Toenail Onychomycosis Research Articles

Omparative Study Between Pulsed and Continuous Itraconazole for the Treatment of Onychomycosis

Objective: To compare efficacy of pulsed versus continuous daily oral Itraconazole in the treatment of onychomycosis. Study Design: Randomized Control Trial (ClinicalTrials.gov: NCT05567484). Place and Duration of Study: Department of Dermatology, Combined Military Hospital, Abbottabad, Pakistan, from May to Dec 2021. Methodology: We enrolled 60 patients whose toenails showed signs of onychomycosis (crumbling nail plates, thicker nail beds, and yellowing). They were randomly divided into Group-A and Group-B, with 30 patients each. Group -A (Pulse Therapy) took two capsules of oral Itraconazole 100 mg twice weekly for one week every month for three months while Group-B (Continuous Therapy) received continuous oral 100 mg of Itraconazole once daily for 12 weeks continuously. Patients were subjected to an Onychomycosis Severity Index-based clinical evaluation. Results: In Group-A (Pulse Therapy), 25(83.3%) patients showed mycological cure whereas in Group-B (Continuous Therapy), 23(76.7%) patients showed mycological cure but difference in the efficacy of both drugs was not statistically significant (p-value=0.519). Conclusion: Pulsed therapy with Itraconazole and continuous Itraconazole therapy have comparable efficacies in treating dermatophyte toenail onychomycosis.

Antifungal Activity of Tea Tree (Melaleuca alternifolia Cheel) Essential Oils against the Main Onychomycosis-Causing Dermatophytes.

Onychomycosis is a common fungal infection that affects the nails and accounts for approximately 50% of all nail diseases. The main pathogens involved include dermatophytes, such as Trichophyton rubrum, members of the T. mentagrophytes complex, and emerging pathogens in this infection, T. schoenleinii and T. tonsurans. Tea tree (Melaleuca alternifolia Cheel) essential oil (EO) has been proposed as a promising natural alternative to traditional treatments due to its antimicrobial properties. Among its more than 100 compounds, terpinen-4-ol is one of the main contributors to the antifungal action of this EO. To determine the antifungal activity of tea tree EO against dermatophytes, we designed an in vitro study using EUCAST-AFST protocols to obtain the values of MIC (minimum inhibitory concentration) and MFC (minimum fungicidal concentration) of several commercial M. alternifolia Cheel EOs against three species of dermatophytes isolated from clinical samples with suspected toenail onychomycosis. The results showed that the microorganism most sensitive to the action of the EO was T. rubrum, which had an MIC value more than 13 times lower than the value obtained for T. schoenleinii (0.4% v/v), the most resistant isolate. No differences in antifungal activity were observed by the analysed EOs or between the MIC and MFC values. These in vitro results suggest that tea tree EO is a viable option for the alternative treatment of onychomycosis, although clinical studies are needed to confirm the long-term antifungal activity, safety and efficacy of the oils studied in a clinical context.

Pediatric dermatophyte onychomycosis: a review.

Recent studies have reported an increase in pediatric onychomycosis prevalence worldwide, suggesting that this population may be increasingly affected by the infection. A summary of the epidemiological impact, antifungal treatment options, special considerations for at-risk subpopulations, and methods to prevent infection and recurrence are discussed. A systematic review of available epidemiological studies found the worldwide prevalence of culture-confirmed pediatric toenail onychomycosis to be 0.33%, with no significant increases in prevalence over time. A systematic review of studies investigating the efficacy of various antifungals in treating pediatric onychomycosis found high cure rates and low frequency of adverse events with systemic itraconazole and terbinafine; however, the studies are few, dated, and lack impact because of small sample sizes. Comparatively, clinical trials implementing FDA-approved topical antifungal treatments report slightly reduced cure rates with larger sample sizes. Patients with immunity-altering conditions, such as Down's syndrome, or those immunosuppressed because of chemotherapy or HIV/AIDS are at a greater risk of onychomycosis infection and require special consideration with treatment. Proper sanitization and hygiene practices are necessary to reduce the risk of acquiring infection. Early diagnosis and treatment of onychomycosis in children, as well as any affected close contacts, are crucial in reducing the impact of the disease.

