Toenail Involvement Research Articles

Global prevalence of onychomycosis in general and special populations: An updated perspective.

Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge. To provide an updated estimate on the prevalence of toenail onychomycosis. We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients. A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture. Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.

Number of Affected Nails Is the Primary Determinant of Efinaconazole 10% Solution Usage for Onychomycosis.

Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112.    doi:10.36849/JDD.7676.

Monthly Usage of Efinaconazole 10% Solution in Two Phase 3 Randomized Trials: Is One 4-mL Bottle Enough for Proper Treatment?

Introduction: In onychomycosis management, excellent treatment adherence is necessary, and requires adequate medication supply. Efinaconazole 10% topical solution is available in 4- or 8-mL bottles; lacking published guidance, 4 mL is most often prescribed. The objective of this analysis was to use clinical data to determine monthly efinaconazole usage by patient demographics and clinical characteristics.
 Methods: In two identical, double-blind, phase 3 studies, adult participants with mild-to-moderate onychomycosis affecting 20-50% of ≥1 great (target) toenail were randomized 3:1 to once-daily treatment with efinaconazole 10% solution or vehicle for 48 weeks. Bottles of study product were weighed upon dispensation at each study visit (every 4 weeks) and upon return at the following visit. Monthly at-home efinaconazole use was analyzed post hoc based on number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex.
 Results: Efinaconazole-treated participants in both studies (n=656 and 580) had on average 3.7-3.8 affected toenails. Among those with usage data (n=1067), over 55% had ≥4 affected toenails. For the 90% of participants with ≥2 affected nails, average usage ranged from 4.39-6.36 mL/month, corresponding to 1.10-1.59 4-mL bottles; only the 10% of participants with one affected toenail used <4 mL of efinaconazole monthly. Additional subgroup analyses revealed no meaningful differences in efinaconazole usage based on target toenail involvement, BMI, or sex; average medication use was 4.69-5.29 mL/month, corresponding to 1.17-1.32 4-mL bottles monthly.
 Conclusions: Given that the 4-mL bottle of efinaconazole is most commonly prescribed, patients with onychomycosis of ≥2 toenails will likely run out of medication in under a month. This can lead to gaps in onychomycosis treatment, which may affect medication efficacy and increase likelihood of relapse or reinfection. The number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe.
 Funding: Ortho Dermatologics

BH01 Experiences of nail pathology seen within a specialist clinic over 1 year

Abstract Nail disorders comprise an important subset of dermatological conditions that can pose diagnostic and therapeutic challenges for clinicians. The pathology can be limited to the nail or reflect wider systemic processes. We present a single-centre cross-sectional study on nail conditions seen within a specialist nail clinic over a 12-month period. Demographic and clinical data were collected retrospectively using electronic patient records and analysed using a coding framework. In total, 62 new patients, including 12 paediatric patients, were seen between August 2021 and July 2022. The average patient age was 41 years. Only four patients were seen twice. In terms of ethnicity, 28 patients were White, six were Asian, two were Black and one patient was of mixed race. Ethnicity data were unavailable for 25 patients. Although most patients presented with a single pathology (76%), 24% presented with two or more pathologies. In total, 79 nail diagnoses were given for 62 patients; aetiological categories included infection (onychomycosis, infection other), inflammatory, tumour, trauma, melanonychia, congenital, structural, systemic and idiopathic. Patients had fingernail involvement alone, toenail involvement alone or involvement of both sites. The most common pathologies seen were infection (other) and infection (onychomycosis), accounting for 33% of the conditions seen; melanonychia was next most frequently observed at 18%. Onychomycosis accounts for up to 40% of all nail diseases in the UK. In our nail clinic, onychomycosis consisted of 17.7% of diagnoses. Across Europe, the overall prevalence has been reported to be 23%. In France, the prevalence of onychomycosis is reported to be 20–30% within general practice and dermatology. The true incidence is difficult to assess due to the lack of large-scale studies. We may see fewer cases in secondary care due to the podiatry service available in the UK. The availability of podiatry professionals varies across the world and we believe this plays a role in the presentation of nail diseases to physician-led clinics. Our review here did not encompass UK 2-week-wait cancer referrals, which were accommodated with our consultant as soon as possible. Patients often present to our clinic due to diagnostic uncertainty, especially regarding linear melanonychia, which generates anxiety in primary care. Secondary complications such as nail dystrophy and toenail displacement are also frequent causes for referral. This review, although single centre and retrospective, is a comprehensive snapshot of nail pathology at a UK specialist centre and demonstrates the pathologies encountered in secondary care, helping to plan future services and direct both primary care and trainee teaching.

