Oral Antifungals Research Articles

Triple therapy approach for treating chromoblastomycosis in a Lebanese patient.

Chromoblastomycosis, though rare in non-endemic regions like Lebanon, should be considered in patients presenting with chronic, verrucous skin lesions unresponsive to conventional therapies. Multimodal treatment combining oral antifungals, cryotherapy, and adjunctive topical 5-Fluorouracil demonstrates efficacy in managing refractory cases. Follow-up visits three and 6 months after treatment cessation showed sustained lesion clearance and no recurrence.

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.

Efficacy of Fractional Versus Fully Ablative CO2 Laser for Distolateral Onychomycosis: Experience With 20 Patients.

Oral antifungals are the treatment choice for onychomycosis, and topical therapies are favored in cases of limited nail involvement. Recently, carbon dioxide (CO2) laser treatment has emerged as an option to enhance the effectiveness of topical therapies. Our objective was to compare the efficacy of fractional ablative and fully ablative CO2 laser treatments for distolateral subungual onychomycosis affecting a single toenail and caused by dermatophytes. The records of 10 patients treated with a single fully ablative CO2 session were matched with those of 10 patients who underwent a single CO2 fractional treatment. All had previously failed topical antifungal lacquers and were discharged with the prescription of topical ciclopirox nail lacquer (8%) for 3 months. The clinical response rates were 80% for the fully ablative group and 60% for the fractional group. Additionally, the mean reduction in Onychomycosis Severity Index from baseline to 8.6±1.6 weeks after treatment completion was 6.9±5.4 in the fully ablative group and 3.6±6.6 in the fractional group. The relapse rate among responders was 12.5% in the fully ablative and 33.3% in the fractional group after a mean follow-up time of 29.4±2.3 weeks. Fractional and fully ablative CO2 laser in combination with ciclopirox lacquer could increase the response rate in onychomycosis resistant to topical antifungals when systemic therapy is contraindicated or not yet pursued. Fully ablative mode therapy is significantly more effective than fractional (P < 0.05). Further studies are needed to identify prognostic response factors and assess the long-term effectiveness of CO2 laser treatment.

Pityriasis Rubra Pilaris Following Administration of the Pfizer-BioNTech COVID-19 Vaccine Successfully Treated with Acitretin and Dupilumab

Introduction: Pityriasis rubra pilaris (PRP) is an inflammatory eruption of unknown origin; rare cases of COVID-19 vaccine-induced PRP have been reported. Here, we present a case of COVID-19 vaccine-induced pityriasis rubra pilaris inadequately managed with acitretin, successfully treated with the IL-4/IL-13 inhibitor dupilumab. Case Report: A 76-year-old male presented to an outpatient dermatology clinic with a 2-month history of a profoundly pruritic worsening rash characterized by large, orange-salmon-colored follicular papules with scale coalescing into plaques covering approximately 80% of the body surface area. The plaques had well-defined borders and multiple islands of sparing characteristic of PRP. Multiple therapies were trialed with no improvement, including oral prednisone, mycophenolate, topical corticosteroids, antiparasitics, antifungals, doxepin, and UVB treatments. A trial of oral acitretin resulted in improvement of the skin plaques and keratoderma, but the patient remained uncontrollably pruritic. Dupilumab was initiated which provided rapid relief, and the patient has remained clear for several months. Conclusion: Clinicians should be aware of dupilumab’s potential for effective treatment of PRP with recalcitrant pruritus.

Treatments for Onychomycosis: A Bibliometric Analysis

Introduction: Oral antifungals were the earliest treatments to receive approval for the management of onychomycosis and have a long-standing record to support their efficacy. Topical antifungals and device-based treatments have been explored and some implemented in more recent years as alternatives to traditional oral antifungals. The present bibliometric analysis summarizes trends in publication frequency for onychomycosis treatment modalities over time and characterizes their body of literature in terms of types of studies available and relative level of evidence. Methods: A comprehensive literature search was performed using Web of Science and SCOPUS databases. Results: Covering all publications from 1970 to present day, our search identified oral therapeutics n = 295 articles (n = 63 randomized control trials [RCTs]), topical therapeutics n = 358 articles (n = 72 RCTs), and device-based treatments n = 158 articles (n = 37 RCTs). Spikes in research activity surround FDA approval of therapeutics for each treatment modality. Research activity within the last decade has focused on topical and device-based treatments. Evidence for efficacy of device-based treatments is lacking from relatively few high-quality RCTs. Conclusion: With growing concern for non-dermatophyte mold onychomycosis and terbinafine resistance, researchers should validate the efficacy and safety of device-based treatments with high-quality studies.

