Toenail Infection Research Articles

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

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

Effects of a Training Course for Andalusian Podiatrists on Antibiotic Management in Ingrown Toenail Infections: A Pilot Study.

The use of antibiotics (ABs) for the prevention and management of infections has been widespread for decades and, at this time, AB resistance is a global health crisis. The available evidence highlights the need to reduce the prophylactic and therapeutic use of ABs to avoid associated risks. A preliminary study with a total sample of 56 Andalusian (Spain) podiatrists was surveyed. The purpose of this study was to identify whether there were changes in prescription habits from a situation before a subsequent training course on AB indications for the management of infections associated with ingrown toenails. An ad hoc questionnaire of 15 items related to therapeutic and prophylactic prescriptions of ABs was developed for this purpose, and the evaluation was carried out before and after the training course. The responses obtained before and after training were compared. The training activity led to improvements in the prescription habits of the participants, producing significant changes in the prescription pattern of the professionals in 10 of the 15 items. The results of this preliminary study show that the podiatrists surveyed improved the rational use of systemic AB therapy in ingrown toenails infections.

Onychomycosis: Old and New.

Onychomycosis is a common chronic fungal infection of the nail that causes discoloration and/or thickening of the nail plate. Oral agents are generally preferred, except in the case of mild toenail infection limited to the distal nail plate. Terbinafine and itraconazole are the only approved oral therapies, and fluconazole is commonly utilized off-label. Cure rates with these therapies are limited, and resistance to terbinafine is starting to develop worldwide. In this review, we aim to review current oral treatment options for onychomycosis, as well as novel oral drugs that may have promising results in the treatment of onychomycosis.

Onychomycosis due to Trichophyton violaceum in HIV/AIDS patients of sub-Saharan Africa

High prevalence of HIV/AIDS in sub-Saharan Africa is responsible for very high burden of mycotic infections. Also, most of the countries here have highly burdened health system compared to their health budget. Onychomycosis is a chronic fungal infection of fingers and toenails. It is usually caused by dermatophytes, yeasts, and non-dermatophyte molds (NDM). Prevalence and severity of infection is more in immunosuppressed individuals, especially with HIV/AIDS. The laboratory diagnosis of the causative organism is very important to initiate the specific treatment. Persistence of infection can be the source of infection to the patient himself by autoinoculation and to others. The treatment of HIV/AIDS is mandatory. Onychomycosis in HIV/AIDS patients is usually due to Trichophyton rubrum and involve the toenails. The reports of onychomycosis due to dermatophytes from sub-Saharan Africa are scanty. There are only two reports, which have mentioned onychomycosis due to (T.violaceum) and involvement of fingernails in HIV/AIDS.

A Case Study of Onychomycosis Caused by Aspergillus Fumigatus

Onychomycosis is known as a nail fungal infection brought on by dermatophytes, yeast, and non-dermatophyte mold. According to epidemiological investigations, Aspergillus fumigatus has been identified as an egregious fungal cause of toenail onychomycosis. Here, we present a case of A. fumigatus-related multiple toenail infections in a 47-year-old woman in good health. The causing agent was determined to be A. fumigatus based on the culture's macroscopic and microscopic features. Keywords: Aspergillus fumigatus, toenail & Onychomycosis

Investigation on utility of some novel terpenes on transungual delivery of fluconazole for the management of onychomycosis.

Onychomycosis, the most prevailing affliction of the nail, accounts for approximately 90% of the toenail infection worldwide. Owing to this infection, the affected patients experience reduced quality of their life as its awful appearance undermines their daily activities and social interactions. Onychomycosis is notoriously strenuous to cure. Systemic therapy, though effective, possess severe complication of toxicities, contra-indication, and drug-drug interaction. Albeit topical therapy is favorable to its localized effect, its potency relates to the effective concentration of the antifungal drugs achieved at the infection site. An approach to accomplish this goal would be acquiring benefits from the terpenes as penetration enhancers from natural sources. This investigation aimed to study the effectiveness of six terpenes, namely safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, as potential penetration enhancers for improved nail permeation of fluconazole through the human nail. Ex vivo permeation experiments were carried out by soaking the nail clippings of human volunteers in control and working solutions containing fluconazole (5mg/ml) per se and fluconazole (5mg/ml) with 6% of each terpene, including safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, respectively, for 48h. The amount of fluconazole in nail clippings was quantified using an HPLC method. Statistical analysis showed that fluconazole transungual permeation was influenced by the studied terpenes in the following order: safranal >lavandulol acetate >limonene > rose oxide (p-value >0.05) while the other terpenes showed no significant difference with the control group and safranal represents as the most effective permeation enhancer for the transungual delivery of fluconazole. It is concluded that the safranal can be successfully used as a safe and potential permeation enhancer to enhance the transungual delivery of fluconazole for the treatment of onychomycosis.