Effect of the age of onset on epidemiology, clinical features, and comorbidity of geriatric psoriasis.

Psoriasis is an immune-mediated chronic, relapsing, inflammatory, systemic disease induced by a combination of genetics and environment. Currently, there are limited reports on the epidemiological and clinical characteristics of geriatric psoriatic patients in mainland China. This study analyzed the epidemiological characteristics, clinical features, and comorbidity rates of geriatric patients with psoriasis and evaluated the influence of age of onset on disease characteristics. This retrospective study enrolled 1259 geriatric patients with psoriasis in hospitals affiliated with the National Standardized Psoriasis Diagnosis and Treatment Center in China from September 2011 to July 2020 to analyze the epidemiological characteristics, clinical features, and prevalence of comorbidity in geriatric psoriasis. The cases were classified according to the age of onset into two groups to compare differences: early-onset psoriasis (EOP) and late-onset psoriasis (LOP). The mean age of geriatric patients with psoriasis was 67, with a 1.8:1 male-to-female ratio and 10.7% positive family history. The clinical manifestations of plaque psoriasis accounted for a high proportion (82.0%) and 85.1% of patients had moderate to severe disease. Overweight (27.8%), hypertension (18.0%), joint involvement (15.8%), diabetes (13.7%), and coronary heart disease (4.0%) were the first five common comorbidities. The LOP group had significantly more patients (79.9%) than the EOP group (20.1%). Positive family history was significantly associated with the EOP group (21.7%) than the LOP group (7.9%). The scalp (60.2%) was the most affected area, followed by the nails (25.3%), palmoplantar region (25.0%), and genitals (12.7%). This study analyzed the epidemiological and clinical characteristics of geriatric psoriasis in China and found that age of onset had no effect on disease characteristics or other comorbidities, except for toenail involvement, diabetes, and joint damage.

The Efficacy of Infrared Light Therapy in the Treatment of Onychomycosis

Objective: To study the efficacy of Infrared light therapy in treating Onychomycosis.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Department of Dermatology, Combined Military Hospital, Bahawalpur Pakistan, from Jan to Jul 2022.
 Methodology: A total of 122 patients of either gender with Onychomycosis were included in the study. Sessions with infrared light (24W Red Bulb, 660nm-850nm wavelength) were arranged once a week. The total duration of therapy consisted of four weeks in the case of fingernails and eight weeks in the case of toenails. Patients were called for follow-up at the end of the first, second, and third months after completion of treatment for efficacy evaluation.
 Results: The mean duration of complaints was 9.12±2.58 weeks, and the mean weight of patients was 84.11±8.38Kg. Male patients were 36(29.5%), and females were 86(70.5%). 98(80.3%) patients had toenail involvement, and 24(19.7%) patients had fingernail involvement. Efficacy was defined as 2/3rd (66.0%) clearance of the nail plate after 90 days of completion of treatment from the first observation at the time of presentation on visual examination. Efficacy in our study was observed in 25(20.5%) patients.
 Conclusion: Our study concluded that infrared light therapy is an effective treatment modality for Onychomycosis.