Fungal Head and Neck Dermatitis: Current Understanding and Management.

Head and neck dermatitis (HND) is a form of atopic dermatitis (AD) that affects the seborrheic areas of the body and causes greater quality of life detriments than other types of AD. HND can be challenging to treat since first-line topical therapies may be ineffective or intolerable for long-term use on areas affected by HND while dupilumab may cause dupilumab-associated HND (DAHND). Current evidence implicates fungi, particularly Malassezia spp., in the pathogenesis of HND. Penetration of fungal antigens through the defective AD skin barrier activates the innate and adaptive immune systems to cause cutaneous inflammation via the T helper (Th)17 and/or Th2 axes. Malassezia sensitization may distinguish HND from other forms of AD. Multiple double-blind, placebo-controlled trials have shown antifungals to benefit HND, yet the persistence of symptom reliefwith sustained use remains unclear. Oral antifungals appear more effective than topical antifungals but may be harmful with long-term use. DAHND may also be fungal-mediated given improvement with antifungals and evidence of an overactive immune response against Malassezia in these patients. Janus kinase inhibitors are effective for HND, including DAHND, but may cause significant side effects when administered systemically. OX40/OX40L inhibitors and tralokinumab may be promising options for HND on the horizon. Demographic and environmental factors influence the host mycobiome and should be considered in future precision-medicine approaches as microbiome composition and diversity are linked to severity of HND.

Clinicomycological Study of Dermatophyte Infections in Patients Attending Dermatology Outpatient Department in a Tertiary Care Hospital

Context: Dermatophytosis is a fungal disease characterized by the infection of skin, hair, and nails. There is an upsurge of complicated superficial dermatophytosis and an increase in the incidence of chronic, relapsing, recurrent cases in India that are also often unresponsive to conventional doses of drugs. Aims: The aim of this study was to study the prevalence of dermatophyte species in the particular study area and it is susceptibility to itraconazole, terbinafine, and fluconazole. Settings and Design: All dermatophytes isolates obtained were subjected to 10% KOH mount, fungal culture, and antifungal sensitivity testing for fluconazole, itraconazole, and terbinafine. Materials and Methods: Newly diagnosed cases of dermatophytosis without treatment for the past 3 months were included in the study. KOH preparation was observed and subjected to fungal culture. Then, the susceptibility of the dermatophytes to oral antifungals (itraconazole, terbinafine, and fluconazole) was done. Results: Out of 28 patients with tinea, 14 males and 12 females were tested KOH positive. Out of them, 23 patients showed positive for dermatophyte growth. In them, 15 isolates were Trichophyton mentagrophytes and 8 isolates were Trichophyton rubrum. Antifungal drug susceptibility testing data indicated that, for the two species, MIC of itraconazole ranged between 0.03 and 16 μg/ml, terbinafine between 0.03 and 16 μg/ml, and fluconazole between 0.25 and 64 μg/ml. Conclusions: The study provided information regarding the prevalent species of dermatophyte in our study area and it is high sensitivity to itraconazole compared to terbinafine and the lowest for fluconazole. This gives us guidance as to which antifungal to use empirically in our clinical practice to treat tinea infection.

Drug-Induced Erythema Annulare Centrifugum after Dupilumab Therapy: A Case Report.

