Nondermatophyte Molds Research Articles

In vitro antifungal activity of luliconazole against nondermatophytic moulds.

In vitro antifungal activity of luliconazole against nondermatophytic moulds causing superficial infections was compared with that of five classes of 12 topical and systemic drugs. The minimum inhibitory concentration (MIC) of the drugs against the genera of Neoscytalidium, Fusarium, Aspergillus, Scedosporium, and Alternaria was measured via modified microdilution method. In results, the nondermatophytic moulds were found to be less susceptible to drugs to which Neoscytalidium spp. and Fusarium spp. were typically drug resistant. However, luliconazole was effective against all the genera tested, including afore-mentioned two species, and had the lowest MICs among the drugs tested.

Clinico-mycological study of onychomycosis in a tertiary care hospital-A cross-sectional study.

Onychomycosis (OM), has a worldwide prevalence of 5% and 0.5%-5% in India. Trichophyton. rubrum (T rubrum) and T mentagrophytes are the most commonly isolated fungi. As the clinical and mycological characteristics change with time and geographical region; it is important to study the temporal and topographic patterns periodically. The study was conducted to identify the epidemiological and clinico-mycological characteristics of patients with OM attending a tertiary care hospital in Delhi. Hundred patients with clinical diagnosis of OM were recruited. Among these, 88 patients who tested positive for OM on direct microscopy with KOH, culture and/or histopathology with periodic acid-Schiff were included in the study. The clinico-mycological characteristics and risk factors associated with OM were evaluated. OM was more common in males (M:F=2.5:1). The mean age of patients with OM was 39±15.3years (SE 1.52) with mean disease duration of 27.6±46.1months (SE 4.9). Seventeen (19.3%) patients had concomitant diabetes mellitus. The patients displayed mean body mass index (BMI) of 25.67±1.35kg/sq m. Concurrent dermatophytosis of skin was present in 35 (39.77%) patients. Two feet-one hand syndrome was present in 5 patients. Fingernail involvement without toenail involvement was more common than toenail involvement alone. (43.18% vs 38.63%). Distal and lateral subungual OM (DLSO) was the commonest clinical variant (81.8%). Mycological culture showed growth in 47 (53.40%) patients. Dermatophytes were isolated in majority, that is in 30 (63.82%) patients followed by non-dermatophytic moulds (NDM) in 7 (14.8%) and Candida spp. in the remaining 10 (21.27%) patients.

Modeling of usage and estimation of cost for efinaconazole 10% topical solution in the treatment of onychomycosis

To the Editor: Onychomycosis is a fungal infection of the nail caused by dermatophytes, nondermatophyte molds, and yeasts. It accounts for half of all nail diseases, with toenails more commonly affected than fingernails.1 Oral medications are often used, although topical therapy may be preferred due to a favorable adverse effect profile. Ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the US Food and Drug Administration for the treatment of onychomycosis.

Dermatomycoses in the Israeli defense forces-Epidemiological and clinical aspects.

Dermatomycoses, involving skin, hair and nail infections, are among the most frequent human infections with global distribution and may have a public health and economic impact. The causative agents include Dermatophytes, Candida, Malassezia and non-Dermatophyte moulds. High morbidity may be associated with certain variables: age, gender, occupation-such as farming or military service, and climate or environmental conditions. The objectives of the present study included: (a). Assessment of epidemiological aspects of dermatomycoses in the Israeli Defense Forces (IDF). (b). Antifungal drug susceptibility of fungi isolated in culture from soldiers. (a) Epidemiological assessment: data based on IDF's medical registry during the period 2009-2013 on 10831 male and female soldiers (8164 and 2667, respectively), of which 2589 were combat soldiers. (b) Susceptibility tests: to ketoconazole, fluconazole, itraconazole, terbinafine and griseofulvin of~100 Dermatophyte and Candida isolates, using E test and/or disc diffusion assays. (c) Statistical analysis: logistic regression, chi-square and ANOVA. (a) Incidence in male soldiers higher than in female soldiers (35% vs. 28%). (b) Incidence in combat soldiers higher than in non-combat soldiers (39% vs 32%). (c) The major site of involvement-nails. (d) Infections peaked during summer months. (e) Dermatophytes constitute close to 90% of the aetiological agents (87% and 86%). (f) Trichophyton rubrum the dominant species. (g) terbinafine was the most active antifungal drug. The most significant conclusion of relevance of this study is the finding of higher morbidity rate among combat soldiers, as this may affect the activity of this group.