P304 Epidemiological and clinical characteristics of patients with onychomycosis caused due to Neoscytalidium spp. in two reference centers in Bogotá D.C.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjective: To describe the sociodemographic and clinical characteristics, diagnostic methods, and therapies received in patients with onychomycosis confirmed due to Neoscytalidium spp, who attended the San José Hospital and the Medical Mycology Laboratory for 1 year, in order to get a better perspective of the disease in our field, enhance its detection and increase early prevention.MethodsA descriptive cross-sectional observational study was carried out in two centers: San José Hospital and Medical Mycology Laboratory from November 2019 to November 2020; patients of all ages with a confirmed diagnosis of onychomycosis due to Neoscytalidium spp. were included. The cases were identified based on ICD-10 codes and the information was collected from the clinical history, questionnaires, clinical photographs, and additional documents.ResultsA total of 465 cases of onychomycosis were confirmed in the chosen period of time, of which 60 cases were caused due to Neoscytalidium spp. Affecting 31 women and 29 men, with an average age of 48.5 years in both sexes; 85% of these patients lived in Bogota D. C. The mean duration between the onset of the disease and its diagnosis was 3 years, 13% of the patients had a history of chronic disease including thyroid disorders, arterial hypertension, and diabetes mellitus. A total of 98% of the patients had toenail involvement, 88% had 1 to 5 nails involved, 33% of the cases showed mild nail involvement, 20% moderate, and 6% severe. Likewise, 35% of the cases presented dermatomycosis. 43% of the patients reported having received topic and systemic treatment, where there was no improvement in the major of the cases (78%).Conclusions: Our results support what is reported in the literature regarding risk factors, sociodemographic findings, and difficulty in therapeutic response to the pharmacological measures available to treat this infection; as well as the opinion of certain authors, onychomycosis caused due to non-dermatophyte mold is clinically indistinguishable from that caused by dermatophytes. Therefore, a complete mycological study (direct examination/KOH and culture) should always be performed to identify the causative agent before starting any treatment, since as our study showed, infections due to Neoscytalidium spp. are, in general frequency, the third most common cause of infection in onychomycosis and the first by non-dermatophyte molds.

Clinico–mycological correlation of onychomycosis: emphasizing the role of non-dermatophytes in a tertiary care hospital from Karnataka, India

Background: Onychomycosis is a widespread problem in the clinical practice of dermatology, caused by dermatophytes, yeasts, and non-dermatophyte molds. In India, relatively little work has been done on this problem. It is a known fact that the geographical distribution of the fungi may change from time to time. Hence, through this study, an attempt was made to identify the clinical patterns and causative agents of onychomycosis. Methods: This study was conducted on 100 clinically suspected onychomycosis patients. The necessary clinical details were noted with their consent. Nail clippings were collected from the most severely affected parts and were subjected to direct microscopy in 40% potassium hydroxide before being inoculated into Sabouraud’s dextrose agar with and without cycloheximide at 25 °C and 37 °C for up to four weeks. Growth was identified following the standard protocols by assessing the rate of growth, colony character, lactophenol cotton blue mount, slide culture, urease test, germ tube test, etc. Results: Among the 100 patients, the mean age was 40.8 years. The male/female ratio was 1.28:1. Fingernail (49%) involvement was more common than toenail involvement (32%). Distal lateral subungual onychomycosis (52%) comprised the predominant clinical pattern. KOH mount was positive in 46%, while the culture was positive in 44% of patients. The causative agents isolated were non-dermatophyte molds (63.6%), dermatophytes (18.2%), and yeasts (18.2%). Conclusion: This work shows the broad spectrum of causative agents of onychomycosis with non-dermatophyte molds as the predominant isolates.

Toenail abnormalities in rheumatoid arthritis patients are associated with radiographic damage and impact disability: a cross sectional study nested within a cohort

Cutaneous involvement is an extra-articular manifestation of rheumatoid arthritis (RA). This includes nail abnormalities, which are often overlooked. We described nail findings in RA patients currently attending an early arthritis cohort (n=145), and associated them with disease activity and/or damage, as well as patient-reported outcomes. A standardised nail examination was performed in 122 patients (84.1% of the cohort), concomitant to the rheumatic assessment. Disability, quality of life and perceived nail-related health were also assessed. Nail findings and their location were recorded and classified according to standardised definitions. Logistic and linear regression models were used to investigate predictors of nail findings and to identify the impact of toenail findings on disability, which was evaluated with the HAQ. Patients consented to participate. Patients were primarily middle-aged females, with median follow-up of 9 years, and had disease under control. Most patients (62.3%) had at least one nail finding and these patients scored lower their nail-related health. The median (IQR) of findings/abnormalities per patient was 3 (2-5) and the number of nails affected per patient was 10 (2-12). Age (OR: 1.04, 95%CI: 1.007-1.074) and erosive disease (OR: 2.26, 95%CI: 1.1-5.1) were associated with nail findings. Toenail involvement was consistently associated with HAQ score out of normal range (OR=3.4, 95%CI=1.24-9.35, p=0.02). There was a linear association between the number of toenails affected and the HAQ score. Nail abnormalities are common and heterogeneous findings in RA patients; they are associated with erosive damage and impact disability.