Introduction: Dupilumab is a fully human monoclonal antibody therapy FDA-approved to treat moderate-to-severe atopic dermatitis (AD) by interrupting the pro-inflammatory signaling pathway of interleukins 4 and 13. Common side effects of dupilumab include injection-site reactions, ophthalmic complications, and upper respiratory infections. We discuss the necessity for early recognition and management of dupilumab-induced EAC which has not been previously reported as a potential adverse effect.&#x0D; Case Report: A 48-year-old woman began treatment with dupilumab for severe AD and subsequently presented with a 3-month history of erythematous annular plaques with trailing scale on the trunk and extremities. She failed treatment with topical corticosteroids as well as topical and oral antifungals prior to being diagnosed with biopsy-confirmed erythema annulare centrifugum (EAC). The condition worsened after replacing dupilumab with tralokinumab but resolved after discontinuation of the drugs and has remained clear since.&#x0D; Conclusion: EAC is a reactive erythema that typically presents as expanding annular papules and plaques with central clearing and in some cases, trailing scale at the rim of the lesions. There are currently no reports in the literature describing the development of EAC secondary to dupilumab. Clinicians should be aware that EAC may be a potential adverse effect of dupilumab.

Dermatophytomas in Onychomycosis: A Scoping Review of Prevalence, Diagnosis, and Treatment.

Dermatophytoma, also described as a longitudinal streak/spike, is a form of onychomycosis that presents as yellow/white streaks or patches in the subungual space, with dense fungal masses encased in biofilm. This scoping review of the literature was conducted to address a general lack of information about the epidemiology, pathophysiology, and treatment of dermatophytomas in onychomycosis. A search was performed in the PubMed and Embase databases for the terms "longitudinal spike" or "dermatophytoma." Outcomes of interest were definition, prevalence, methods used for diagnosis, treatments, and treatment efficacy. Inclusion and exclusion of search results required agreement between two independent reviewers. Of a total of 51 records, 37 were included. Two reports provided the first unique definitions/clinical features of dermatophytomas. Overall, many descriptions were found, but one conclusive definition was lacking. Prevalence data were limited and inconsistent. The most frequently mentioned diagnostic techniques were clinical assessment, potassium hydroxide/microscopy, and fungal culture/mycology. Oral terbinafine and topical efinaconazole 10% were the most frequently mentioned treatments, followed by topical luliconazole 5% and other oral treatments (itraconazole, fluconazole, fosravuconazole). In studies with five or more patients without nail excision, cure rates were highest with efinaconazole 10%, which ranged from 41% to 100% depending on the clinical and/or mycologic assessment evaluated. Other drugs with greater than or equal to 50% cure rates were topical luliconazole 5% (50%), oral fosravuconazole (57%), and oral terbinafine (67%). In studies that combined oral terbinafine treatment with nail excision using surgical or chemical (40% urea) methods, cure rates ranged from 50% to 100%. There is little published information regarding dermatophytomas in onychomycosis. More clinical research and physician education are needed. Although dermatophytomas have historically been considered difficult to treat, the efficacy data gathered in this scoping review have demonstrated that newer topical treatments are effective, as are oral antifungals in combination with chemical or surgical methods.

Antifungal medication use during early pregnancy and the risk of congenital heart defects in the National Birth Defects Prevention Study, 1997-2011.

Fungal infections are common among pregnant people. Recent studies suggest positive associations between oral antifungals used to treat fungal infections and congenital heart defects (CHDs). We estimated associations between first trimester antifungal use and 20 major, specific CHDs using data from the National Birth Defects Prevention Study (NBDPS), a multi-site, case-control study that included pregnancies with estimated delivery dates from October 1997 through December 2011. Infants with CHDs ("cases") were ascertained from 10 birth defect surveillance programs. Live born infants without major birth defects ("controls") were randomly selected from birth records or hospital discharge lists. First trimester antifungal use was self-reported via maternal interview. We estimated adjusted odds ratios (AORs) and 95% confidence intervals (CIs) using logistic regression with Firth's penalized likelihood. First trimester antifungal use was reported by 148/11,653 (1.3%) case and 123/11,427 (1.1%) control participants. We estimated AORs for 12 CHDs; six had AORs >1.5 (tetralogy of Fallot, double outlet right ventricle with transposition of the great arteries [DORV-TGA], atrioventricular septal defect, hypoplastic left heart syndrome, pulmonary atresia, muscular ventricular septal defect), and one (pulmonary valve stenosis) had an AOR <0.7. All CIs included the null, except for DORV-TGA. First trimester antifungal use was rare. We observed some positive associations for several specific CHDs in our analysis, although the CIs largely included the null. Results do not support a large increase in risk, but smaller increases in risk for certain CHD cannot be ruled out.

