物测定。结果:每次冲击后4周,血清中均未测得伊曲康唑;甲组织中伊曲康唑水平较高,在8或12周时达到高峰,停药后,伊曲康唑仍能以较高的水平在甲中储留36周;同一时间点,指甲和趾甲中的药物水平相似(P>0.05)。在第52周时,趾甲真菌病的临床治愈率为66.7％,临床有效率为79.5％,真菌学清除率为64.1％。结论:伊曲康唑口服吸收后从血液迅速向甲组织分布,停药后仍以较高水平储留在甲组织中并持续存在36周以上。     

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.     

Comparative study of nail sampling techniques in onychomycosis

Onychomycosis is a common problem. Obtaining accurate laboratory test results before treatment is important in clinical practice. The purpose of this study was to compare results of curettage and drilling techniques of nail sampling in the diagnosis of onychomycosis, and to establish the best technique and location of sampling. We evaluated 60 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and vertical and horizontal drilling sampling techniques from three different sites of the infected nail. KOH examination and fungal culture were used for detection and identification of fungal infection. At each sample site, the horizontal drilling technique has a better culture sensitivity than curettage. Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. The drilling technique was found to be statistically better than curettage at each site of sampling, furthermore vertical drilling from the proximal part of the affected nail was found to be the best procedure for nail sampling. With each technique 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 by both methods from proximal parts of the affected nails.     

Infektionen an Finger- und Zehennägeln durch Pilze und Bakterien

Infections of the finger and the toe nails are most frequently caused by fungi, primarily dermatophytes. Causative agents of tinea unguium are mostly anthropophilic dermatophytes. Both in Germany, and worldwide, Trichophyton rubrum represents the main important causative agent of onychomycoses. Yeasts are isolated from fungal nail infections, both paronychia and onychomycosis far more often than generally expected. This can represent either saprophytic colonization as well as acute or chronic infection of the nail organ. The main yeasts causing nail infections are Candida parapsilosis, and Candida guilliermondii; Candida albicans is only in third place. Onychomycosis due to molds, or so called non-dermatophyte molds (NDM), are being increasingly detected. Molds as cause of an onychomycosis are considered as emerging pathogens. Fusarium species are the most common cause of NDM onychomycosis; however, rare molds like Onychocola canadensis may be found. Bacterial infections of the nails are caused by gram negative bacteria, usually Pseudomonas aeruginosa (recognizable because of green or black coloration of the nails) but also Klebsiella spp. and gram positive bacteria like Staphylococcus aureus. Treatment of onychomycosis includes application of topical antifungal agents (amorolfine, ciclopirox). If more than 50?% of the nail plate is affected or if more than three out of ten nails are affected by the fungal infection, oral treatment using terbinafine (in case of dermatophyte infection), fluconazole (for yeast infections), or alternatively itraconazole are recommended. Bacterial infections are treated topically with antiseptic agents (octenidine), and in some cases with topical antibiotics (nadifloxacin, gentamicin). Pseudomonas infections of the nail organ are treated by ciprofloxacin; other bacteria are treated according to the results of culture and sensitivity testing.     

Candida onychomycosis—an evaluation of the role of Candida species in nail disease

