Nails (Onychomycosis): Clinical Aspects
Raimo E Suhonen, Rodney P R Dawber, David H Ellis in Fungal Infections of the Skin, Hair and Nails, 2020
In distal and lateral subungual onychomycosis—the most common route of invasion—dermatophytes reach the nail bed via the hyponychium. The distal nail bed reacts to dermatophyte invasion by becoming somewhat inflamed and hyperkeratotic. In proximal subungual onychomycosis, dermatophytes breach the nail matrix keratogenous zone through the proximal nail-fold horny layer. In white superficial onychomycosis, the dermatophytes invade the most superficial layers of the nail plate but do not penetrate it. Gross colony morphology and microscopic examination of the mycelia stained with lactophenol cotton blue permit the identification of the commonest causative dermatophytes. The isolation of dermatophytes from the nails may be difficult as the fungi may be scarcely viable and will not grow in cultures. Examination of material taken from associated skin lesions is advisable since these usually demonstrate profuse dermatophyte growth. Primary nail-plate invasion by Candida albicans is extremely rare in the absence of immunosuppression.
Hair and Nail Manifestations of HIV Infection
Clay J. Cockerell, Antoanella Calame in Cutaneous Manifestations of HIV Disease, 2012
Infection with human immunodeficiency virus (HIV) may result in a variety of hair and nail changes, some of which may be the initial manifestation of the disease. Telogen effluvium, which presents as an acute to subacute diffuse noninflammatory alopecia, is the most common type of HIV-related hair loss. Hair straightening is a characteristic sign of HIV infection, especially in black patients. Onychomycosis is often a sign of HIV disease progression in an otherwise asymptomatic individual. Onychomycosis is most commonly caused by Trichophyton rubrum in both HIV-infected and non-infected individuals. The most common organism causing WSO is T. rubrum in HIV-infected patients and T. mentagrophytes in non-HIV-infected individuals. The antimicrobial susceptibility of organisms causing onychomycosis in HIV-infected patients appears to be the same as that in non-HIV-infected patients; therefore, treatment does not change based on HIV status. In the non-HIV-infected population chronic paronychia is usually caused by contact irritants or repeated exposure to water.
Onychomycosis
Dimitris Rigopoulos, Chander Grover, Eckart Haneke in Nail Therapies, 2021
A revised new classification has been proposed in order to modify the basic model and to include subsequent changes such as the following subtypes of fungal nail plate invasion ( Figure 3.1 ). The purpose of the revised classification is to provide a framework to assist selection of treatment, estimate prognosis, and evaluate new diagnostic methods. Distal and lateral subungual onychomycosis (DLSO) This is the most common clinical presentation of onychomycosis. It is often a consequence of tinea pedis and is primarily caused by T. rubrum . It may be associated with four major clinical features whose contribution may vary with individual cases. Subungual hyperkeratosis ( Figure 3.2 ) Onycholysis ( Figure 3.3 ) Paronychia ( Figure 3.4 ) Chromonychia particularly melanonychia ( Figure 3.5 ) Proximal subungual onychomycosis (PSO) This is a rare type of onychomycosis, which may occur equally as often in the toenails as in the fingernails. It is mostly caused by T. rubrum and is most common in patients with acquired immunodeficiency syndrome (AIDS). With paronychia So-called Candida paronychia ( Figure 3.6 ). Either as a commensal or from the colonization of a previous paronychia. True Candida paronychia (very rare), is usually observed in Chronic mucocutaneous candidosis (CMCC) or HIV-positive subjects. Nondermatophyte mold paronychia, sometimes associated with leukonychia (e.g., Fusarium) ( Figure 3.7 ). Dermatophyte infection (exceptional). Without paronychia We call this type PSO. There are three variants of dermatophytic infection: Classical PSO ( Figure 3.8 ) Proximal transverse subungual onychomycosis (PTSO) presents as a PSO with atypical patterns: striate leuconychia as isolated or multiple ( Figure 3.9 ). Transverse subungual white strips, separated by areas of nail that are both clinically and histologically normal, affecting the same digit. Proximal to distal longitudinal leukonychia affecting a single digit is exceptional. Acute PSO: A rapidly developing form of PSO is recorded in patients with human immunodeficiency virus, who usually have a CD4+ cell count of less than 450 cells/mm 3 . This acute type of nail invasion involves several digits simultaneously ( Figure 3.10 ). 18 Candida PSO has been reported in chronic mucocutaneous candidiasis (CMC). Another combination pattern is seen in AIDS patients, where PSO and SO may develop at the same time and spread rapidly to involve the nail plate (see 3.6.2). Superficial onychomycosis (SO) This type occurs primarily in the toenails and is usually caused by T. mentagrophytes (90% of cases). Classical SO type restricted to the visible NP ( Figure 3.11 ). (There is a black variant) SO from under PNF ( Figure 3.12 ) Acute SO ( Figure 3.13 ) Superficial white transverse onychomycosis (STO) ( Figure 3.14 ) SO with deep invasion ( Figure 3.15 ) Mixed forms with three variants: SO associated with DLSO SO associated with PSO SO associated with histologically restricted involvement of the ventral aspect of the NP (bipolar type) Endonyx onychomycosis (due to Trichophyton soudanense but this fungus also causes other forms of onychomycosis) ( Figure 3.16 ). The infection penetrates the nail keratin instead of infecting the nail bed. It is most often caused by T. soudanense and T. violaceum, which have high affinity for keratin. Total dystrophic onychomycosis (TDO) Secondary TDO to other forms ( Figure 3.17 ) It is the complete progression of any of the above mentioned clinical patterns of onychomycosis. Primary TDO (CMC) ( Figure 3.18 ). It only occurs in immunocompromised patients.