Screening of Foeniculum Vulgare L, Coriandrum Sativum L, Pegnum Harmala L. and Achilleae Millefolium L Collected from Balochistan Against Fungi Causing Onychomycosis

Onychomycosis is referred to as fungal nail infection or toe nail infection generally caused by Trichophyton, Candida albicans , Microsporum and Aspergillus species. The Aim of the study was to investigate antifungal potential of four medicinal flora of Balochistan namely, Foeniculum vulgare L. , Coriandrum sativum L. , Pegnum harmala L. and Achilleae milefolium L. against causative fungal strain of nail infection. Different fractions were prepared using different solvents such as hexane, chloroform and ethyl acetate and antifungal activity was determined through agar well diffusion method against fungal strain candida albicans. For the qualitative determination of phytochemical composition different tests were carried out including tests for alkaloids, terpenoids , carbohydrates, glycosides, proteins, steroids, saponins, phenols and tannins. The highest inhibition zone were observed in aqueous 80% crude methanolic extracts of Foeniculum vulgare L. i.e 26 mm and Coriandrum sativum L. 30mm respectively. Aqeous layer of the crude extract of both plants showed potent activity that were 24 mm and 25mm for Foeniculum L. vulgare and Coriandrum sativum L.. the ethylacetet fractions showed inhibition zone 19mm and 18mm in Foeniculum vulgare L. and Coriandrum sativum L. Chloroform and hexane fractions showed least activity against fungi causing onychomycosis. An Antifungal activity highest inhibition zones were observed in aqueous 80% crude methanolic extracts of Pegnum harmala L. i.e 39 mm and Achilleae millefolium 34 mm respectively. Aqeous layer of the crude extract of both plants showed potent activity that were 32 mm for Pegnum harmala L. and 25mm for Achilleae millefolium L. The choloroform fractions showed inhibition zone 19mm in Pegnum harmala L. while 16mm in Achilleae millefolium L. Hexane and ethyl acetate fractions of Pegnum harmala L. and Achilleae millefolium L. showed least activity against fungi causing onychomycosis. Keywords: Onychomycosis , Phytochemical composition , Candida albicans, Agar well diffusion, Antifungal activity.

Images in Emergency Medicine: Acute Generalized Exanthematous Pustulosis.

A 27-year-old man presented to the emergency department with a whole-body rash for 2 weeks. The patient had been started on trimethoprim-sulfamethoxazole and terbinafine for a toenail infection 1 day before the rash began. The rash progressed over the subsequent 2 weeks, sparing his oropharynx, genital area, and conjunctiva (Figures 1 and 2). The patient reported that his rash was extremely painful. On arrival, the patient's vital signs were notable for temperature of 100.1°F and heart rate of 112 beats/min; laboratory work showed a creatinine of 1.34 mg/dL, aspartate transaminase 96 U/L, and alanine transaminase 58 U/L, up from a normal baseline.

Commercial Multiplex Polymerase Chain Reaction versus Periodic Acid-Schiff Testing for the Diagnosis of Onychomycosis.

Diagnosis of onychomycosis using the periodic acid-Schiff (PAS) test for sensitive identification of hyphae and fungal culture for identification of species has become the mainstay for many clinical practices. With the advent of polymerase chain reaction (PCR) testing, physicians can identify a fungal toenail infection quickly with the added benefit of species identification. We compared PAS testing with multiplex PCR testing from a clinical perspective. A total of 209 patients with clinically diagnosed onychomycosis were recruited. A high-resolution picture was taken of the affected hallux nail, and the nail was graded using the Onychomycosis Severity Index. A proximal sample of the affected toenail and subungual debris were obtained and split into two equal samples. One sample was sent for multiplex PCR testing and the other for PAS testing. The results were analyzed and compared. Six patients were excluded due to insufficient sample size for PCR testing. Of the remaining 203 patients, 109 (53.7%) tested positive with PAS, 77 (37.9%) tested positive with PCR. Forty-one patients tested positive with PAS but negative with PCR, and nine tested positive with PCR but negative with PAS. Physicians should continue the practice of using PAS biopsy staining for confirmation of a fungal toenail infection before using oral antifungal therapy. Because multiplex PCR allows species identification, some physicians may elect to perform both tests.