Nail infections caused by Candida species are normally associated with chronic paronychia or chronic mucocutaneous candidiasis (CMCC). However, the role of Candida in the pathogenesis of other primary nail dystrophies has been questioned in view of their response to antifungal therapy alone. In the present study of 86 patients with primary nail dystrophies from which Candida was isolated, three patterns of nail involvement were found. Nineteen patients, of whom 17 had CMCC, had total dystrophic onychomycosis of at least two nails. The second group consisted of 27 patients with paronychia and lateral onycholysis. In a further 40 patients, who did not have paronychia, Candida was isolated from nails showing primary distal and lateral onycholysis. These changes were mainly seen in patients with peripheral vascular disease, particularly Raynaud's disease, or Cushing's syndrome. Nail biopsies from patients in the latter two groups confirmed the presence of yeasts and mycelium in the nail plate and 17 (46%) of those receiving antifungal therapy with ketoconazole or itraconazole showed complete clearance of the nail dystrophy. Good responses to therapy were seen more frequently in patients with peripheral vascular disease or Cushing's syndrome of whom 15 (72%) recovered; distal erosion of the nail plate, mycelium in the nail plate on biopsy or direct microscopy together with the isolation of C. albicans were all associated with good responses to antifungals. In addition to patients with CMCC or paronychia, therefore, Candida appears to be a significant pathogen in some patients with primary onycholysis of the finger nails, particularly where there is underlying peripheral vascular disease or Cushing's syndrome.     

伊曲康唑间歇冲击疗法治疗甲真菌病的血清及甲中药物水平的研究

目的 了解伊曲康唑间歇冲击疗法治疗甲真菌病的血清及甲中药物水平的变化,为该疗法提供药物动力学依据。方法 １５例趾甲真菌病患者经伊曲康唑间歇冲击疗法治疗;于服药前、服药后每月取患者血清（共３月）并收集远端甲标本,将指甲和趾甲分开;以高效液相色谱（ＨＰＬＣ）测定伊曲康唑的含量。结果 １．每次冲击后４周,血清中均未测得伊曲康唑;２．甲组织中伊曲康唑水平较高,在２或３月时达到高峰;３．停药后,伊曲康唑仍能以较高的水平在甲中存在至６月后;同一时间点,指甲和趾甲中的药物水平无统计学差异（Ｐ〉０．０５）。结论 伊曲康唑经口服吸收后从血液迅速向甲组织分布,停药后,以较高水平在甲组织中持续存在６月以上。     

Onychomycosis in Inflammatory Bowel Diseases

Background  As far as we have sought for in Medline and PubMed, not one study until now has evaluated the prevalence of onychomycosis in patients with inflammatory bowel disease (IBD). As there are great evidence of immunological disturbances linked to IBD, a possible relationship of this nail infection in association with those diseases and the possible risk factors might be relevant in IBD patients.
Methods  A case-control prospective study using combined direct smear and cultures for fungus was performed. Sociodemographics, clinical and laboratorial data were recorded at baseline and samples of suspected nails were collected from 141 IBD (61 men and 80 women) and from a group of 100 non-IBD subjects (41 men and 59 women). Direct smear and cultures were performed on each suspected case to exclude other onychodystrophies.
Results  The incidence of onychomycosis in IBD patients was highly significant in comparison to non-IBD patients (14.9% vs. 6%, respectively, P  < 0.05). The risk factors predisposing IBD patients to onychomycosis were older age ( P  = 0.02) and leucopoenia in those using azathioprine therapy ( P  = 0.04) beyond a trend to lymphopenia ( P  = 0.06). The dermatophytes predominated (76.2%) over yeasts (19%) and moulds (4.8%).
Conclusion  The prevalence of onychomycosis in IBD patients was expressively high (14.9%) in comparison with non-IBD patients. Considering the sociodemographic factors, any one but two were related to fungal onychomycosis incidence. Therefore, as far as we are concerned, IBD must be included in the high-risk underlying conditions for onychomycosis occurrence.     

IDIOPATHIC ATROPHY OF THE NAILS

SUMMARY.— A group of 9 patients is presented in whom painless loss of nails is the principal cutaneous abnormality. The nails are normal at birth but after a few years one or more finger or toe nails become affected. The condition is progressive for a time but then remains stationary and no further nails are involved. The nail changes range from discoloration and ridging, through pterygium formation to permanent total loss with obliteration of the nail fold. Some nails remain quite normal. The condition occurs without apparent cause and is apparently not genetically determined. The diseases with which it is most likely to be confused are nail loss from lichen planus or from impaired peripheral circulation.