Fungal Nail Infections Research Articles

Prevalence, aetiology and factors associated with onychomycosis among patients with diabetes at a Tertiary Care Centre in Galle, Sri Lanka

Introduction: Epidemiological data of onychomycosis, a common fungal nail infection found in diabetics, is scarce in Sri Lanka. Objective: To determine the prevalence, aetiological agents and associated factors of onychomycosis among patients with clinically suspected diabetics in southern Sri Lanka. Method: A cross-sectional study was done using a sample of 97 diabetic patients suspected of having onychomycosis in a tertiary diabetes care centre in Galle. Nail clippings were collected, and microscopic and cultural examinations were done. Both microscopic and culture positive cases were considered as having onychomycosis. Results: The prevalence of onychomycosis was 18.6% (95% CI: 11.38%, 27.73%). Non-dermatophyte moulds (NDMs) (55.7%) and yeast (30.9%) were the dominant aetiological agents. The leading pathogens found among NDMs were Aspergillus sp. (35.1%) and Fusarium sp. (1.4%) and Candida albicans (8.2%). Aspergillus niger (20.6%) was the most frequently isolated Aspergillus sp. in the NDMs. Frequent use of detergents and walking bare foot were the significant risk factors of onychomycosis. Only 15.5% of the participants were aware of onychomycosis. Conclusion: Onychomycosis is prevalent to a considerable level among diabetics. Regular dermatological investigations of nails and health education are needed to combat the disease. Large scale research is warranted to confirm these assertions.

Nail Lacquer Containing Origanum vulgare and Rosmarinus officinalis Essential Oils and Biogenic Silver Nanoparticles for Onychomycosis: Development, Characterization, and Evaluation of Antifungal Efficacy.

Onychomycosis is a common fungal nail infection for which new antifungals are needed to overcome antimicrobial resistance and the limitations of conventional treatments. This study reports the development of antifungal nail lacquers containing oregano essential oil (OEO), rosemary essential oil (REO), and biogenic silver nanoparticles (bioAgNPs). The formulations (F) were tested against dermatophytes using agar diffusion, ex vivo nail infection, and scanning electron microscopy techniques. They were evaluated for their pharmacotechnical characteristics and by FTIR-PAS to assess permeation across the nail. F-OEO and F-OEO/bioAgNPs were promising candidates for the final nail lacquer formulation, as they permeated through the nail and showed antifungal efficacy against dermatophytes-contaminated nails after 5 days of treatment. Treated nails exhibited decreased hyphae and spores compared to the untreated control; the hyphae were atypically flattened, indicating loss of cytoplasmic content due to damage to the cytoplasmic membrane. The formulations were stable after centrifugation and thermal stress, maintaining organoleptic and physicochemical characteristics. Both F-OEO and F-OEO/bioAgNPs had pH compatible with the nail and drying times (59-90 s) within the reference for nail lacquer. For the first time, OEO and bioAgNPs were incorporated into nail lacquer, resulting in a natural and nanotechnological product for onychomycosis that could combat microbial resistance.

Impact of new antifungal medications on onychomycosis prescriptions and costs in Japan: A nationwide claims database study.

Onychomycosis, a fungal nail infection, is a common dermatological condition in Japan, with a prevalence of approximately 5%-10%. Despite the introduction of new antifungal medications and updated treatment guidelines published in 2019, data on real-world prescription trends and the associated medical costs are limited. This study aimed to investigate the prescription patterns and medical costs of topical and oral antifungal medications for onychomycosis in Japan from fiscal years 2014 to 2021 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data. We analyzed the annual prescription volumes and medical costs of four antifungal medications: efinaconazole, luliconazole, fosravuconazole, and terbinafine. The prescription volume of efinaconazole, a topical medication launched in 2014, rapidly increased and dominated the market share. Fosravuconazole, an oral medication introduced in 2018, showed an increasing trend, coinciding with a decline in efinaconazole prescriptions. Terbinafine, a well-established oral medication, experienced a substantial decrease in prescription volume. The sex- and age-adjusted prescription volume per 100 000 population was higher among older adults, particularly for efinaconazole. The total medical costs for onychomycosis treatment more than doubled in fiscal year 2015 compared with that for 2014, mainly driven by efinaconazole prescriptions, and exceeded 30 billion Japanese yen in fiscal years 2019-2021. The costs slightly decreased in fiscal years 2020 and 2021, possibly due to the introduction of fosravuconazole. The predominance of topical prescriptions, especially in older adults, raises concerns regarding adherence to the Japanese guidelines that recommend oral antifungals as the first-line treatment for onychomycosis. The substantial increase in medical costs also highlights the economic burden of onychomycosis and the need for cost-effective treatment strategies. This study provides valuable insights into the real-world prescription trends and medical costs of onychomycosis treatment in Japan, suggesting an opportunity to assess potential gaps between guideline recommendations and clinical practice.