Extended Use of Topical Efinaconazole Remains Safe and Can Provide Continuing Benefits for Dermatophyte Toenail Onychomycosis.

Efinaconazole 10% topical solution labeling for onychomycosis describes phase III trials of 12 months of treatment; the slow growth of onychomycotic nails suggests a longer treatment period may increase efficacy. We present here the first evaluation of extended use of efinaconazole 10% topical solution for up to 24 months. Enrolled patients (n = 101) had one target great toenail with mild to moderate distal lateral subungual onychomycosis and applied efinaconazole 10% topical solution to all affected toenails once daily for 18 months (EFN18) or 24 months (EFN24). Efficacy and safety were evaluated at each visit by visual review and mycology sampling. Regarding the target toenail for patients treated for 24 months (EFN24), mycological cure (negative microscopy and culture) was 66.0% at Month 12, increasing to 71.7% at Month 24; effective cure (mycological cure and ≤10% affected nail) was 13.2% at Month 12, rising to 22.6% at Month 24. Mild to moderate application site reactions (symptoms of erythema/scaling) were the only efinaconazole-related reactions, in eight patients (7.9%). No systemic efinaconazole events or drug interactions were found. Patients aged 70 years or more had similar efficacy to younger patients at all time periods and did not show any increased treatment risks. Thinner nails exhibited better clearance versus thicker nails. A higher proportion of patients with Trichophyton mentagrophytes complex infection experienced application site reactions (35.7%), and a higher effective cure was found at Month 24 versus T. rubrum patients. There is a trend of increasing mycological cure and effective cure beyond Month 12 to Month 24, without an increased safety risk. The enrolled population in this trial was significantly older than in the phase III trials, with a greater degree of onychomycosis severity; however, increased age did not appear to reduce the chance of efficacy to Month 24 in this study. Our data suggest that lack of ability to clear nail dystrophy remains a significant problem for patients, rather than any lack of efinaconazole action over long-term treatment periods.

Transungual Penetration and Antifungal Activity of Prescription and Over-the-Counter Topical Antifungals: Ex Vivo Comparison.

Topical antifungals for toenail onychomycosis must penetrate the nail to deliver an inhibitory concentration of free drug to the site of infection. In two ex vivo experiments, we tested the ability of topical antifungals to inhibit growth of Trichophyton rubrum and Trichophyton mentagrophytes, the most common causative fungi in toenail onychomycosis. Seven topical antifungals were tested: three U.S. Food and Drug Administration-approved products indicated for onychomycosis (ciclopirox 8% lacquer; efinaconazole 10% solution; tavaborole 5% solution) and four over-the-counter (OTC) products for fungal infections (tolnaftate 1% and/or undecylenic acid 25% solutions). The ability to inhibit fungal growth was tested in the presence and absence of keratin. Products were applied either to human cadaverous nails or keratin-free cellulose disks prior to placement on an agar plate (radius: 85mm) seeded with a clinical isolate of T. rubrum or T. mentagrophytes. After incubation, the zone of inhibition (ZI), defined as the radius of the area of no fungal growth, was recorded. In the nail penetration assay, average ZIs for efinaconazole (T. rubrum: 82.1mm; T. mentagrophytes: 63.8mm) were significantly greater than those for tavaborole (63.5mm; 39.1mm), ciclopirox (7.4mm; 3.6mm) and all OTC products (range: 10.5-34.2mm against both species; all P < 0.001). In the cellulose disk diffusion assay, efinaconazole and tavaborole demonstrated maximal antifungal activity against both species (ZIs = 85mm); average ZIs against T. rubrum and T. mentagrophytes were smaller for ciclopirox (59.0 and 55.7mm, respectively) and OTC products (range: 31.2-57.8mm and 25.7-47.7mm, respectively). Among all antifungals tested, the ability to penetrate human toenails to inhibit growth of both T. rubrum and T. mentagrophytes was greatest for efinaconazole, followed by tavaborole. These results indicate superior transungual penetration of efinaconazole compared to the other antifungals, suggesting lower keratin binding in the nail.

Comparison of dermoscopic characteristics on toenail onychomycosis in psoriatic and non-psoriatic patients: A prospective study.