Endogenous Fungal Endophthalmitis: A Single-Center Retrospective Study and Review of the Literature

To evaluate factors that inform systemic antifungal choices in patients with endogenous fungal endophthalmitis (EFE). Single-institution retrospective case series. Charts of EFE patients from 2010 to 2023 were reviewed. Patients treated systemically for EFE with a minimum of 14 days of follow-up were included. Outcome measures included time to improvement in vitritis or chorioretinitis, systemic therapy modification, and need for surgical intervention. A total of 20 eyes of 16 patients were included. Candida species were most common (43.8%), followed by culture-negative EFE (37.5%) and Aspergillus species (18.8%). In all, 90% of eyes had vitritis and/or macula-involving chorioretinitis. The majority of Candida infections (60%) or culture-negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, positive fungal culture, or positive Fungitell assay were more likely to be treated with early intravenous (IV) antifungal therapy. Two patients required systemic antifungal therapy modification because of worsening chorioretinitis, in 1 case due to voriconazole-resistant Aspergillosis that demonstrated chorioretinal lesion growth despite intravitreal amphotericin B injections and systemic voriconazole, and in the second case due to worsening chorioretinitis from Candida dubliniensis infection that regressed upon switch from oral to IV fluconazole. Initial systemic treatment decisions in patients with EFE were driven by systemic culture positivity, systemic symptoms, or comorbidities. Intravitreal antifungal therapy may be insufficient to arrest progression of chorioretinal lesions in some cases. Larger studies are needed to determine whether visible end-organ damage in the form of chorioretinitis may be useful for guiding systemic therapy changes.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents.

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and invitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy invitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Are oral antifungals more effective than intravaginal antifungals at treating women with uncomplicated vulvovaginal candidiasis?

Are oral antifungals more effective than intravaginal antifungals at treating women with uncomplicated vulvovaginal candidiasis?

Antifungal medication use during pregnancy and the risk of selected major birth defects in the National Birth Defects Prevention Study, 1997-2011.

Recent studies suggest increased birth defect risk associated with maternal use of specific oral antifungals. We estimated associations between first-trimester antifungal use and selected non-cardiac birth defects using National Birth Defects Prevention Study (NBDPS) data. Participants with a pregnancy affected by a study-eligible birth defect ("cases") were ascertained from 10 birth defect surveillance programs; participants who delivered livebirths without a major birth defect ("controls") were randomly selected from birth records or hospital discharge lists. First-trimester antifungal use was self-reported via maternal interview. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for birth defects with ≥5 exposed cases using logistic regression. We estimated crude ORs and exact 95% CIs for birth defects with 3-4 exposed cases. Additionally, we conducted a probabilistic bias analysis of exposure misclassification. Our analysis included 19 624 cases and 11 427 controls; 257 (1.3%) cases and 123 (1.1%) controls reported first-trimester antifungal use. Of those who reported antifungals, 62.6% of cases and 64.2% of controls reported topical antifungals; 10.1% of cases and 4.9% of controls reported oral antifungals. We observed the strongest associations for encephalocele and Dandy-Walker malformation and modestly elevated estimates for several other defects. Bias-adjusted estimates were similar to the main analysis. First-trimester antifungal use was positively associated with several birth defects in our analysis, although CIs were imprecise. Further study is warranted to investigate associations between antifungal use and birth defects, including potential bias due to confounding by indication.

Combination oral antifungal therapy for paediatric fungal infection: An option to improve efficacy and overcome clinical resistance.