Artificial Intelligence in the Diagnosis of Onychomycosis-Literature Review.

Onychomycosis is a common fungal nail infection that is difficult to diagnose due to its similarity to other nail conditions. Accurate identification is essential for effective treatment. The current gold standard methods include microscopic examination with potassium hydroxide, fungal cultures, and Periodic acid-Schiff biopsy staining. These conventional techniques, however, suffer from high turnover times, variable sensitivity, reliance on human interpretation, and costs. This study examines the potential of integrating AI (artificial intelligence) with visualization tools like dermoscopy and microscopy to improve the accuracy and efficiency of onychomycosis diagnosis. AI algorithms can further improve the interpretation of these images. The review includes 14 studies from PubMed and IEEE databases published between 2010 and 2024, involving clinical and dermoscopic pictures, histopathology slides, and KOH microscopic images. Data extracted include study type, sample size, image assessment model, AI algorithms, test performance, and comparison with clinical diagnostics. Most studies show that AI models achieve an accuracy comparable to or better than clinicians, suggesting a promising role for AI in diagnosing onychomycosis. Nevertheless, the niche nature of the topic indicates a need for further research.

Clinico-mycological study of onychomycosis and in vitro antifungal susceptibility of Trichophyton rubrum.

Onychomycosis, a fungal nail infection, is primarily caused by dermatophytes, yeasts, and non-dermatophyte moulds (NDMs). The incidence of this disease and the predominance of specific pathogens vary across different regions and evolve. This study aimed to elucidate the epidemiology of onychomycosis and the pattern of causative pathogens in Beijing, and to ascertain the in vitro antifungal susceptibility profiles of Trichophyton rubrum against itraconazole (ITR), terbinafine (TER), and fluconazole (FLU). Involving 245 patients of onychomycosis with positive fungal culture results, the study implemented internal transcribed spacer (ITS) sequencing of ribosomal DNA (rDNA) on all collected samples. The mean age of the participants was 37.93 ± 13.73 years, with a male-to-female ratio of 1.53:1. The prevalence of toenail infections was significantly higher than that of fingernails. Distal and lateral subungual onychomycosis (DLSO) were the most frequent clinical classifications. PCR results indicated that dermatophytes were the most prevalent pathogens, followed by yeasts and NDMs, among which T. rubrum was the most dominant dermatophyte. TER demonstrated high sensitivity to T. rubrum. However, in clinical settings, some patients with onychomycosis exhibit a poor response to TER treatment. The relationship between in vitro antifungal sensitivity and clinical effectiveness is complex, and understanding the link between in vitro MIC values and clinical efficacy requires further investigation.

Onychomycosis in Foot and Toe Malformations.

Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

Retrospective Analysis of Onychomycosis Risk Factors Using the 2003-2014 National Inpatient Sample.