Psoriatic patients may experience the coexistence of onychomycosis (OM). However, the evaluation of OM in psoriatics has been hindered by potential clinical differences from OM in non-psoriatics. To assess and compare dermoscopic features between toenail OM in psoriatic and in non-psoriatic patients. Between September 2020 and September 2023, dermoscopy was conducted on 183 affected toenails by OM in psoriatics and 232 affected toenails by OM in non-psoriatics in two centres. The dermoscopic characteristics were compared using the Chi-squared test. Among toenail OM cases in psoriatic subjects, the most prevalent dermoscopic features included pitting (147/183, 80.33%) and subungual hyperkeratosis (118/183, 64.48%). Conversely, toenail OM in non-psoriatics was characterized by subungual hyperkeratosis (175/232, 75.43%) and nail spikes (139/232, 59.91%). Comparative analysis revealed a significantly higher occurrence of pitting (80.33% vs. 15.96%, p < .001), periungual telangiectasis (22.40% vs. 4.74%, p < .001), oil patches (12.57% vs. 0.43%,p < .001) and transverse grooves (43.72% vs. 28.45%,p < .01) in toenail OM in psoriatics. Furthermore, toenail OM in psoriatics exhibited a significantly lower frequency of yellow structureless area (13.11% vs. 42.67%, p < .001), nail spikes (43.17% vs. 59.91%, p < .01), ruin appearance of sulphur nugget (8.20% vs. 31.03%, p < .001), dotted/blocky haemorrhage (6.01% vs. 20.69%,p < .001) and partial onycholysis (32.79% vs. 46.98%, p < .01). Dermoscopic features of toenail OM in psoriatic and non-psoriatic patients exhibit notable differences. OM in psoriatics shows a higher frequency of pitting and periungual telangiectasis, while a lower frequency of yellow structureless areas and nail spikes under dermoscopy.

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.

Concealing Meets Healing in the Treatment of Toenail Onychomycosis: A Review of Concurrent Nail Polish Use With Topical Efinaconazole 10% Solution

Introduction: Females are more likely than males to seek help or treatment for onychomycosis and are more likely to camouflage affected nails with nail polish. Between 2016 and 2022, over half of prescriptions for topical efinaconazole 10% solution were written for females, suggesting that there may be particular interest in the interaction between nail polish use concurrent with efinaconazole treatment for onychomycosis.&#x0D; Methods: Review in vitro data on effects of nail polish on nail penetration of efinaconazole 10% solution and clinical studies on the impact of nail polish use on efficacy of topical efinaconazole in the treatment of toenail onychomycosis.&#x0D; Results: Only 4 small studies have assessed interactions between efinaconazole 10% solution and concurrent nail polish use. In vitro, penetration of efinaconazole 10% solution through cadaverous human nails coated with traditional nail polish was similar to penetration through uncoated nails. In a 1-year clinical study, once-daily efinaconazole treatment for 48 weeks was associated with improvements in onychomycosis severity and clear toenail growth that were similar for participants who used traditional nail polish and those who did not use nail polish. In a second, 6-month clinical study, participants received once-daily efinaconazole treatment concurrent with monthly gel nail polish pedicures. After 6 months, 100% of participants tested negative for fungal infection (mycological cure) and all participants experienced visible improvements in their treated toenails. In clinical and in vitro studies, efinaconazole application was associated with degradation of traditional nail polish texture and appearance as well as color transfer to the applicator and unused medication. In contrast, efinaconazole did not affect the duration, quality, or texture of gel nail polish.&#x0D; Conclusions: Application of nail polish did not prevent penetration of efinaconazole 10% solution through human nails or its successful use in the treatment of toenail onychomycosis. Further, efinaconazole did not impact the texture or appearance of gel-polished nails. To our knowledge, these findings represent the only available data on topical treatment of toenail onychomycosis with concurrent nail polish use, and may be of particular importance when selecting treatment options for female patients with onychomycosis.&#x0D; Funding: Ortho Dermatologics

Toenail Onychomycosis with or without Diabetes in Canada: Patient Treatment Preferences and Health State Utilities.