There is increasing evidence of clinically resistant cutaneous fungal infections. The use of combination oral antifungals is described in adults but not in paediatric patients. We present seven paediatric cases of clinically resistant fungal infections treated successfully with combination oral antifungal therapy after inadequate response to a single agent.

Photodynamic inactivation by hypericin-P123 on azole-resistant isolates of the Trichophyton rubrum complex as planktonic cells and biofilm

IntroductionThe Trichophyton rubrum complex comprises the majority of dermatophyte fungi (DM) responsible for chronic cases of onychomycosis, which is treated with oral or topical antifungals. However, owing to antifungal resistance, alternative therapies, such as photodynamic therapy (PDT), are needed. This study investigated the frequency of the T. rubrum species complex in onychomycosis cases in the northwestern region of Paraná state, Brazil, and evaluated the efficacy of (PDT) using P123-encapsulated hypericin (Hyp-P123) on clinical isolates of T. rubrum in the planktonic cell and biofilm forms. Material and methodsThe frequency of the T. rubrum complex in onychomycosis cases from 2017 to 2021 was evaluated through a data survey of records from the Laboratory of Medical Mycology (LEPAC) of the State University of Maringa (UEM). To determine the effect of PDT-Hyp-P123 on planktonic cells of T. rubrum isolates, 1 × 105 conidia/mL were treated with ten different concentrations of Hyp-P123 and then irradiated with 37.8 J/cm2. Antibiofilm activity of PDT-Hyp-P123 was tested against T. rubrum biofilm in the adhesion phase (3 h), evaluated 72 h after irradiation (37.8 J/cm2), and the mature biofilm (72 h), evaluated immediately after irradiation. In this context, three different parameters were evaluated: cell viability, metabolic activity and total biomass. ResultsThe T. rubrum species complex was the most frequently isolated DM in onychomycosis cases (approximately 80 %). A significant reduction in fungal growth was observed for 75 % of the clinical isolates tested with a concentration from 0.19 μmol/L Hyp-P123, and 56.25 % had complete inhibition of fungal growth (fungicidal action); while all isolates were azole-resistant. The biofilm of T. rubrum isolates (TR0022 and TR0870) was inactivated in both the adhesion phase and the mature biofilm. ConclusionPDT-Hyp-P123 had antifungal and antibiofilm activity on T. rubrum, which is an important dermatophyte responsible for onychomycosis cases.

Efficacy of super bioavailable itraconazole in the management of dermatophytosis in India

Itraconazole (ITZ) is a commonly prescribed oral antifungal agent in India and has a low minimum inhibitory concentration when compared to other oral antifungals. However, clinicians have reported inconsistent clinical responses despite its high skin levels, which may be due to variations in pelletization parameters, which affect its bioavailability and serum levels. Conventional ITZ has a maximum bioavailability of 55%; however, this is unpredictable and inconsistent. In contrast, the novel ITZ formulation, super bioavailable ITZ (ITZ-SB), has targeted drug release in the small intestine, resulting in predictable serum levels with minimal interindividual variability. This makes it a potentially useful drug in treating recalcitrant dermatophytosis. This expert opinion highlights the benefits of novel ITZ-SB with the incorporation of SUBA® technology. The SUBA® technology improves the bioavailability of poorly soluble drugs by ‘solid dispersion’ in polymer to increase drug absorbency. This technology also has potential to reduce variability in absorption and adverse effects. Benefits of this technology include more predictable clinical response and lower drug quantities necessary to achieve therapeutic blood levels, making it a promising treatment option for recalcitrant dermatophytosis. Fixtral SB, which uses this technology, is a novel weapon in the arsenal of treatments for superficial mycoses.