An Open Study to Evaluate Effectiveness and Tolerability of a Nail Oil Composed of Vitamin E and Essential Oils in Mild to Moderate Distal Subungual Onychomycosis

Background: Onychomycosis is the most common nail disease and can affect both fingernails and toenails. When possible, topical treatment is generally preferred both by patients and physicians because it is associated with lower risk of systemic side effects and drug interactions than oral antifungals, avoiding laboratory monitoring. Objective: The aim of our study was to evaluate the efficacy, tolerability, and patient’s compliance of a new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree. Patients and Methods: We enrolled 20 patients with mild-moderate distal subungual onychomycosis due to dermatophytes or non-dermatophyte molds. The product was applied once daily on the periungual tissues and on the nail plate for 6 months. Follow-up without therapy continued for another 6 months in order to evaluate the product’s effect maintenance. Periodic evaluation of treatment efficacy was performed by standardized photography and mycological examination (KOH + culture) of the target nail at baseline (T0), after 3 months (T1) and 6 months (T2) of therapy, and after 6 months of follow-up (T3). Results: At the end of the 12-month study, the majority of patients achieved a complete cure of onychomycosis (78.5%). All patients were very satisfied by the treatment. No side effects were recorded. Conclusions: The results of our study indicate that this new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree is an effective and safe option for topical therapy of onychomycosis. This topical antifungal nail oil restructures the nail appearance, improving patient’s adherence to therapy and reducing the risk of relapses, maintaining results over time.

A study on non-dermatophyte moulds as pathogens of onychomycosis

Introduction: Onychomycosis, a fungal infection of nails is ordinarily caused by dermatophytes non dermatophytes and yeasts. The isolation of non-dermatophyte moulds in onychomycosis specimens are being reported increasingly in different geographic regions. Therefore aim of this study was to determine the role and pattern of non- dermatophyte moulds as causative agents of onychomycosis. Materials and Methods: The study was carried out from September 2017 to September 2018 and 70 samples were included in the study. KOH examination and culture have been carried out in all the samples. Moulds were identified based on colony morphology, microscopic examination with Lacto phenol cotton blue stain (LPCB) and slide culture & Yeasts were identified by Gram staining germ tube test‚ urease test and using Chrome agar. Results: Out of 70 samples 42(61%) showed growth in culture, among this most common isolate belongs to non- dermatophyte fungi. Fusarium species (45%) was the most common among the non dermatophyte isolates followed by candida species. Curvulera, Acremonium sps‚ Fonsacea and Trichosporon species were the other non-dermatophyte moulds isolated. Conclusion: Non-dermatophyte moulds should be considered as important pathogens with a high index of suspicion in evaluating the patients with culture negative for dermatophytes or those subjects ending up in treatment failure. Keywords: Non- dermatophyte moulds, Dermatophytes, Onychomycosis, Yeast, Fusarium.

Continuous terbinafine and pulse itraconazole for the treatment of non-dermatophyte mold toenail onychomycosis

Introduction Although dermatophytes are considered the predominant causative organisms in onychomycosis, non-dermatophyte mold (NDM) infections may be more prevalent than originally thought and may be more difficult to treat. There are limited data of oral antifungal efficacy in treating NDM onychomycosis. Method A retrospective chart review (2009–2016) was conducted in patients receiving continuous oral terbinafine or pulse itraconazole for toenail onychomycosis due to NDMs. Mycology results and percent nail affected were recorded with patient characteristics including demographics and concurrent diseases. Complete, clinical, and mycological cure were tabulated. Results Data from 176 patients were collected. Mycological and complete cure rates for terbinafine (69.8% and 17%) and itraconazole (67.5% and 22%) were not significantly different from each other. Regardless of oral treatment, age (p = .013), baseline severity (p = .016), and presence of atherosclerosis (p = .040) or hyperlipidemia (p = .033) decreased the likelihood of mycological cure, while age decreased the likelihood of complete cure (p = .001). Conclusion Continuous terbinafine and pulse itraconazole were similar in efficacy for curing NDM onychomycosis. Age was the most consistent prognostic factor affecting likelihood of cure, with factors that may influence drug reaching the site of infection also decreasing likelihood of mycological cure.

