Onychomycosis, by definition, is a mycotic infection of the keratinized tissue of the nail plate. Although it is commonly considered to be caused by one of the dermatotropic fungi, a variety of other organisms have been implicated as etiologic agents in the disease, including some bacteria and yeasts. When it is caused by a fungus, any or all of three types of organisms can be involved: dermatophytes, yeasts, and nondermatophyte organisms. The purpose of this study was to identify the microorganisms found in fungal cultures of clinically suspected onychomycosis in the patient population of the Foot Clinics of New York in New York City, the largest foot clinic in the world. Of the 1,800 medical charts reviewed, 214 had culture results, of which 120 were positive. Trichophyton rubrum was the most prevalent pathogen, found in 67% of positive cultures. The most remarkable risk factor was age, with 80% of affected individuals older than 35 years. False-negatives may account for the high percentage (44%) of negative cultures in this study. (J Am Podiatr Med Assoc 92(6): 327-330, 2002)
This study was conducted to investigate the efficacy of oral terbinafine with and without aggressive debridement for the treatment of toenail onychomycosis. Onychomycosis patients aged 18 to 75 years received 12 weeks of terbinafine, 250 mg/day, alone (n = 255) or with aggressive debridement (n = 249). Both groups showed marked improvement from baseline at all time points. At week 48, complete, mycologic, and clinical cure rates were higher in the terbinafine plus debridement group compared with the terbinafine alone group, although significance was reached only for clinical cure (59.8% versus 51.4%; P = .023). Although approximately 39% of the patients received at least one antidiabetic, antihypertensive, or cholesterol-lowering agent concomitantly, including statins, the incidence of treatment-emergent adverse events was low and the adverse events were generally mild to moderate in severity. No clinically significant changes in liver transaminase levels were observed 6 weeks after treatment or after 12 weeks in those tested. These results support the well-established safety and efficacy of terbinafine for treatment of onychomycosis. (J Am Podiatr Med Assoc 96(6): 465–473, 2006)
A study on the incidence and causative organisms of pedal superficial white onychomycosis within several patient populations is presented. Early recognition, debridement, and topical antifungal therapy for several weeks with attention to biomechanical factors should resolve the infection and prevent progression to a more destructive form of onychomycosis.
Onychomycosis is one of the most common diseases of the toenails. The costs of diagnosis and treatment are substantial, and as the population ages, the overall cost burden will continue to escalate. The purpose of this study was to correlate dermoscopic features with pathologic diagnosis to support the accuracy of point-of-care diagnosis by dermoscopic examination.
Nail unit pathology reports of 52 patients with abnormal great toenails were compared with the dermoscopic features detected by nail unit dermoscopy.
The dermoscopic analysis predicted the laboratory diagnosis in 90.4% of the study patients. The specific dermoscopic findings of short spikes (P < .001), long striae (P < .001), aurora borealis (P < .001), irregular termination (P = .003), dermatophytoma (P = .011), transverse onycholysis (P = .018), and dry scale (P = .04) patterns were all significantly associated with pathology test results consistent with oncyhomycosis. Transverse onycholysis (P = .018) was significantly associated with negative pathology results consistent with the diagnosis of nail dystrophy.
Point-of-care examination by dermoscopy positively correlates with histopathologic tests and could be used to diagnose onychomycosis while reducing diagnostic costs.
Background: Onychomycosis is the most common nail disease seen in clinical practice. Medication safety, severity of disease, comorbidities, concomitant medications, patient age, and cost are all important considerations when treating onychomycosis. Because cost may affect treatment decisions, we sought to analyze Medicaid formulary coverage of onychomycosis antifungals.
Methods: Public state Medicaid formularies were searched for coverage of US Food and Drug Administration–approved onychomycosis medications and off-label oral fluconazole. Total drug cost for a single great toenail was calculated using the National Average Drug Acquisition Cost. Pearson correlation coefficients were calculated to compare coverage and cost, mycologic cure rate, and complete cure rate.
Results: Oral terbinafine and off-label fluconazole were widely covered for onychomycosis treatment. There was poor coverage of oral itraconazole and topical ciclopirox, and there was no coverage of topical efinaconazole and tavaborole without step-edits or prior authorization. There was a significant negative correlation between medication coverage and cost (r = −0.758; P = .040). There was no correlation between medication coverage and mycologic (r = 0.548; P = .339) and complete (r = 0.768; P = .130) cure rates.
Conclusions: There is poor Medicaid coverage of antifungals for the treatment of onychomycosis, with step-edits and prior authorization based on cost rather than treatment safety and efficacy. We recommend involving podiatrists and dermatologists in developing criteria for insurance approval of onychomycosis treatments.