Onychomycosis, a fungal nail infection, is associated with significant morbidity and negative impact on quality of life. Therefore, understanding associated risk factors may inform onychomycosis screening guidelines. This retrospective study investigated common demographic and comorbidity risk factors among hospitalized patients using the National Inpatient Sample. The 2003-2014 National Inpatient Sample (NIS) database was used to identify onychomycosis cases and age and sex matched controls in a 1:2 ratio. Chi-square tests and T-tests for independent samples were utilized to compare categorical and continuous patient factors. Demographic and comorbidity variables significant (P < 0.05) on univariate analysis were analyzed via a multivariate regression model with Bonferroni correction (P < 0.0029). 119,662 onychomycosis cases and 239,324 controls were identified. Compared to controls, onychomycosis patients frequently were White (69.0% versus 68.0%; P < 0.001), Black (17.9% versus 5.8%; P < 0.0001), and insured by Medicare or Medicaid (80.1% versus 71.1%; P < 0.0001). Patients had greater hospital stays (9.69 versus 5.39 days; P < 0.0001) and costs ($39,925 versus $36,720; P < 0.001) compared to controls. On multivariate analysis, onychomycosis was commonly associated with tinea pedis (odds ratio [OR]: 111.993; P < 0.0001), human immunodeficiency virus (OR: 4.372; P < 0.001), venous insufficiency (OR: 6.916; P < 0.0001), and psoriasis (OR: 3.668; P < 0.001). Onychomycosis patients had longer hospital stays and greater costs compared to controls. Black patients were disproportionately represented among cases compared to controls. Onychomycosis was associated with tinea pedis, venous insufficiency, human immunodeficiency virus, psoriasis, obesity (body mass index [BMI] ≥ 30 kg/m2), peripheral vascular disease, and diabetes with chronic complications, suggesting that inpatients with onychomycosis should be screened for these conditions.

Clinical and microbiological characteristics of onychomycosis in a tertiary hospital: a cross-sectional study

BACKGROUND Onychomycosis is a common fungal nail infection with a low cure rate. While dermatophytes are the most common causal agent for onychomycosis, the incidence of Candida and nondermatophyte mold (NDM) onychomycosis is increasing. This study aimed to analyze the clinical and microbiological characteristics of patients with onychomycosis. METHODS Patients who visited the Department of Dermatology and Venereology, Cipto Mangunkusumo Hospital, and were diagnosed with onychomycosis from 2017 to 2022 were included. Diagnosis was established through clinical examination, supported by the result of direct microscopic examination with potassium hydroxide. RESULTS Of 171 patients, 93.6% had onychodystrophy, 65.5% were females, and 62.0% were aged 19–59 years. Most patients had onychodystrophy in more than three nails, affecting fingernails (31.6%) and toenails (34.5%). Interestingly, 84.8% of patients had no history of nail diseases. The median onset of disease was 24.0 (1–1,040) weeks, while the median onychomycosis severity index was 10.0 (2–40). Most cases were caused by Candida albicans (48.3%). Fusarium was the only NDM documented (2.3%). Some patients were resistant to itraconazole (11.4%) and miconazole (4.5%). Overall, 49.1% of the patients were declared not cured. CONCLUSIONS Candida was the predominant cause of onychomycosis, and onychodystrophy was the dominant feature. Current treatment regimens with systemic or topical antifungal agents did not yield satisfactory results, with more than half of the patients deemed not cured.

Onychomycosis caused by &lt;i&gt;Acremonium species:&lt;/i&gt; A case report

Onychomycosis is a common condition constituting fungal infection of nails. It is generally caused by dermatophytes but non-dermatophytic mold and yeast as its causative agent are on the rise. Acremonium, a non-dermatophytic mold, is commonly found in decaying vegetation, soil, and air. Identification of the causative agent is important as non-dermatophytic molds are resistant to commonly used antifungals. This is a case of an Indian woman who presented with onychomycosis of the toenail and the causative agent was documented and reported as Acremonium species.