How do topical treatments compare with vehicle/placebo for curing fungal toenail infections in adults?

How do topical treatments compare with vehicle/placebo for curing fungal toenail infections in adults?

Anti-fungal activity of some native essential oils against emerging multi-drug resistant human nondermatophytic moulds

Interest in medicinal and aromatic plants as a source of anti-microbial drugs has emerged, mainly due to increased resistance in pathogenic moulds. The aims of this study were to evaluate the prevalence and factors influencing the presence of onychomycosis in immunocompromised patients as well as to assess the anti-fungal activity of Zataria multiflora, Origanum vulgare, Heracleum persicum, Rosmarinus officinalis, Pimpinella anisum, Thymus kotschyanus and Artemisia sieberi essential oils against nondermatophytic moulds. During the period of 5 years (2012–2017), a total of 379 patients with suspected onychomycosis were examined for mould etiologic agents, with mycological examinations. The minimum inhibitory concentrations (MICs) of essential oils were determined based on the Clinical and Laboratory Standards Institute (CLSI, M38-A) protocol. Among 379 subjects, onychomycosis due to moulds was confirmed in 145 cases (83 males and 62 females, aged 20–80 years). The most frequent moulds isolated were Fusarium solani (F. solani), followed by Scopulariopsis brevicaulis (S. brevicaulis), Acremonium spp., Aspergillus fumigatus (A. fumigatus), F. oxysporum, A. flavus and Cladosporium spp. All isolated moulds were sensitive to the essential oils, ranging from 20 to 530 μg/mL. The MIC values ranged from 20 to 50 μg/mL for Zataria multiflora, 20–60 μg/ml for Origanum vulgare, 40–250 μg/ml for Thymus kotschyanus, 20–340 μg/ml for Artemisia sieberi, 50–490 μg/ml for Pimpinella anisum, 85–410 μg/ml for Rosmarinus officinalis and 80–530 μg/ml for Heracleum persicum. The results confirmed the importance of nondermatophyte moulds in fungal nail and toenail infections and efficiency of the essential oils, in different ranges, against the moulds obtained from onychomycosis patients.

Diversity of phenotypically non-dermatophyte, non-Aspergillus filamentous fungi causing nail infections: importance of accurate identification and antifungal susceptibility testing

ABSTRACT Onychomycosis is most commonly caused by dermatophytes. In this study, we examined the spectrum of phenotypically non-dermatophyte and non-Aspergillus fungal isolates recovered over a 10-year period from nails of patients with onychomycosis in Hong Kong. A total of 24 non-duplicated isolates recovered from 24 patients were included. The median age of the patients was 51 years, and two-thirds of them were males. One-third and two-thirds had finger and toe nail infections respectively. Among these 24 nail isolates, 17 were confidently identified as 13 different known fungal species, using a polyphasic approach. These 13 species belonged to 11 genera and ≥9 families. For the remaining seven isolates, multilocus sequencing did not reveal their definite species identities. These seven potentially novel species belonged to four different known and three potentially novel genera of seven families. 33.3%, 41.7% and 95.8% of the 24 fungal isolates possessed minimum inhibitory concentrations of >1 µg/mL to terbinafine, itraconazole and fluconazole, respectively, the first line treatment of onychomycosis. A high diversity of moulds was associated with onychomycosis. A significant proportion of the isolates were potentially novel fungal species. To guide proper treatment, molecular identification and antifungal susceptibility testing should be performed for these uncommonly isolated fungal species.

A cohort study of risk factors, clinical presentations, and outcomes for dermatophyte, nondermatophyte, and mixed toenail infections

A cohort study of risk factors, clinical presentations, and outcomes for dermatophyte, nondermatophyte, and mixed toenail infections

Validation of the Healthy Foot Screen: A Novel Assessment Tool for Common Clinical Abnormalities.