Toenail onychomycosis affects approximately 6.7% of Canadians. Symptoms include nail discolouration/disfiguration and pain; psychosocial impacts contribute to reduced health-related quality-of-life. Comorbid diabetes increases the risk of complications and exacerbates burden. Treatment may include topical therapy and/or oral agents. To understand toenail onychomycosis treatment preferences, and to quantify the impact of toenail onychomycosis, with or without diabetes, on patient well-being. Adults living in Canada with self-reported, physician-diagnosed, toenail onychomycosis were recruited online. A discrete choice experiment was used to quantify treatment preferences. Scenarios were randomized; data were analyzed using conditional logit regression. Health state utilities were estimated using the Health Utilities Index Mark 3®. Results were stratified by diabetes status and toenail onychomycosis severity; the Wilcoxon Rank Sum test was used to assess between-group utility differences. Three-hundred thirteen participants with toenail onychomycosis were included (161 had comorbid diabetes; 61.3%, severe onychomycosis). The mean age was 57.7 years; 55.9% were male. Treatment attributes with statistically significant impacts on patient preferences were efficacy (odds ratio [OR],1.04; 95% confidence interval [CI], 1.02-1.05 per 1% increased treatment success), administration method (one pill versus topical nail lacquer reference, 1.14; 1.04-1.26; topical solution applicator versus reference: 1.15; 1.03-1.29), severe adverse events (0.85; 0.80-0.90 per 1% increased risk), and risk of potential pharmacodynamic (0.80; 0.76-0.85) and alcohol (0.93; 0.88-0.98) interactions; preferences were more pronounced for efficacy and avoiding severe adverse events among toenail onychomycosis patients with comorbid diabetes. The mean (95% CI) utility value was 0.73 (0.70-0.75) overall, and statistically significantly lower (p=0.02) for toenail onychomycosis patients with diabetes (0.70; CI, 0.66-0.73) than those without (0.76; CI, 0.72-0.79). Among patients with toenail onychomycosis, the presence of diabetes was associated with differing treatment-related preferences. Utility values for patients with toenail onychomycosis represent a significant decline from full health that is exacerbated by comorbid diabetes.

Prevalence and Associated Factors of Toenail Onychomycosis Among Patients with Diabetes in Jordan.

Toenail onychomycosis is common in patients with diabetes and it can increase the risk of secondary infections and foot complications. Despite several studies investigating the prevalence and associated factors of toenail onychomycosis from different parts of the world, there are no data from Jordan. To determine the prevalence and the associated factors of toenail onychomycosis among patients with diabetes in Jordan. A cross-sectional study was conducted on 375 patients with diabetes at the National Centre for Diabetes, Endocrinology, and Genetics in Amman, Jordan. Several socio-demographic and health-independent variables including foot self-care practices were collected. Toenail onychomycosis was assessed by a specimen culture and microscopic examinations. Descriptive and inferential statistics were used for data analysis. The prevalence of toenail onychomycosis was 57.6% (n=216). Multiple logistic regression revealed four significant associated factors; the presence of neuropathy (β=1.87, p=0.02), being an ex-smoker (β=2.69, p=0.01), being treated by both insulin and oral hypoglycemics drugs (β=1.32, p=0.03), and using antibiotics in the last year (β=1.78, p=0.02). The prevalence of toenail onychomycosis among patients with diabetes in Jordan is high. Regular foot screening and podiatric care are recommended especially among patients with diabetic neuropathy, current treatment by insulin and oral hypoglycemics drugs, previous history of smoking, and previous use of antibiotics.

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.

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, &gt;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.&nbsp; &nbsp; doi:10.36849/JDD.7676.

Natural Remedies for Onychomycosis: A Review

Onychomycosis, a fungus that causes nail colouring, nail separation, and nail plate growth, has infected the nail unit. There is a chance that the nail structure, nail bed, or nail layer could be infected. The term “onychomycosis” derives from the Greek words “onyx” (nail) and “mykes” (fungus). Around 50% of all consultations for nail diseases are for onychomycosis, the most common nail infection disorder. About 90% of toenail onychomycosis and 75% of fingernail onychomycosis are caused by dermophytes like Trichophyton rubrum and Trichophyton mentagrophytes. About 70% of yeast-borne onychomycosis cases are caused by Candida albicans. Epidemiological studies that have just been released estimate that onychomycosis affects every community worldwide at a rate of about 5.5 per cent. Onychomycosis is managed in different ways based on clinical categorization, the number of damaged nails, and the severity of the condition. The disadvantages of treatment are that oral therapies are frequently limited by drug interactions and probable hepatotoxicity, and topical antifungals have low efficacy if administered without nail plate biosurgery. The use of plants in medical treatments and herbal therapies is one of the less harmful, cheaper, and widely available alternatives to synthetic pharmaceuticals for treating fungal infections. Undoubtedly, dermatophytes can be inhibited by plant-based extracts as well as essential oils’ antifungal activities.