Risk Factors Associated with Onychomycosis in Patients Attending Dermatology Units of Some Hospitals in Benue State, Nigeria

Onychomycosis is caused by different organisms especially the genus Trichophyton responsible for fungal nail infection. If left untreated, infection can spread to every nail and over time, the nails become thick, brittle, and ingrown causing pain and discomfort. To investigate the risk factors associated with onychomycosis in patients attending some hospitals within Benue state. A total of 384 finger and toenail samples were collected, disinfected, and subjected to laboratory examination using standard microbiological procedures. Some risk factors for onychomycosis including age, occupation, gender, diabetes mellitus condition, household contacts with animals, use of occlusive footwears, obesity, immune status, family history of onychomycosis, exposure to humid environments among others were investigated using structured questionnaire. The logistic regression for multivariate analysis was further used to identify the relationship between risk factors and onychomycosis. From the 384 samples collected, 226 fungal species were isolated from culture of toeand fingernails samples. Tinea rubrum was identified in159 (70.36%) followed by As per gillusspp., 30 (13.27%), Candida (Yeast), 19 (8.41%), Trichophytoninterdigitale,11 (4.87%) and Epidermophy tonfloc cosum was8 (3.54%). Age was statistically significant toony chomycos is with a positive association (OR=3.06, P=0.02; ≤0.05), while gender (OR=0.85, P=0.45&gt;0.05)and occupation was not statistically significant (OR=1.21, P=0.66; &gt;0.05). Use of occlusive footwear, keeping of long nails, and wearing used shoes showed statistically significant associations with onychomycosis. Individuals who engaged in the afore mentioned risk factors had high odds ratio (39.0, 5.95 and 1.26 respectively). Diabetes mellitus condition, trauma/damage to nails, nail psoriasis, obesity, and immunosuppression also showed statistically significant associations with onychomycosis. Odds ratio was (1.27, 1.86, 4.12, 1.05 and 3.14) respectively. Onychomycosis remains the most common nail disorder with a significant burden. There is need for prevention through practice of good personal hygiene and prescribed treatment of onychomycosis as it can have a considerable impact on patients’ quality of life.

Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes.

Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.

Morphological and ultrastructural changes in fungal agents after LASER application.

Onychomycosis is a fungal nail infection of difficult treatment due to the fungal survival capacity and reduced number of effective therapies. The present study aimed to isolate fungal agents that cause onychomycosis in immunocompetent patients and evaluate how LASER treatments affect the growth and ultrastructure of isolates. In total, 21 patients with positive direct microscopic examination (DME) for onychomycosis had nail samples collected for cultivation and phenotypic identification of microorganisms. From these patients, 12 underwent LASER treatment, divided in Group 1 (n = 5) treated with Nd: YAG 1,064 nm, and Group 2 (n = 7) treated with Nd: YAG 1,064 nm + Er: YAG 2,940 nm + topical isoconazole. Transmission Electron Microscopy (TEM) was performed to evaluate ultrastructural changes after treatment. DME, cultivation, and phenotypic identification showed that the most identified fungus was Trichophyton rubrum spp. After LASER therapy, sample cultivation showed alterations in the fungal morphology with reduction of hyphae, conidia, and reproductive structures. Alterations in fungal cell wall structure, cytoplasm density, and organelles were observed by TEM. LASER irradiation causes changes in the fungal cells, especially in the number of hyphae and the presence of conidia. In addition, it affects fungal growth and reproduction capacity, which interferes with their infection ability and virulence.

Development by design of experiment and validation of a HPLC-UV method for simultaneous quantification of 1-nitro-2-phenylethane and methyleugenol: Application to nail permeation/retention studies

Aniba canelilla (Kunth) Mez is an aromatic tree from Amazon region whose essential oil presents 1-nitro-2-phenylethane (NP) and methyleugenol (ME) as major compounds. Several properties are attributed to Aniba canelilla essential oil (ACEO), such as antifungal. Onychomycoses are fungal nail infections that require novel therapeutic alternatives, especially topical ones. However, to ensure the success of topical therapy, the active compound should be able to penetrate/permeate the nail plate, which is challenging due to the highly keratinized composition of this structure. Thus, the aims of this article were to develop, validate and apply a high-performance liquid chromatography method (HPLC-UV) to quantify NP and ME in porcine hoof extract (PHE) and receptor fluid (RF) during in vitro permeation/retention studies in nail model, for which porcine hoof membranes were used. For method development, two Designs of Experiment (DoE) were adopted: 23 Full Factorial and Box-Behnken. Retention times of 5.65 and 7.49 min were achieved for NP and ME, respectively. The method was full validated for NP and ME quantification in receptor fluid, in accordance with the recommended parameters by ICH Q2(R1) Guideline. In addition, the method was full validated for NP and ME quantification in porcine hoof extract, considering the parameters and criteria of ICH M10 Guideline. In vitro permeation/retention studies were carried out in nail model, and promising results were obtained. NP reached the receptor fluid in the order of 441.1 ± 92.1 µg/cm2 at 72 h. The amount of NP and ME retained into porcine hoof membrane was 1272.6 ± 225.7 µg/cm2 and 84.7 ± 20.4 µg/cm2, respectively, at 72 h. Our findings open perspective to develop topical formulations containing ACEO as active compound aiming the management of onychomycosis.