Study of ocular manifestations of COVID-19 patients in a tertiary care hospital of Rural North Maharashtra

Objectives: The purpose of the study is to understand profile of ocular manifestations in recovered post COVID 19 patients and to suggest recommendations based on observations. Materials and Methods: It was a prospective hospital-based case analysis study done at tertiary care hospital of rural North Maharashtra from April 2020 to June2021 and included 104 patients with recent history of COVID 19 infection and various ocular symptom Results: Diabetes mellitus is most common associated factor observed. Viral conjunctivitis was observed in 52 cases .2 cases reported subconjunctival hemorrhage. Retinal vein occlusions were seen in 3 cases. Total ophthalmoplegia was seen in 23 cases. Orbital cellulitis with mucormycosis was documented in 12 cases. Orbital apex syndrome with an impending intracranial spread in 4 case required orbital exenteration. Peribulbar Amphotericin B was given in 3 cases and intravenous and oral antifungals also given simultaneously Conclusion: COVID 19 infection can lead to various ocular symptoms even in the recovery period. Early diagnosis by high degree of suspicion and prompt treatment with multidisciplinary approach is required for prevention of visual disability.

Clinicomycological Profile and Risk Factors for Dermatophytosis at a Teaching Tertiary Care Centre in North India: A Cross-sectional Study.

Dermatophytosis has gained significant importance in recent years owing to increased incidence, more atypical lesions, changing mycological profile and growing antifungal resistance. Therefore, this study was planned to know the clinicomycological profile of dermatophytic infections in patients attending our tertiary care centre. A total of 700 patients with superficial fungal infections belonging to all age groups and both sexes were taken up for this cross-sectional study. Sociodemographic and clinical details were noted on a prestructured proforma. Superficial lesions were clinically examined and the sample was collected by appropriate collection methods. Direct microscopy by potassium hydroxide wet mount was done to see hyphae. For culture Sabouraud's dextrose agar (SDA) with chloramphenicol and cyclohexamide was used. Dermatophytic infections were detected in 75.8% (531/700) patients. Young people belonging to age group of 21-30 years were commonly affected. Tinea corporis was the commonest clinical picture seen in 20% of the cases. Oral antifungals were taken by 33.1% and topical creams were used by 74.2% of the patients. Direct microscopy was positive in 91.3% and culture was positive for dermatophytes in 61% of the study subjects. T. mentagrophytes was the commonest dermatophyte isolated. Irrational use of topical steroids needs to be controlled. KOH microscopy can be useful as a point of care test for rapid screening of dermatophytic infections. Culture is necessary to differentiate various dermatophytes and to guide the antifungal treatment.

Onychomycosis Treatment Prescribed at Only Twenty Percent of Visits: A Cross-Sectional Analysis of the National Ambulatory Medical Care Survey 2007 to 2016.

Onychomycosis represents the highest proportion of nail disorders seen in clinical practice. Onychomycosis management may differ amongst specialties, with impact on patient outcomes and quality of life (QoL). We aimed to characterize onychomycosis treatment across specialties, accounting for patient demographics, to assess for potential onychomycosis practice gaps. We conducted a population based cross-sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) 2007 to 2016 (the most recent years available). Overall, 71.6% of onychomycosis visits were with general practitioners (GPs), 25.8% with dermatologists, and 2.58% with pediatricians. No onychomycosis treatment was prescribed at 82.0% of dermatology visits and 78.9% of GP visits. Dermatologists (Odds Ratio (OR):2.27 [95% Confidence Interval (CI):[2.14-2.41]; P&lt;0.0001) and GPs (OR:2.32 [2.21-2.44]; P&lt;0.0001) were more likely than pediatricians to prescribe treatment vs no treatment. Dermatologists were more likely than GPs to prescribe both no treatment vs treatment and topical vs oral antifungals (OR:1.33 [1.16-1.52]; P&lt;0.0001 and OR:4.20 [3.80-4.65]; P&lt;0.0001), respectively. Our study showed that there is a low treatment rate for onychomycosis, with treatment prescribed at only 20% of visits. Untreated onychomycosis might result in secondary infection, pain, and negative QoL impact.1 Although dermatologists are specialists in nail disease management, they saw only about 25% of onychomycosis visits. Future efforts should be directed towards promoting onychomycosis therapy, and educating both patients and referring physicians that dermatologists are primary resources for nail disorder treatment.J Drugs Dermatol. 2023;22(10):1040-1045 doi:10.36849/JDD.6770.