Onychomycosis is an extremely common condition that is increasing in prevalence. Although often innocuous, it may be complicated by discomfort and secondary bacterial infections. Recently introduced oral medications may be highly effective in the eradication of this condition; however, they may carry with them significant expense and potentially serious side effects. Prior to the initiation of antifungal oral therapy, definitive diagnosis is mandatory. This study compares the sensitivity of potassium hydroxide (KOH) preparations, surgical pathology diagnostic testing (SPDT), and culture techniques for the detection of onychomycosis in 50 cases of clinically suspected onychomycosis. Analysis showed that SPDT was significantly more sensitive when compared to KOH and culture. The results suggest that SPDT may be the true gold standard for the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 91(7): 351-355, 2001)
Onychomycosis is a very common disease, especially in podiatric medical practice. It can be associated with significant patient distress, major disability and pain, and is challenging to treat successfully. This is a case study of a 41-year-old man with distal lateral subungual onychomycosis of 5 years' duration. Forty percent of the great toenail was affected and a total of six toenails were involved. Baseline fungal cultures were positive for Trichophyton rubrum. This patient was treated with efinaconazole 10% solution, a new topical antifungal, once daily for 48 weeks. Mycological cure was noted at the first assessment period (12 weeks), and compete cure was seen at follow-up. This case study alerts physicians to a promising new topical treatment for onychomycosis under development, and to the importance of mycological cure as an early indicator of treatment success.
Topical onychomycosis therapies are usually inadequate, and patient compliance to systemic therapies is poor. Recently, interest in laser therapy for the treatment of onychomycosis has increased. We sought to investigate the efficacy of long-pulsed Nd:YAG laser therapy for onychomycosis.
Thirty patients with mycologically confirmed onychomycosis received long-pulsed 1064-nm Nd:YAG laser therapy, moving the beam in a spiral pattern over the whole nail plate two times, with a 1-minute pause between passes. Laser therapy was performed with a spot diameter of 4 mm at a speed of 25 mm/sec once weekly for 4 weeks using fluencies ranging from 40 to 60 J/cm2, depending on the thickness of the nail plate. Patients were evaluated in terms of clinical improvement and mycologic cure.
Thirty patients started and 15 completed the study. Mycologic cure was achieved in nine patients (60%), of whom eight (89%) were infected with Trichophyton sp. Complete clinical improvement was achieved in seven patients (47%), all of whom were infected with Trichophyton sp. Mycologic cure was not achieved in one of two patients infected with Epidermophyton or in either patient in whom the agent was Candida or Aspergillus; complete clinical improvement did not occur in any of these patients. No serious adverse events were observed.
Based on these results, long-pulsed Nd:YAG laser can be used as an effective treatment for onychomycosis, but further studies are needed to draw firmer conclusions.
Background: We sought to determine the frequency of toenail onychomycosis in diabetic patients, to identify the causative agents, and to evaluate the epidemiologic risk factors.
Methods: Data regarding patients’ diabetic characteristics were recorded by the attending internal medicine clinician. Clinical examinations of patients’ toenails were performed by a dermatologist, and specimens were collected from the nails to establish the onycomycotic abnormality. All of the specimens were analyzed by direct microscopy and culture.
Results: Of 321 patients with type 2 diabetes mellitus, clinical onychomycosis was diagnosed in 162; 41 of those diagnoses were confirmed mycologically. Of the isolated fungi, 23 were yeasts and 18 were dermatophytes. Significant correlations were found between the frequency of onychomycosis and retinopathy, neuropathy, obesity, family history, and duration of diabetes. However, no correlation was found with sex, age, educational level, occupation, area of residence, levels of hemoglobin A1c and fasting blood glucose, and nephropathy. The most frequently isolated agents from clinical specimens were yeasts.
Conclusions: Long-term control of glycemia to prevent chronic complications and obesity and to promote education about the importance of foot and nail care should be essential components in preventing onychomycosis and its potential complications, such as secondary foot lesions, in patients with diabetes mellitus. (J Am Podiatr Med Assoc 101(1): 49–54, 2011)
Onychomycosis is estimated to occur in approximately 10% of the global population, with most cases caused by Trichophyton rubrum. Some persistent onychomycosis is caused by mixed infections of T rubrum and one or more co-infecting nondermatophyte molds (NDMs). In onychomycosis, T rubrum strain types may naturally switch and may also be triggered to switch in response to antifungal therapy. T rubrum strain types in mixed infections of onychomycosis have not been characterized.
T rubrum DNA strains in mixed infections of onychomycosis containing co-infecting NDMs were compared with a baseline North American population through polymerase chain reaction amplification of ribosomal DNA tandemly repetitive subelements (TRSs) 1 and 2. The baseline DNA strain types were determined from 102 clinical isolates of T rubrum. The T rubrum DNA strain types from mixed infections were determined from 63 repeated toenail samples from 15 patients.
Two unique TRS-2 types among the clinical isolates contributed to four unique TRS-1 and TRS-2 strain types. Six TRS-1 and TRS-2 strain types represented 92% of the clinical isolates of T rubrum. Four TRS-1 and TRS-2 strain types accounted for 100% of the T rubrum within mixed infections.
Four unique North American T rubrum strains were identified. In support of a shared ancestry, the T rubrum DNA strain types found in mixed infections with NDMs were among the most abundant types. A population of T rubrum strains in mixed infections of onychomycosis has been characterized, with more than one strain detected in some nails. The presence of a co-infecting NDM in mixed infections may contribute to failed therapy by stabilizing the T rubrum strain type, possibly preventing the antifungal therapy–induced strain type switching observed with infections caused by T rubrum alone.