The Plant Defensin Ppdef1 Is a Novel Topical Treatment for Onychomycosis.

Onychomycosis, or fungal nail infection, causes not only pain and discomfort but can also have psychological and social consequences for the patient. Treatment of onychomycosis is complicated by the location of the infection under the nail plate, meaning that antifungal molecules must either penetrate the nail or be applied systemically. Currently, available treatments are limited by their poor nail penetration for topical products or their potential toxicity for systemic products. Plant defensins with potent antifungal activity have the potential to be safe and effective treatments for fungal infections in humans. The cystine-stabilized structure of plant defensins makes them stable to the extremes of pH and temperature as well as digestion by proteases. Here, we describe a novel plant defensin, Ppdef1, as a peptide for the treatment of fungal nail infections. Ppdef1 has potent, fungicidal activity against a range of human fungal pathogens, including Candida spp., Cryptococcus spp., dermatophytes, and non-dermatophytic moulds. In particular, Ppdef1 has excellent activity against dermatophytes that infect skin and nails, including the major etiological agent of onychomycosis Trichophyton rubrum. Ppdef1 also penetrates human nails rapidly and efficiently, making it an excellent candidate for a novel topical treatment of onychomycosis.

Retrospective analysis of onychomycosis prescribing patterns using the medicare part D prescribers database 2016-2020.

Onychomycosis, defined as a fungal nail infection, affects 5.5% of the global population. Our objectives were to analyse prescription trends of onychomycosis medications using the Medicare Part D Prescribers database from 2016 to 2020, stratified by physician specialty. There was a 4% annual increase in the total cost of onychomycosis medications, with a notable decrease of 12.8% in 2020 during the COVID-19 pandemic. Physicians demonstrated a strong consideration for price when selecting treatments, with the least expensive medications (ciclopirox and terbinafine) accounting for nearly 99% of all prescriptions. In contrast, the more costly medications (efinaconazole and tavaborole) were rarely prescribed. In addition, physicians often opted for the less costly generic versions of ciclopirox and itraconazole, prescribing them 99% and 91% of the time, respectively. Notably, physician assistants and nurse practitioners had higher overall increases in prescription rates, at 15%, compared to 1%-6% for other specialties. There are no recent United States onychomycosis guidelines, and our study emphasizes cost considerations when prescribing onychomycosis treatments.

Effect of the 1064 nm Nd: YAG Laser on the MICs of Antifungals Used in Clinical Practice for the Treatment of Fungal Nail Infections.

Introduction: The fungal nail infection (onychomycosis) involves 18%-40% of all nail disorders, which, although not fatal, can cause mechanical, aesthetic, occupational, and economic problems. Drug treatments due to prolonged treatment periods, drug interactions, adverse effects, and slow progression may associate with numerous negative outcomes. This study aimed to evaluate the long-pulsed 1064-nm Nd: YAG laser effect on fungal colonies and subsequently possible change in the minimum inhibitory concentrations (MICs) of common antifungals compared with the same non-lasered colonies as a novel way to investigate laser and antifungal interaction. Methods: Sixty onychomycosis samples consisting of saprophyte (n=20), dermatophyte (n=20), and yeast (n=20) duplicate colonies were isolated. A series was treated by a long-pulsed 1064-nm Nd: YAG laser. Afterward, the MIC (CLSI-M38-A2 and CLSI-M27-A3) of two series against common antifungals were compared. Results: After 1064-nm Nd: YAG laser irradiation in all 20 tested saprophytes, the MICs of terbinafine (P value<0.035) were changed, and in all 20 tested dermatophytes, the MICs of voriconazole (P value<0.021) were changed. Also, in all 20 tested yeasts, the MICs of caspofungin (P value<0.037) were changed. Moreover, in saprophytes, dermatophytes, and yeasts, significant changes in the MICs of itraconazole (P value<0.032), terbinafine (P value<0.025), and caspofungin (P value<0.037) were detected. Our result showed the GM MICs of the 1064-nm Nd: YAG laser in all saprophyte, dermatophyte, and yeast groups were lower than in the control group. Conclusion: The present study indicated that the long-pulsed 1064-nm Nd: YAG laser significantly changes the MICs of antifungals in onychomycosis clinical samples.