Revisiting pachyonychia congenita: a case-cohort study of 815 patients.

Pachyonychia congenita (PC) is a group of autosomal dominant disorders caused by mutations in one of five keratin genes (KRT6A, KRT6B, KRT6C, KRT16, KRT17). The establishment of an international registry containing clinical and molecular data led to the development of a disease classification based on the mutant gene and associated features. To harness the same resource to clarify the prevalence of PC-associated clinical features, delineate phenotype-genotype correlations and identify prognostic features for disease severity. In total, 815 individuals with confirmed keratin mutations registered in the International Pachyonychia Congenita Research Registry were surveyed for clinical findings associated with PC. Data were analysed using various statistical methods, including the Student's t-test, χ2 -test and anova tests for differences in means/proportions. Spearman correlation and logistic regression were used for phenotype-genotype correlations. KRT6A mutations were associated with oral leucokeratosis, hoarseness, youngest age or highest number of fingernails/toenails involved, and use of walking aids. KRT17 mutations were most commonly associated with cysts and natal teeth. Using logistic regression, we found that oral leucokeratosis was correlated with earlier toenail involvement, walking aids, nursing difficulties and hoarseness. Cysts were correlated with oral leucokeratosis, natal teeth and ear wax. Natal teeth predicted earlier toenail involvement, walking difficulties and cyst formation. Hoarseness was correlated with an increased number of involved fingernails. Here, we establish phenotype-genotype correlations in the largest cohort of patients with PC described to date and reveal novel and clinically useful predictors of disease course and manifestations. What's already known about this topic? Pachyonychia congenita (PC) is a group of autosomal dominant disorders caused by mutations in one of five keratin genes (KRT6A, KRT6B, KRT6C, KRT16, KRT17). The main clinical features are nail dystrophy, palmoplantar keratoderma, oral leucokeratosis and cysts. The establishment of an international registry containing the clinical and molecular data of patients with PC led to the development of a disease classification based on the mutant gene and associated features. What does this study add? Data were collected via an international registry to clarify the prevalence of PC-associated clinical features, delineate phenotype-genotype correlations and identify prognostic features for disease severity. This is the largest cohort of patients with PC described to date. The earliest clinical manifestations of PC are nail dystrophy and palmoplantar keratoderma. Diagnosis can be suspected and confirmed in preschool years. Painful plantar keratoderma has the most profound and debilitating effect on quality of life and daily function. Linked Editorial: Steele and O'Toole. Br J Dermatol 2020; 182:521-522. Linked Comment: Mordaunt. Br J Dermatol 2020; 182:537.

Linking the effect of psoriatic arthritis-related foot involvement to the Leeds Foot Impact Scale using the International Classification for Functioning, Disability and Health: a study to assess content validity

BackgroundPrevious research to describe the impact of foot involvement in psoriatic arthritis has used the Leeds Foot Impact Scale in Rheumatoid Arthritis (LFIS-RA) in the current absence of any psoriatic arthritis foot-specific tools. However, the LFIS-RA is a rheumatoid arthritis disease-specific outcome measure and its content validity for evaluating the experiences of people with psoriatic arthritis-related foot involvement is unknown. The study objective was to determine the content validity of the LFIS-RA for assessing people with psoriatic arthritis, using the International Classification of Functioning, Disability and Health (ICF) as the frame of reference.MethodConcepts within each item of the LFIS-RA were linked to the best-matched ICF categories using established linking rules, which enable a systematic and standardised linking process. All concepts were independently linked to the ICF by 2 investigators with different professional backgrounds, which included occupational therapy and podiatry. The list of ICF categories derived from previous research that pertained to the foot in psoriatic arthritis was then compared with the ICF categories linked to the LFIS-RA. The comparison was undertaken in order to determine the extent to which concepts important and relevant to people with psoriatic arthritis-related foot involvement were addressed.ResultsThirty-five distinct ICF categories were linked to the LFIS-RA, which related to body functions (44%), activities and participation (35%), environmental factors (16%) and body structure (5%). In comparison with the ICF categories derived from concepts of the foot in psoriatic arthritis previously defined, the LFIS-RA provided coverage of key constructs including pain, functioning, daily activities, footwear restrictions and psychological impact. Other concepts of importance in psoriatic arthritis such as skin and toenail involvement, self-management and paid employment were not addressed in the LFIS-RA.ConclusionContent validity of the LFIS-RA to determine the impact of foot functional impairments and disability in people with psoriatic arthritis was not supported by the results of this study. Future work should consider the development of a psoriatic arthritis foot-specific patient reported outcome measure, using the LFIS-RA as an important foundation.