Fractional carbon dioxide laser assisted delivery of topical tazarotene versus topical tioconazole in the treatment of onychomycosis
Published in Journal of Dermatological Treatment, 2019
Essam Bakr Abd El-Aal, Hamed Mohamed Abdo, Shady Mahmoud Ibrahim, Mostafa Taha Eldestawy
Background: Onychomycosis is a chronic fungal infection of the nails, and the treatment has been proven to be a challenge to healthcare professionals. Objective: To evaluate the efficacy of fractional carbon dioxide laser-assisted delivery of topical tazarotene versus topical tioconazole in the treatment of onychomycosis. Materials and Methods: A total of 102 patients with onychomycosis were randomly assigned to groups A and B, and both groups were treated with four sessions of fractional CO2 laser and followed by topical tazarotene 0.1% in Group A and topical tioconazole 28% in Group B. The clinical effect, KOH examination, and culture for the affected nails in the two groups were analyzed. Results: One month after the last session, regarding clinical response, 35.3% showed complete improvement in Group A versus 33.3% in Group B without significant difference. There was a significant difference between the two studied groups as regards KOH test and culture result before and after treatment (p value
Efinaconazole (Jublia) for the treatment of onychomycosis
Published in Expert Review of Anti-infective Therapy, 2014
Aditya K Gupta, Fiona C Simpson
Efinaconazole 10% nail solution (Jublia®) is a new topical triazole antifungal designed for the topical treatment of distal and lateral subungual onychomycosis. It inhibits ergosterol biosynthesis enzyme sterol 14α-demethylase. Efinaconazole has lower minimum inhibitory concentrations than terbinafine, ciclopirox, itraconazole and amorolfine in Trichophyton rubrum, Trichophyton mentagrophytes and Candida albicans. The solution based formula has low surface tension and keratin binding properties that increase penetrance through the nail plate. Safety studies have shown that this formulation is not associated with atopic dermatitis or contact sensitivity. Duplicate Phase III clinical trials in adults with mild to moderate distal and lateral subungual onychomycosis indicate that efinaconazole 10% solution is an effective therapy with a pooled complete cure rate of 17% and a pooled mycological cure rate of 54%. Efinaconazole 10% nail solution is a safe and effective new topical therapy for onychomycosis, which will fill a pressing need for more effective topical therapy in this disease.
Efinaconazole 10% topical solution for the topical treatment of onychomycosis of the toenail
Published in Expert Review of Clinical Pharmacology, 2015
Shari R Lipner, Richard K Scher
Efinaconazole 10% topical solution is a new antifungal therapy for the topical treatment of mild to moderate toenail onychomycosis. In vitro and in vivo data have shown significant antifungal activity against dermatophytes, Candida spp. and nondermatophyte molds, and its mechanism of action is through inhibition of fungal lanosterol 14α-demethylase. In two parallel, double-blind, randomized, controlled, Phase III trials, complete cure rates were 17.8 and 15.2%, respectively, and mycological cure rates were 55.2 and 53.4%, respectively, for efinaconazole 10% topical solution, which were superior to vehicle, with minimal adverse events. This drug profile reviews the most recent basic science and clinical data for efinaconazole in the treatment of toenail onychomycosis.
Related Knowledge Centers
- Epidermophyton
- Trichophyton
- Yeasts
- Tinea
- Nail Diseases
- Dermatophytes
- Molds