The purpose of this learning activity is to provide information about the Healthy Foot Screen, a new tool for assessment of common foot abnormalities. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After completing this continuing education activity, you should be able to:1. Recognize prevalence, causes, risk factors, signs, and types of common foot problems.2. Identify the results of this study about the new foot screening tool and its implications in primary care. Foot health is a key component of general health and well-being. Nevertheless, feet are often overlooked by healthcare providers and patients. Common foot problems include infections or inflammatory conditions, abnormal nail disorders (eg, onychomycosis), structural bony abnormalities, circulation disorders, and other conditions. The development of an easy-to-use, rapid, clinical tool to assess foot health can facilitate primary care provider recognition and treatment of common foot problems. This study ascertained interrater item reliability and validity from the preliminary version of one such tool called the Healthy Foot Screen.A total of 18 patients from a community dermatology clinic were individually screened by 11 interprofessional healthcare assessors using the preliminary tool. The assessors included a dermatologist/internist, family physicians, nurses, and podiatrists. The initial draft of the Healthy Foot Screen was created through an extensive literature review, complemented by the clinical judgment of the study team. Cronbach α was calculated for each item to determine interrater reliability. A minimum value of 0.6 was set for an item to be included in the final tool. Where applicable, scores for each item on the screen were calculated for right and left lower limbs and then averaged. Assessors were asked to complete a short survey.Interrater reliability scores for items on the screen were as follows: diabetes and smoking, 1.0; neuropathy, 0.988; palpable foot pulse, 0.916; abnormal fourth to fifth toe web space, 0.905; previous ulcer/amputation, 0.869; pitting edema, 0.872; bony abnormality, 0.804; dry bottom of foot, 0.799; toenail infection, 0.793; other spots/lesions,0.688; and red areas/blisters/pustules, 0.659. Generally, assessors found the tool easy to use, although some areas for improvement were noted.The Healthy Foot Screen can facilitate primary care provider diagnosis and treatment of common foot problems.

Onychomycosis due to dermatophytes species in Iran: Prevalence rates, causative agents, predisposing factors and diagnosis based on microscopic morphometric findings

Onychomycosis (OM) or fungal nail infection is one of the most common fungal infections, which is increasingly prevalent. OM is caused by dermatophytes spp, yeasts and non-dermatophyte moulds (NDMs). The purpose of this study was to identify and determine the prevalence rates, predisposing factors and causative agents of OM using clinical symptoms and microscopic morphometric findings. In the present study, 180 patients suspected of OM were evaluated by direct microscopy using KOH 20%, culturing in Mycosel and Sabouraud dextrose agar media and Olysia software for identifying the causative fungi of OM. From 180 referred patients, 118 (65.56%) had OM, of whom 79 (66.94%) were positive for infection with dermatophytes spp. Of the 79 cases, the commonest age group was 61-70 years (21%) with males being 46 (58.23%) and females being 33 (41.77%). Both the fingernail and toenail infections were most prevalent in male patients. Sex, diabetes and age above 60 years were significant predisposing factors for OM development. DLSO was observed as the only clinical pattern of OM and T. rubrum was the commonest dermatophyte isolate (49.34%). This study showed that T. rubrum was the most common dermatophyte agent of OM in Iran.

Marjolin’s squamous cell carcinoma of the hallux following recurrent ingrown toenail infections

Marjolin’s squamous cell carcinoma (SCC) affecting the toe is rare. Due to resemblance with benign conditions it can often result in misdiagnosis. We report a case of Marjolin’s SCC affecting...