Retrospective Analysis of Liver Enzyme Abnormalities in Patients Prescribed Terbinafine and Itraconazole for Onychomycosis.

Introduction Onychomycosis (OM) is defined as a nail fungal infection. Its prevalence increases with advancing age. Human-to-human transmission makes it a serious public health risk. Although OM is not a life-threatening disease, it has a detrimental effect on patients' quality of life. Due to the long therapy duration and potential side effects of systemic antifungal medicines, physicians may be reluctant to treat OM orally. In this study, we aimed to evaluate the effect of terbinafine and itraconazole on liver transaminases, the side effects of these treatments, and patients' adherence to systemic treatment of OM. Methods This is a retrospective study conducted in our dermatology department (Ordu University, Ordu) between June 2020 and October 2021. Hospital records were analyzed, and patients with the diagnosis of tinea unguium (ICD code B35.1) were investigated. Patients who were prescribed terbinafine or itraconazole were included in the study. Following a clinical diagnosis of OM, the researchers first tried to confirm it through direct microscopic examination with potassium hydroxide (KOH). If the direct microscopic examination was negative but the suspicion about OM continued, confirmation was done through a fungal culture. Results This study included 735 patients, of whom 409 (55.6%) were female and 326 (44.4%) were male. The research covered all of the patients who were given one of these two medications. To find patients who could apply to other hospitals, the Turkish National Healthcare System was checked in addition to hospital information. To identify patients who could apply to other healthcare institutions, all hospitals share their data with this national healthcare system. Terbinafine was used by 433 patients (76.4%), 75 patients (13.2%), and 37 patients (6.5%), respectively, for one, two, and three months. A total of 119 patients (70.8%) took itraconazole for a month, 32 patients (19%) took it for two months, and four patients (2.33%) took it for three months. At the end of the first month, the proportion of the patients with elevated aspartate transaminase (AST) levels was 5.2% for terbinafine and 0% for itraconazole. Eighteen (8.4%) patients with terbinafine had elevated alanine aminotransferase (ALT) levels, and four patients (7.5%) who were on itraconazole treatment had high ALT levels. None of the patients reported cutaneous adverse drug reactions, gastrointestinal disturbances, or headaches due to OM treatment. Also, no patients discontinued treatment because of hepatotoxicity. Conclusion In this study, none of the patients discontinued the treatment because of hepatotoxicity. According to the results of this study, oral terbinafine and itraconazole can be used with close follow-up. Baseline and regular laboratory monitoring for AST and ALT should be done to monitor liver toxicity with terbinafine and itraconazole. Besides, we did not observe other side effects like cutaneous or cardiac side effects or drug-drug interactions.