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.

087 Revisiting pachyonychia congenita: a case cohort study in 815 patients

Pachyonychia congenita (PC) is a group of autosomal dominant disorders caused by mutations in one of 5 keratin genes (KRT6A, KRT6B, KRT6C, KRT16, or KRT17). The establishment of an international registry containing both clinical and molecular data led to the development of a disease classification based on the mutant gene and associated features. Here we harnessed the same resource to clarify the prevalence of PC-associated clinical features, delineate phenotype-genotype correlations and identify prognostic features for disease severity. 815 individuals with confirmed keratin mutations registered in the International Pachyonychia Congenita Research Registry (IPCRR) were surveyed for clinical findings associated with PC. Data were analyzed using Student T-test, Chi-Square, ANOVA tests (for differences in means/proportions), Spearman correlation and logistic regression (for phenotype-genotype correlation). KRT6A mutations were most common and evident in 40% of cases. Plantar keratoderma and toenail dystrophy were the most common clinical findings, with plantar keratoderma most significantly affecting patient’s quality of life. KRT6A mutations were associated with young age of onset, high number of fingernails/toenails involvement, oral leukokeratosis and hoarseness. Cysts and natal teeth were most common among patients carrying KRT17 mutations. Logistic regression models revealed that oral leukokeratosis correlated with earlier toenail involvement, walking aids use, nursing difficulties and hoarseness. Natal teeth and oral leukokeratosis were inversely correlated one relative to the other, while natal teeth and cysts positively correlated one with the other. Hoarseness predicted an increased number of involved fingernails. Our study reveals novel and clinically useful prognostic predictors in PC, and more generally demonstrates the importance of large registry-based careful studies in rare disorders.

Radio-frequency Ablation for Matricectomy in the Management of Ingrown Toenail: A Pilot Study.

Introduction:Ingrown toenail is one of the most commonly encountered nail disorders that adversely affect the quality of life. The common surgical intervention includes partial nail avulsion with chemical matricectomy but it has a relatively longer recovery period. We attempted to study the efficacy and safety of radio frequency (RF) for matricectomy.Materials and Methods:Eight patients with total 10 ingrown toenails (grade 2) were recruited. Partial nail avulsion with RF ablation of matrix was performed. The radio-frequency electrode was placed over the lateral matrix horn for the duration of 3–5s, two to three times. Patients were followed up at regular interval. Outcome was measured in terms of ooze, erythema, pain, and swelling of the lateral nail folds.Results:Of the eight patients, six were males and two were females. Total 10 nails were treated as two patients had bilateral toenail involvement. Average number of days required for postprocedural healing was 7.5 days. Significant improvement was observed in terms of erythema, pain as well as swelling within 4 days of surgery. None of the cases showed any adverse effects or relapse within 3–5 months of follow-up.Conclusion:Matricectomy by radio-frequency ablation is a safe and effective method in the management of ingrown toenail with significant reduction in downtime.

Pediatric Onychophagia: A Survey-Based Study of Prevalence, Etiologies, and Co-Morbidities.

Onychophagia, defined as habitual nail biting, is a common disorder affecting 6-45% of the population and is more prevalent in children. Our primary objective was to determine the prevalence of nail biting in the pediatric population. Secondary objectives were to assess the presence of psychiatric co-morbidities associated with nail biting, and the effect of treatment on nail biting. An anonymous voluntary survey was administered to participants at an outpatient academic pediatric clinic at Weill Cornell Medicine. Age, sex, psychiatric diagnosis, treatment sought, family history, and frequency of nail biting were analyzed across 282 enrolled patients aged 3-21years. One patient was subsequently excluded due to incomplete data. Of 281 patients, 101 (37%) reported past or present nail biting lasting more than a month. Median age of onset was 5years old (range 1-13years). A significantly higher percentage of biters (18%; 19/104) than non-biters (6%; 11/177) were diagnosed with a psychiatric disorder (p<0.01). Amongst biters, concurrent fingernail and toenail involvement was much less common (12%; 12/104) than that of fingernails alone (88%; 92/104). However, the ratio of fingernail and toenail biters to fingernail biters alone was greater in those with psychiatric diagnosis (0.36) than without (0.09) (p=0.07). Our study highlights behavioral patterns as well as familial, psychiatric, and other factors associated with pediatric nail biting. Familiarity with such factors, the clinical presentation of onychophagia, and available treatment options may aid in reducing its severity in affected patients and overall prevalence.