Monotherapy for toenail onychomycosis: a systematic review and network meta-analysis.

Onychomycosis is a fungal infection of the nail caused by dermatophytes, yeasts and nondermatophyte moulds that accounts for approximately 50% of all nail-related disease. This study aims to assess the effectiveness and safety of monotherapy and combination treatments for toenail onychomycosis using a network meta-analysis (NMA). Quality of evidence was assessed using Cochrane-compliant rules and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Efficacy and safety outcomes were compared using a random-effects NMA to estimate pooled odds ratios (ORs) of direct and indirect comparisons among oral and topical treatments (PROSPERO 2015: CRD42018086912). There were not enough eligible combination and device-based therapy trials to include in the NMA. Of 77 randomized controlled trials, 26 were included in the ORs (8136 patients). There were no significant inconsistencies between the direct and indirect evidence. Relative effects show that the odds of mycological cure with continuous terbinafine 250 mg or continuous itraconazole 200 mg are significantly greater than topical treatments. Fluconazole, pulse regimens of terbinafine and itraconazole, and topical treatments did not differ significantly in the odds of achieving mycological cure. The ORs of adverse events occurring with oral or topical treatments were not significantly different from each other. For mycological cure, evidence was of moderate or high quality while evidence ranged from very low to high quality for adverse events. Our review suggests that oral and topical treatments for toenail onychomycosis are safe and effective in producing mycological cure. What's already known about this topic? Topical treatments traditionally have lower success rates than oral treatments. Oral treatments have the advantage of shorter treatment durations, but also present challenges in cases of drug-drug interactions or immunosuppression. A network meta-analysis (NMA) gathers data from indirect evidence to gain confidence about all treatment comparisons and allows for estimation of comparative effects that have not been investigated in head-to-head randomized clinical trials (RCTs). What does this study add? This NMA of efficacy and safety includes all RCTs of oral, topical, combination and device-based treatments for toenail onychomycosis, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for NMA. The odds of achieving mycological cure with continuous terbinafine 250 mg or continuous itraconazole 200 mg were significantly greater than topical treatments. Fluconazole, pulse regimens of terbinafine and itraconazole, and topical treatments did not differ significantly in the odds of achieving mycological cure.

Onychomycosis Caused by Malassezia pachydermatis in a Dog

Background: Malassezia species are commensal skin organisms of warm-blooded vertebrates that can act as opportunistic pathogens. Malassezia pachydermatis is of importance in both veterinary and human medicine. Recognised initially as causes of infection of the skin, they are now known to be superficial commensals as well as potential causes of infections in domestic animals and more serious human conditions such as fungemia. They have also been implicated in the pathogenesis of allergic and other inflammatory diseases. Onychomycosis is defined as fungal infection of the claw (nail disease) caused by dermatophytes (Microsporum and Trichophyton genus), non-dermatophyte molds (hyaline and dematiaceous) and/or yeasts. The objective of this work was to report a case of canine onychomycosis by Malassezia pachydermatis based on reference standard diagnostics of this pathology.Case: A 9-year-old male West Highland White Terrier presented history of claw abnormality: brown staining and partly brittle. The dog has no apparent history of trauma on the affected claw and no skin disease was reported. Direct examination of claw was performed using the tape strip technique revealed Malassezia organisms. Nail fragments were cultured onto Sabouraud Dextrose Agar with Chloramphenicol and Cycloheximide. After 10 days of incubation (32ºC) nail fragments allowed the isolation of pure colonies of Malassezia pachydermatis. The histopathological evaluation was performed by Sector of Veterinary Clinical Pathology, Faculdade de Veterinária (FAVET/UFRGS) and fungal infection due to Malassezia pachydermatis was confirmed by histopathologic examination (Hematoxylin and eosin and Grocott’s methenamine silver stain) of the nail, that revealed abundant yeasts (blastoconidia).Discussion: Fungal infection of the skin, hair and nails are common and are primary caused by the dermatophyte molds. Non-dermatophyte molds isolated from nails constitute a long list, but only a few species cause onychomycoses. These include Scopulariopsis brevicaulis, Fusarium sp., Acremonium spp., Aspergillus spp., Penicillium spp. Yeasts like Malassezia and Candida spp. are saprophytes and usually represent incidental contaminants associated with a non-sterile specimen at mycological culture, however in some cases they may parasite the nails and become an etiological agent of the disease. M. pachydermatis, normally present on the skin and in the ear canal of dogs and cats, can act as opportunistic pathogenic microbe and frequently causes dermatitis and otitis in mammals. In the case of onychomycosis, there is little evidence that Malassezia yeasts are implicated in nail plate invasion, although this may be a rare occurrence. All species of the genus are obligatory lipid-dependent forms, with the exception of M. pachydermatis, as well as absence of keratinolytic ability. Malassezia organisms were commonly retrieved from the subungual claw fold region of normal healthy dogs (should be considered resident microflora of the normal canine claw fold). Some authors suggests that high numbers of yeast can be detected on cytological evaluation of the skin surface of the canine claw fold from allergic dogs in both the absence and presence of concurrent signs of pruritus and paronychia.