Clinical picture, causative agents and diagnostics of dermatomycoses

Dermatomycoses affect free skin, hairy scalp, fingernails and toenails. In addition, oral mucosa and genital mucosa can also be affected by fungal infections. The most common pathogens causing skin fungal infections are dermatophytes. They are responsible for, among others, tinea corporis, tinea capitis and onychomycosis (tinea unguium). Mainly anthropophilic dermatophytes are found as pathogens. In the case of tinea capitis-at least in Europe and in German-speaking countries-zoophilic skin fungi must also be considered. Rarely, geophilic dermatophytes can also be isolated. Yeast infections of the skin, mostly caused by Candida albicans, primarily affect the intertriginous skin areas, for example, the groin region, but also the submammary area and the spaces between the fingers and toes. Elderly patients are often affected, but also infants and, in particular, immunocompromised patients. These patient groups are also more frequently affected by oral mucosal infections caused by Candida albicans and other Candida species. Pseudomembranous candidiasis of the oral mucosa and tongue typically affects patients with HIV/AIDS. Mold infections in dermatology are relevant in onychomycosis of the big toenail. The causative agent is usually Scopulariopsis brevicaulis. Cutaneous mold infections are rare and only occur in immunocompromised patients. The mycological diagnosis of dermatomycoses is based on the microscopic, if possible fluorescence-optical detection of fungal hyphae and spores from skin scales, nail shavings and hair roots. The culture detection of dermatophytes, yeasts and molds allows the identification of the causative fungal species, but often fails, especially in patients who have already been treated with antifungal agents. In view of the high sensitivity and specificity of the molecular methods for fungal detection compared to culture, polymerase chain reaction (PCR) must realistically be regarded as the gold standard for dermatophytosis diagnostics. However, it should not be neglected that the three pillars of diagnostics-preparation, culture, PCR-currently deliver the best results.

Medium-term antifungal effects of methylene blue versus flavin mononucleotide in the treatment of moderate toenail onychomycosis.

Methylene blue (MB) and flavin mononucleotide (FMN)-mediated photodynamic therapy (PDT) have demonstrated local antimicrobial effect, but no direct comparative study has been published so far for the treatment of toenail onychomycosis. To directly compare the short and medium-term efficacy of MB versus FMN as photosensitizers in PDT for toenail onychomycosis by applying them in a 40% w/w urea cream in two different dye concentrations. Forty toenails with distal and lateral subungual moderate onychomycosis due to dermatophyte fungi were randomised to receive 10 weekly sessions of PDT mediated by four topical formulations including MB or FMN at two different concentrations: Group I: 0.1% w/w MB; Group II: 2% w/w MB; Group III: 0.1% w/w FMN; and Group IV: 2% w/w FMN. Photographs were used for onychomycosis severity index (OSI) estimation allowing clinical assessment at any point of the study. Microscopic and microbiological evaluations were carried out at baseline, 27- and 35-week follow-ups. Side effects were recorded along with patient satisfaction. At week 27, mycological cure rates were 60%, 30%, 50% and 40% and complete cure rates were 0%, 20%, 10% and 20%, for Groups I, II, III and IV respectively. At week 35, mycological cure rates were 70%, 70%, 70% and 60% and complete cure rates were 30%, 50%, 70% and 30%, for Groups I, II, III and IV respectively. All cream formulations were safe and patients were fairly satisfied. Results of the present work confirm PDT as a therapeutic alternative for onychomycosis. Although all cream formulations were safe and effective, with a good degree of satisfaction, higher cure rates were obtained with 2% w/w MB cream and 0.1% w/w FMN cream.

Comparing the Efficacy for Pulse Versus Continuous Dose Terbinafine Therapy in Patients With Onychomycosis.