Coexistence of Fungal Infections in Psoriatic Nails and their Correlation with Severity of Nail Psoriasis.

Background:Nail involvement in psoriasis is often complicated by concomitant fungal infections. The aim of this study was to investigate the prevalence of fungal infections in nail psoriasis and correlate it with the severity of nail psoriasis.Materials and Methods:This retrospective study included patients with nail psoriasis aged ≥18 years with at least one fingernail and one toenail involvement who were treated at Siriraj Hospital from September 2012 to January 2014. Severity of nail psoriasis was assesed by Nail Psoriasis Area Severity Index (NAPSI) score. The nail clippings from the the least and most severely involved psoriatic fingernails and toenails were cultured to determine the presence of coexisting fungal infections and isolate the fungal species.Results:Sixty-two patients (33 males, 29 females) fulfilling the inclusion criteria were included in the study. The mean age at the time of presentation was 51.3 years mention SD. The most common nail change consistent with psoriasis was onycholysis, followed by subungual hyperkeratosis. The most commonly isolated fungi in the most severely affected fingernails were Candida spp. (41.9%) manifesting as paronychia in 5 patients (19.2%). The most commonly isolated fungi in the most severely affected toenails were nondermatophytes (NDMs) other than candida (32.3%). Dermatophytes were not detected from any of the psoriatic nails. The fungal species isolated from the most severely affected fingernails were significantly different than the isolated fungal species in the most severely affected toenails (P = 0.026). Fungal organisms were identified in 32.3% of the most severely affected fingernails and in 27.4% of the most severely affected toenails. The overall rate of isolation of fungus was significantly significantly higher in severely affected nails than in the least affected nails (P < 0.005).Conclusion:A high rate of concomitant fungal infections, especially yeasts and NDMs, was found in psoriatic nail patients. The rate of isolation of fungal species was higher in severely involved psoriatic nails than mildly involved ones. The spectrum of fungal species isolated from the the severely involved toenails and fingernails were also different from each other. These organisms may be true pathogens that cause onychomycosis or their presence may reflect colonization, contamination, or concurrent infection.

A clinicomycologic study of onychomycosis at a tertiary health-care center in Chennai

Background: Onychomycosis poses to be an important public health problem. There has been a worldwide increase in the prevalence of onychomycosis with factors such as diabetes mellitus, poor peripheral circulation, indulgence in sporting activities, and prolonged antibiotic usage playing major contributory roles. Further, management of fungal infections of nails usually requires a prolonged course with a tendency for relapse. Aim: To study the clinical, epidemiologic, and demographic profile of onychomycosis and determine various organisms responsible for the same. Methods: A cross-sectional study was done over a 1-year period, wherein after patient enrollment, a thorough clinical evaluation was performed, followed by microscopically examining the infected nail specimen under 40% potassium hydroxide, which was succeeded by cultivating the organisms on fungal culture media and identifying the pathogen both by closely studying colony morphology in culture and also microscopically utilizing lactophenol cotton blue staining. Results: Females (67.3%) were more commonly affected than males (32.7%). The most common age group affected was 20-40 years(47%). Majority of patients demonstrated both finger and toe nail involvement (43.6%). Distal and lateral subungual onychomycosis (55.4%) was the most common clinical variant of onychomycosis identified in our study. Out of the 101 patients in our study, 86 demonstrated a positive fungal growth on culture. Non-dermatophyte moulds (NDM) (58.1%) were the most common fungal isolate followed by Candida species (36%) and dermatophytes (5.8%). Conclusion: Unlike most studies, NDM constituted the major pathogen among our participants.