Cumulative arsenic exposure is associated with fungal infections: Two cohort studies based on southwestern and northeastern basins in Taiwan

Long-term arsenic exposure results in atherosclerosis and cancers, along with aberrant immune responses. Animal-based and epidemiological studies indicate that arsenic exposure increases susceptibility to viral and bacterial infections. This study aimed to assess whether arsenic exposure is associated with the development of fungal infection, which is substantially attributed to as a cause of aberrant immunity. Based on two well-established cohorts from two basins in southwestern (SW; high arsenic area) and northeastern (NE; low arsenic area) Taiwan (n=297 and 2738, respectively), the arsenic exposure in well water was estimated using HPLC-ICP-MS. Fungal infections were defined via clinical and mycological assessments (PCR of fungal 18S rRNA) of nail samples. Individuals in SW cohort with cumulative arsenic exposure >10,000μg/L∗years had a higher risk of developing fungal infections (OR=1.57, 95% CI=1.08–1.92) after adjusting for diabetes and occupation. In NE cohort, female sex, alcohol consumption, and chronic kidney diseases were associated with toenail infections. In contrast, fingernail infections (OR=1.33, 95% CI=1.05–1.68) were highly associated with arsenic exposure in a dose-dependent manner. We are the first to report palmar and plantar hyperkeratosis upon low arsenic exposure in 3.9% and 6.7% individuals, respectively. This is the first large-scale study showing arsenic exposure is associated with fungal infections in a dose-dependent manner.

준모수적 방법을 이용한 랜덤 절편 로지스틱 모형 분석

Logistic models with a random intercept are useful to analyze longitudinal binary data. Traditionally, the random intercept of the logistic model is assumed to be parametric (such as normal distribution) and is also assumed to be independent to variables. Such assumptions are very strong and restricted for application to real data. Recently, Garcia and Ma (2015) derived semiparametric efficient estimators for logistic model with a random intercept without these assumptions. Their estimator shows the consistency where we do not assume any parametric form for the random intercept. In addition, the method is computationally simple. In this paper, we apply this method to analyze toenail infection data. We compare the semiparametric estimator with maximum likelihood estimator, penalized quasi-likelihood estimator and hierarchical generalized linear estimator.

Environmental and Genetic Factors on the Development of Onychomycosis.

Since the early 20th century, onychomycosis originated with the onset of war, the use of occlusive footwear, and the mass migration of people by transportation in the United States. Even though onychomycosis has a high prevalence in the US, other parts of the world including Canada, West Africa, Southeast Asia, Northern Australia, and Europe have been well documented with cases of fungal toenail infection in their environments. Trichophyton rubrum (T. rubrum) is the major dermatophyte responsible for toenail fungal infection and is typically diagnosed in conjunction with tinea pedis, especially in individuals older than 60 years. Gender roles, age, cultural habits, shoe gear, sports activities, and genetic predisposition all contribute to the different presentation of onychomycosis in these areas where organisms like dermatophytes, candida, and molds were isolated in a variety of cases. Despite the differences in isolated pathogens, treatment outcomes remained consistent. This literature review discusses the influence of tinea pedis, genetics, shoe gear, sports, and age on the development of onychomycosis.

Aspergillus species: An emerging pathogen in onychomycosis among diabetics.

Introduction:Approximately, 33% patients with diabetes are afflicted with onychomycosis. In the past, nondermatophyte molds have been regarded as opportunistic pathogens; recently, Aspergillus species are considered as emerging pathogens of toenail infections. In Sri Lanka, the prevalence of Aspergillus species in onychomycosis among diabetics is not well documented.Objective:To determine the proportion of Aspergillus onychomycosis, risk factors and knowledge among diabetics.Materials and Methods:This was descriptive cross-sectional study. Three hundred diabetic patients were included. Clinical examinations of patients’ toenails were performed by a clinical microbiologist. Laboratory identification was done, and pathogens were identified to the species level by morpho-physiological methods. All inferential statistics were tested at P < 0.05.Results:Among clinically suspected patients, 85% (255/300) were mycologically confirmed to have onychomycosis. Aspergillus species were most commonly isolated n = 180 (71%) followed by dermatophytes, yeasts, and other molds n = 75 (29%). Of the patients having Aspergillus onychomycosis, 149 (83%) were in the > age group. In men, Aspergillus onycomycosis was seen in 82%. Among patients who had Aspergillus nail infection, 114 (63%) had diabetes for a period of > years. Among patients who were engaged in agricultural activities, 77% were confirmed to have infected nails due to Aspergillus species.Conclusion:Aspergillus niger was the most common pathogen isolated from toenail infection. Aspergillus species should be considered as an important pathogen in toenail onychomycosis in diabetic patients. Risk factors associated with Aspergillus onychomycosis were age, gender, duration of diabetes, length of exposure to fungi, and occupation.