Recently, treatment outcomes in patients with toenail onychomycosis have improved considerably due to more effective oral antifungal medications such as terbinafine and itraconazole. These medications can either be used continuously for several weeks at a lower dose or intermittently (pulsed) at a higher dose. Previous literature comparing pulse and continuous therapy has generated mixed results.&nbsp; Our study aims to compare the efficacy, in terms of clinical cure rate, of continuous vs pulse dose terbinafine regimens for toenail onychomycosis. Sixty patients with onychomycosis of Fitzpatrick skin types IV to VI, between 15 and 65 years of age, were divided into a continuous treatment group receiving 250 mg terbinafine once daily for 12 weeks and a pulse treatment group receiving 250 mg twice daily terbinafine for 1 week repeated every 4 weeks for 12 weeks. Each patient was followed up at weeks 4, 8, and 12.&nbsp; Efficacy of the continuous treatment group was significantly greater at 76.67% compared with 26.67% in the pulse treatment group. Thus, we conclude that the clinical cure rate of a continuous dose regimen of terbinafine is a superior treatment option for toenail onychomycosis. However, we also suggest further studies including combinations of multiple agents and hybrid regimen models for the optimal onychomycosis treatment.&nbsp;&nbsp; J Drugs Dermatol. 2023;22(10):&nbsp; &nbsp; &nbsp;doi:10.36849/JDD.7323R1.

Individual Article: Updated Review of Topical Pharmaceuticals and Complementary and Alternative Medications for the Treatment of Onychomycosis in Both General and Special Populations in the United States.

Onychomycosis is a prevalent condition affecting the United States and global population. Treatment options are limited, with only 3 topical anti-fungal medications garnering approval in the US within the last 25 years: ciclopirox, tavaborole, and efinaconazole. The economic impact and quality of life burden due to onychomycosis are high. Here we provide an up-to-date review of all approved topical anti-fungal therapies for toenail onychomycosis. We discuss treatment efficacies, pharmacology, and use in special populations, as well as current evidence for complementary and alternative medicine.&nbsp; J Drugs Dermatol. 2023;22:9(Suppl 1):s5-10.

Prevalence of Non-Dermatophytic Molds in Toenails among Diabetic Patients in Homs, Syria

Diabetes Mellitus (DM) is a risk factor for fungal infections, including onychomycosis. The study aims to determine the prevalence of toenail onychomycosis in diabetic patients and its correlation with associated factors, identify the causative agents and compare the fungal culture findings with the real-time polymerase chain reaction (RT-PCR) findings of diagnosing 6 fungal isolates. A total of 126 diabetic patients were included between November 2020 to June 2021. Nail samples were subjected to potassium hydroxide 20%. Culture was done on Sabouraud dextrose agar medium (SDA), both with and without cycloheximide. Identification of non-dermatophytic molds was based on colony characteristics, colony reverse, cello-tape flag method and slide culture technique. Molecular analysis was done to make sure of the identification of 6 fungal isolates. Out of 126 cases, 106 (84.1%) had toenails onychomycosis. Non-dermatophytic molds (NDM) were the most common isolates 75 (70.8%), followed by yeasts 8 (7.5%) and mixed infections 23 (21.7%). Distal lateral subungual onychomycosis (DLSO) was the most frequent clinical type 90 (85%). Onychomycosis was found to correlate significantly with advancing age, type 2 diabetes, its duration and clinically abnormal nails. However, there was no significant correlation with gender and glycosylated hemoglobin (HbA1C). When the results obtained by RT-PCR were compared with the results obtained by fungal culture, a 100% match of the isolates was found.

Review of treatments for toenail onychomycosis caused by dermatophytes.

Review of treatments for toenail onychomycosis caused by dermatophytes.

A Retrospective Study on Toenail Onychomycosis: Efficacy of Combination Therapy and Correlating Factors to Washout Time

Onychomycosis in the toenail is a common fungal infection. Moderate to severe onychomycosis, especially, may persist chronically with a considerable recurrence rate that can be a challenge for management. Oral antifungal therapy is the current gold standard to treat for moderate to severe toenail onychomycosis. However, there are alternative combination modalities including topical agents and/or procedural modalities that are emerging because of potential adverse effects of oral antifungals and to prevent recurrence. In this study, oral terbinafine with debridement combination therapy had the shortest washout time. Factors that were related to longer washout times were female sex, extreme body mass index, and diabetes.