Aspergillus species as emerging causative agents of onychomycosis

Onychomycosis is a common nail infection caused by dermatophytes, non-dermatophyte molds (NDM), and yeasts. Aspergillus species are emerging as increasing causes of toenail onychomycosis. The purpose of this study was species delineation of Aspergillus spp. isolated from patients with onychomycosis. During a period of one year (2012-2013), nail samples were collected from patients clinically suspected of onychomycosis and subjected to microscopic examination and culture. Species identification was performed based on macro- and micro-morphology of colonies. For precise species identification, PCR-amplification and sequencing of the beta-tubulin gene followed by BLAST queries were performed where required. A total of 463/2,292 (20.2%) tested nails were diagnosed with onychomycosis. Among the positive specimens, 154 cases (33.2%) were identified as saprophytic NDM onychomycosis, 135 (29.2%) of which were attributable to Aspergillus. Aspergillus species isolated from the infected nails included Aspergillus flavus (77.3%, n=119), Aspergillus niger (n=4), Aspergillus tubingensis (n=4), Aspergillus terreus (n=3), Aspergillus sydowii (n=2), Aspergillus spp. (n=2), and Aspergillus candidus (n=1). Among the patients diagnosed with onychomycosis due to Aspergillus (average patient age, 47.4 years), 40 had fingernail and 95 toenail involvement. The large toenails were most commonly affected. This study identified a markedly high occurrence of A.flavus, and this fungus appears to be an emerging cause of saprophytic onychomycosis in Iran. The study moreover highlights the necessity of differentiating between dermatophytic and non-dermatophytic nail infections for informed decisions on appropriate therapy.

Current clinico-mycological trends of onychopathies in Casablanca

Results A total of 88 subjects were examined (45men and 43 women); the average age were 41 years old. Abnormal appearing nails were present in 48 cases. Mycologic evidence of onychomycosis were present in 42 cases. The clinical presentation of onychomycosis was: distal and lateral subungual onychomycosis (47%); white superficial onychomycosis (5%); proximal subungual onychomycosis (21%); total dystrophic onychomycosis (26%). Toenail involvement was seen in 26 patients, fingernail in 11 patients while 5 patients had involvement of both fingernail and toenail. The various aspects noted were: Xanthonychia (19 cases), pachonychia (17 cases), onycholysis (7 cases), leuconychia (6 cases) and melanonychia (4 cases). The culture has allowed the confirmation of onychomycosis in 73.3%. Among the 16 positive dermatophytes cultures, Trichophyton rubrum was isolated in 12 cultures, Trichophyton interdigitale in 3 cultures, and Trichophyton Mentagrophyte in one case. Of the 12 non-dermatophytic cultures, Candida albicans and Candida dubliensis were isolated in 4, Candida parapilosis in 2 while Trichosporon spp., and Penicillium spp. in each one.

Best treatment practices for pachyonychia congenita

Numerous therapeutic modalities have been proposed to treat the manifestations of pachyonychia congenita (PC). While research hopes lie with molecular therapies, patients are in need of answers regarding the efficacy of conventional treatments. To determine patients' experience and preferences regarding conventional treatments for PC. The study population included 120 PC patients from 20 countries. The study was based on a patient survey developed by physicians and researchers from the International Pachyonychia Congenita Consortium and conducted via the internet. Using an effectiveness scale of 1 to 5, the patients were asked to grade treatments for different manifestations, including keratoderma, cysts, follicular hyperkeratosis, fingernail and toenail involvement. Patients reported surgical treatments being most effective for cysts and mechanical treatments the most effective conventional therapeutic approach for all other investigated manifestations. The other conventional medical treatments were found to be non-effective to only slightly effective. Among patients with keratoderma, older people were more likely to report beneficial effect from mechanical treatments (P=0.04), topical retinoids (P=0.04) and topical steroids (P=0.02). Likewise, females were more inclined to report filing and grinding beneficial than males (P=0.02). Finally, carriers of KRT16 and KRT6a were more likely to benefit from keratolytics than carriers of mutations in KRT17 (P=0.04). None of the currently available therapeutic options for PC are ideal, although they provide some relief, with mechanical/surgical options being preferred over medical therapies. These results emphasize the need for more efficient and targeted therapies.