Investigation of active laser delivery and antimycotic activity of zinc-containing nanomaterials and photodynamic drugs in the treatment of onychomicosis

One of the most common nail pathologies is onychomycosis, a fungal nail infection. The low efficiency of existing methods for the treatment of onychomycosis stimulates the search for new drugs and technologies for their delivery under the nail plate. The aim of the investigation was to study the possibility of using Er:YLF laser radiation for sequential laser microporation of the human nail plate and active laser delivery of modern photodynamic preparations and zinc-containing nanomaterials under the nail plate, as well as to determine their antimycotic activity against the Candida albicans fungus under photodynamic exposure with a wavelength of 656±10 nm. A 0.001 % aqueous solution of methylene blue, a chlorine-containing Revixan gel, as well as zinc-containing nanomaterials, which are aqueous solutions of polyvinylpyrrolidone gel with different concentrations of Zn(NO3)2 nanoparticles and acidity, were studied. It was established that the smallest number of laser pulses required for in vitro microporation of the nail plate and active laser delivery under the nail plate is required when using a 0.001 % aqueous solution of methylene blue, and the largest is required when using Revixan gel. For zinc-containing nanomaterials, an increase in the concentration of Zn(NO3)2 nanoparticles from 14 to 40 % leads to an increase in the number of laser pulses required for active drug delivery under the nail plate by 1.25 times, while a change in the acidity of the pH gel from 7.0 to 6.7 does not has a significant impact on it. It was found that all the studied drugs in combination with photodynamic action at a wavelength of 656±10 nm have an antimycotic effect on the Candida albicans fungus culture. The minimum growth rate of Candida albicans colonies was observed when using the Revixan gel, for which the antimycotic activity reached 73.8 %. The obtained results can be applied in the development of laser systems and technologies for the treatment of fungal diseases, including for photodynamic therapy of onychomycosis.

Case of Mixed Infection of Toenail Caused by Candida parapsilosis and Exophiala dermatitidis and In Vitro Effectiveness of Propolis Extract on Mixed Biofilm

Onychomycosis is a chronic fungal nail infection caused by several filamentous and yeast-like fungi, such as the genus Candida spp., of great clinical importance. Black yeasts, such as Exophiala dermatitidis, a closely related Candida spp. species, also act as opportunistic pathogens. Fungi infectious diseases are affected by organisms organized in biofilm in onychomycosis, making treatment even more difficult. This study aimed to evaluate the in vitro susceptibility profile to propolis extract and the ability to form a simple and mixed biofilm of two yeasts isolated from the same onychomycosis infection. The yeasts isolated from a patient with onychomycosis were identified as Candida parapsilosis sensu stricto and Exophiala dermatitidis. Both yeasts were able to form simple and mixed (in combination) biofilms. Notably, C. parapsilosis prevailed when presented in combination. The susceptibility profile of propolis extract showed action against E. dermatitidis and C. parapsilosis in planktonic form, but when the yeasts were in mixed biofilm, we only observed action against E. dermatitidis, until total eradication.

The First Report of In Vitro Antifungal and Antibiofilm Photodynamic Activity of Tetra-Cationic Porphyrins Containing Pt(II) Complexes against Candida albicans for Onychomycosis Treatment.

Onychomycosis is a prevalent nail fungal infection, and Candida albicans is one of the most common microorganisms associated with it. One alternative therapy to the conventional treatment of onychomycosis is antimicrobial photoinactivation. This study aimed to evaluate for the first time the in vitro activity of cationic porphyrins with platinum(II) complexes 4PtTPyP and 3PtTPyP against C. albicans. The minimum inhibitory concentration of porphyrins and reactive oxygen species was evaluated by broth microdilution. The yeast eradication time was evaluated using a time-kill assay, and a checkerboard assay assessed the synergism in combination with commercial treatments. In vitro biofilm formation and destruction were observed using the crystal violet technique. The morphology of the samples was evaluated by atomic force microscopy, and the MTT technique was used to evaluate the cytotoxicity of the studied porphyrins in keratinocyte and fibroblast cell lines. The porphyrin 3PtTPyP showed excellent in vitro antifungal activity against the tested C. albicans strains. After white-light irradiation, 3PtTPyP eradicated fungal growth in 30 and 60 min. The possible mechanism of action was mixed by ROS generation, and the combined treatment with commercial drugs was indifferent. The 3PtTPyP significantly reduced the preformed biofilm in vitro. Lastly, the atomic force microscopy showed cellular damage in the tested samples, and 3PtTPyP did not show cytotoxicity against the tested cell lines. We conclude that 3PtTPyP is an excellent photosensitizer with promising in vitro results against C. albicans strains.