Fusarium onychomycoses in Switzerland-A mycological and histopathological study.

Onychomycoses in temperate climates are most commonly due to dermatophytes, particularly Trichophyton rubrum. Non-dermatophyte nail infections are much less frequent, and their diagnosis requires a careful and repeated search for a potential dermatophyte that may have been overgrown in culture. A series of histological slides of suspected onychomycoses with uncommon fungal morphology prompted us to search for non-dermatophytic moulds causing dermatophytosis-like nail infections. Thirty cases were identified by culture as Fsolani, Foxysporum, Fdimerum or F spp, and two more were only diagnosed histopathologically. None of these patients was immunocompromised. Treatment was mostly unsuccessful with terbinafine whereas itraconazole showed a moderately better treatment result; in all cases, a topical ciclopirox nail varnish in a hydroxychitosan base was added.

Onychomycosis due to mixed infection with non-dermatophyte molds and yeasts

Onychomycosis due to mixed infection with non-dermatophyte molds and yeasts

Recent advances in therapies for onychomycosis and its management

Onychomycosis is the most common affliction of the nail. It may be caused by dermatophytes, yeasts, and non-dermatophyte molds. Traditionally, oral antifungal treatments have been used to treat the fungus, although they can be accompanied by side effects and drug interactions. Topical treatments provide an alternative modality, bypassing the systemic effects of oral drugs; recent research has centered on topical drug improvement and development. Physical and laser treatments are being used in conjunction with topicals, which may help penetrate the thick nail plate. In this review, techniques from all categories are outlined: both novel experimental approaches and progress and effectiveness of recently developed treatments. More long-term studies are required to determine the efficacy of various treatments, but cure rates are improved when patients adhere to treatments and follow preventative measures to avoid disease recurrence.

Prevalence, Risk Factors, and Spectrum of Fungi in Patients with Onychomycosis in Addis Ababa, Ethiopia: A Prospective Study.

Background Onychomycosis is a common refractory infection deleteriously affecting quality of life via social stigma and upsetting day-to-day activities. Objective To study the prevalence of onychomycosis, spectrum of fungal etiological agents, and associated risk factors. Methods A prospective nonrandomized study on the prevalence of onychomycosis was carried out from September 2017 to April 2018 at a dermatology center in Addis Ababa. Nail scrapings were collected from 303 patients clinically identified with nail disorders of fungal origin by dermatologists. Fungal etiological agents were identified microscopically and by culture method following standard procedures. Results The prevalence of onychomycosis was 60.4%. Fungi neither were detected nor showed visible fungal growth in 39.6% of the cases. Females were more likely to present dystrophic nails than men. Patients in the middle age group were more affected. The isolation rates of dermatophytes, yeasts, and nondermatophyte molds were 44.7%, 33.3%, and 32.3%, respectively. Trichophyton rubrum, Scytalidium dimidiatum, and Candida albicans were the dominant species of dermatophytes, nondermatophyte molds, and yeasts, respectively. There was no statistically significant association between onychomycosis and risk factors. Conclusions The prevalence rate of onychomycosis in the present study was high. The isolation rate of nondermatophyte molds was comparable with that of dermatophytes. Further studies on the prevalence of onychomycosis, fungal etiological agents, and changes in species distribution of the etiological agents of nail infection in Ethiopia are important.

Mycoses in northeastern Brazil: epidemiology and prevalence of fungal species in 8years of retrospective analysis in Alagoas.

Superficial and cutaneous mycoses are common in tropical countries, caused by dermatophytes, yeast, and non-dermatophyte molds in different clinical specimens. In order to define the epidemiology of mycoses and the profile of their etiological agents in Alagoas (northeastern Brazil) between 2009 and 2016, we obtained data of patients from the main laboratories of Alagoas, by examining clinical samples with direct microscopy and culture on Sabouraud dextrose agar and Chromagar®Candida. A total of 3316 patients were confirmed with mycoses (595 men/2716 women) and 40.25 of average age. Positive samples totaled 3776, mainly vaginal secretion (1593/42.2%), toenails (876/23.2%), and fingernails (589/15.6%). Yeasts were the most isolated (3129/82.9%), including 3012 Candida spp. (79.8%), 57 Malassezia spp. (1.5%), 42 Trichosporon sp. (1.1%), 10 Geotrichum spp. (0.3%), and 8 Rhodotorula spp. (0.2%). Candida albicans was the most frequent species (715/18.9%), followed by C. krusei (194/5.1%), C. tropicalis (24/0.6%), and 2079 unspecified species (55.1%). Among 17.1% filamentous fungi, 14.8% dermatophytes were distributed as 211 Trichophyton sp. (5.6%), 125 T. rubrum (3.3%), 106 T. tonsurans (2.8%), 72 T. mentagrophytes (1.9%), 2 Microsporum sp. (0.1%), 15 M. canis (0.4%), and 26 Epidermophyton sp. (0.7%). Other fungi represented the minority: Fusarium sp. and Aspergillus sp. These are the first clinical data on the Alagoas population affected by fungi pathogens, confirming a higher incidence of candidiasis (mainly vulvovaginal and onychomycosis) and dermatophytes, providing a better understanding of different mycoses in northeastern Brazil.

Antifungal Activity of Petroleum Ether and Ethanol Extracts of Moringa Oleifera Seeds

The activity of petroleum ether and ethanol extracts of Moringa olifera seeds have antifungal activity on different fungi including dermatophyte, non-dermatophyte molds and yeasts, which isolated from human skin and nail fungal infections. From 70 samples collected from skin and nail infection; 20 dermatophyte isolates, 21 non dermatophyte moulds and 25 yeast were isolated. While macromorphological and micromorphological as well as cultivation on differential media identified all isolated molds (derematophyte and non dermatophye molds), cultivation on corn meal media and chromogenic Candida agar could identified isolated yeasts. EME is having more antifungal activity than PME on all tested fungi.

Changing Trend of Superficial Mycoses with Increasing Nondermatophyte Mold Infection: A Clinicomycological Study at a Tertiary Referral Center in Assam.

Background:Superficial mycosis is the commonest infections affecting human globally. Though they do not cause mortality, their clinical significance lies in their morbidity, recurrence, and cosmetic disfigurement, thus creating a major public health problem. The infections are more prevalent in the tropical regions. The etiological agents are also seen to vary with time and geographical location.Aim:This study was carried out to find out the trend of superficial mycosis in Assam, along with a clinicomycological correlation.Materials and Methods:A total of 130 clinically diagnosed cases of superficial mycoses attending the outpatient department (OPD) of a tertiary hospital in Assam for a period of 1 year were taken up for the study. After taking the informed consent and a proper history, the clinical materials like skin scrapings, nail clippings, and infected hair were sent for mycological examination.Results:The infection was found to be more prevalent among males than females (M:F, 3:2) and among the farmers and laborers (24.61%). Tinea corporis was the commonest clinical type (21.5%). Among the fungal isolates, dermatophytes were the most frequent isolates (43.54%), out of which Trichophyton rubrum was commonest. nondermatophyte moulds like Fusarium, Aspergillus, Scopulariopsis, Trichosporon, and Penicillium spp. were isolated.Conclusion:The epidemiology of fungal infection and the causative fungi is seen to vary geographically and with time. This study reflects the changing trend of fungal infection in the north eastern region with a high rate of isolation of nondermatophyte moulds as the causative agent.

Fungal Diversity and Onychomycosis An Analysis of 8,816 Toenail Samples Using Quantitative PCR and Next-Generation Sequencing.

Onychomycosis is a fungal infection of the nail that is often recalcitrant to treatment and prone to relapse. Traditional potassium hydroxide and culture diagnosis is costly and time-consuming. Therefore, molecular methods were investigated to demonstrate effectiveness in diagnosis and to quantify the microbial flora present that may be contributing to disease. A total of 8,816 clinically suspicious toenail samples were collected by podiatric physicians across the United States from patients aged 0 to 103 years and compared with a control population (N = 20). Next-generation sequencing and quantitative polymerase chain reaction were used to identify and quantify dermatophytes, nondermatophyte molds, and bacteria. Approximately 50% of suspicious toenails contained both fungi and bacteria, with the dermatophyte Trichophyton rubrum contributing the highest relative abundance and presence in 40% of these samples. Of the remaining 50% of samples, 34% had bacterial species present and 16% had neither. Fungi only were present in less than 1% of samples. Nondermatophyte molds contributed to 11.0% of occurrences in fungus-positive samples. All of the control samples were negative for fungi, with commensal bacterial species composing most of the flora population. Molecular methods were successful in efficiently quantifying microbial and mycologic presence in the nail. Contributions from dermatophytes were lower than expected, whereas the opposite was true for nondermatophyte molds. The clinical significance of these results is currently unknown.

Clinicomycological and Histopathological Profile of Onychomycosis: A Cross-sectional Study from South India.

Background:Onychomycosis (OM) is a fungal infection of the finger or toenails caused by dermatophytes, yeasts, or nondermatophyte molds (NDMs) and can involve any component of the nail unit. OM, apart from being asymptomatic, is a chronic disease and warrants long-term treatment.Aims:The aim was to study the clinicoepidemiological features of OM and to evaluate the mycological and histopathological features among patients attending the dermatology outpatient department.Subjects and Methods:A cross-sectional hospital-based study was performed in 500 patients with symptoms related to the nails and nail folds. OM was confirmed in 284 patients by potassium hydroxide (KOH) mount, fungal culture, or biopsy. Descriptive analysis of the data was undertaken.Results:The study included 284 confirmed cases of OM of which 117 (41.1%) were positive for fungal elements by KOH mount, 168 (59.1%) samples showed positivity in fungal culture, and 62 (21.8%) samples had positive nail biopsy results. Distolateral subungual OM was the most common clinical type (47.6%). Among the fungal isolates, a predominance of dermatophytes was observed followed by yeasts and NDMs. The most common dermatophytic fungal isolate in the culture was Trichophyton rubrum (45%).Conclusion:Our study implies the importance of laboratory diagnosis of OM as it can mimic diverse nail disorders. As the role of NDMs and yeasts is on the rise for etiology of OM, investigations such as KOH examination, culture, or nail biopsy becomes essential for correct diagnosis and management.

A rare case of onychomycosis due to Aspergillus species in a neonate

Onychomycosis is a common condition affecting 5.5% of the population worldwide and represents 20%–40% of all onychopathies and about 30% of cutaneous mycotic infections. It is common in elderly, uncommon in children, and rare in neonates. Onychomycosis is caused by dermatophytes, nondermatophytic molds (NDM), and yeasts. Onychomycosis due to NDM is even rarer in neonates. Here, we report a case of a 3-week-old neonate who was diagnosed as a case of onychomycosis due to Aspergillus species. The neonate was started on topical antifungal amorolfine 5% and improved in 8 weeks.

Global perspectives for the management of onychomycosis.

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophyte molds, and yeasts. This difficult-to-treat chronic infection has a tendency to relapse despite treatment. This paper aims to offer a global perspective on onychomycosis management from expert physicians from around the world. Overall, the majority of experts surveyed used systemic, topical, and combination treatments approved in their countries and monitored patients based on the product insert or government recommendations. Although the basics of treating onychomycosis were similar between countries, slight differences in onychomycosis management between countries were found. These differences were mainly due to different approaches to adjunctive therapy, rating the severity of disease and use of prophylaxis treatment. A global perspective on the treatment of onychomycosis provides a framework of success for the committed clinician with appreciation of how onychomycosis is managed worldwide.