Onychomycosis: Diagnosis and management.

Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Increased prevalence in the recent years is attributed to enhanced longevity, comorbid conditions such as diabetes, avid sports participation, and emergence of HIV. Dermatophytes are the most commonly implicated etiologic agents, particularly Trichophyton rubrum and Trichophyton mentagrophytes var. interdigitale, followed by Candida species and non dermatophytic molds (NDMs). Several clinical variants have been recognized. Candida onychomycosis affects fingernails more often and is accompanied by paronychia. NDM molds should be suspected in patients with history of trauma and associated periungual inflammation. Diagnosis is primarily based upon KOH examination, culture and histopathological examinations of nail clippings and nail biopsy. Adequate and appropriate sample collection is vital to pinpoint the exact etiological fungus. Various improvisations have been adopted to improve the fungal isolation. Culture is the gold standard, while histopathology is often performed to diagnose and differentiate onychomycosis from other nail disorders such as psoriasis and lichen planus. Though rarely used, DNA-based methods are effective for identifying mixed infections and quantification of fungal load. Various treatment modalities including topical, systemic and surgical have been used.Topically, drugs (ciclopirox and amorolfine nail lacquers) are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include terbinafine, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis. Despite good therapeutic response to newer modalities, long-term outcome is unsatisfactory due to therapeutic failure, relapse, and reinfection. To combat the poor response, newer strategies such as combination, sequential, and supplementary therapies have been suggested. In the end, treatment of special populations such as diabetic, elderly, and children is outlined.

The Efficacy of Electric Nail Grinding with Nail Lacquer in the Treatment of Onychomycosis / 대한피부과학회지

BACKGROUND: There is a need for additional effective treatments for onychomycosis. Aggressive debridement has been explored as a therapeutic option for onychomycosis, but rigorously designed studies in this area have been limited. OBJECTIVE: We sought to examine the efficacy of the nail grinder and nail lacquer in the treatment of onychomycosis. We planned the study to determine whether adding aggressive nail grinding to nail lacquer for treating toenail onychomycosis improves the efficacy. METHODS: To provide better delivery of drug to bed and nail plate, we trimmed with electric nail grinder (KHP 3000 Frees(R), Germany), and then applied nail lacquer (Amorolfine HCl, Loceryl(R), Galderma korea). Clinical photo was taken for infected area evaluation. The phototrichogram system (Folliscope, LeadM Corporation, Seoul, Korea) was used for the computer-aided evaluation of the nail plate thickness. RESULTS: Aggressive debridement of infected nail with electric nail grinder made an improvement over the duration of the treatment with nail lacquer. CONCLUSION: Aggressive debridement with an electric nail grinder is likely to be more effective than with a nail file. Electric nail grinder could be adopted as the treatment of onychomycosis. The potential for synergism of electric nail grinder with topical antifungal agent is expected.

Two Cases of Onychomycosis Treated with Electric Nail Grinder and Nail Lacquer / 대한의진균학회지

rue fungal infection of the nail plate is known as onychomycosis. Systemic therapy of onychomycosis is more likely to be effetive than topical treatment. However, the potential for adverse reactions and for interaction with the metabolism of other medication can preclude their use. Furthermore, some people do not want to take oral medicine for treatment of onychomycosis. Because of this, the prospect of effective topical therapy is a welcome alternative. To provide better delivery of drug to bed and nail plate, we trimmed with electric nail grinder (KHP 3000 Frees(R), Germany), and then applied nail lacquer (Amorolfine HCl, Loceryl(R), Galderma korea). The potential for synergism of electric nail grinder with topical antifungal agent is expected.

Experience of Combination Treatment of Toenail Onychomycosis with Oral Itraconazole and Topical 5% Amorolfine Nail Lacquer / 대한의진균학회지

BACKGROUND: Target of oral itraconazole is nail matrix via nail bed diffusion. On the contrary, topical amorolfine directly acts on nail plate through a transungual drug delivery system. When this combination treatment of oral itraconazole and topical amorolfine nail lacquer is applied for onychomycosis, we may expect their synergistic effects. OBJECTIVE: We will discuss our clinical experiences of 78 patients in Chung Ang University hospital about combination treatment of onychomycosis with oral itraconazole and topical 5% amorolfine nail lacquer. METHODS: We treated 135 toenail onychomycosis patients (M/F=79/56) from January 2001 to April 2004. But, among 135 patients, we analyzed only 78 (57.8%) patients (M/F=46/32) treated by combination treatments composed of twice weekly application of topical 5% amorolfine nail lacquer and 3 pulse therapy of oral itraconazole. Efficacies of treatment are composed of clinical cure based on decrement of affected nail area by digital camera recording and mycological cure based on KOH exam, and fungus cultures on after 6 months. RESULTS: Distribution of patients by clinical types is as follows; distal subungual onychomycosis (DSO) : 68 patients (87.2%), whitish superficial onychomycosis (WSO) : 4 patients (5.1%), and total dystrophic onychomycosis (TDO) : 6 patients (7.7%). Reduction rates of affected area by clinical types are DSO: 85.1%, WSO: 83.1%, and TDO: 70.3%. Isolated strains from the fungal culture are T. rubrum: 67 (85.9%), T. mentagrophytes: 5 (6.4%), and Candida spp.: 6 (7.7%). Reduction rate of affected nail area (75.0%) in patients with diabetes mellitus is significantly reduced comparing with that (80.8%) of patients without associated disease. The total reduced rate of affected nail area and cure rate are 81.5%, and 57.4% respectively. CONCLUSION: Oral itraconazole and topical amorolfine nail lacquer combination therapy will be a promising treatment modality for onychomycosis.

Effects of Nail Lacquer on Transonychial Water Loss / 대한피부과학회지

BACKGROUND: Nail lacquer strengthens and protects the nail plate by preventing excess loss of moisture and providing a hard surface. On the other hand, it may produce allergic contact and irritant dermatitis, paronychial and nail bed inflammation and infection, dystrophic nails and onycholysis. OBJECTIVE: The purpose of study was to investigate the effect of the nail lacquer on the barrier function of the nail. METHODS: The study populatian consisted of 25 healthy young subjects who had not applied the nail lacquer to the nail for the last 3 months. Nail lacquer was applied to the left thumb and middle fingernail for 6 weeks and then removed by acetone. Transonychial water loss(TOWL) of the treated left fingernails and the untreated corresponding right fingernails was measured with an Evaporimeter. Lipids of the nails were extracted from distal nail cuttings and analysed by thin layer chromatography. RESULTS: 1. Before application of the nail lacquer, there was no difference in TOWL between the left and right fingernails while the TOWL of the thumb nail was higher than that of the middle fingernail with a statistical significance(p<0.05). 2. The TOWL of the left fingernails, measured 1 day, 2, 4 and 6 weeks after application of the nail lacquer, was lower than that of the untreated right fingernails with a statistical significance( p< 0.05). 3. The TOWL of the left fingernails, measured 1, 3 and 7 days after removal of the nail lacquer by acetone, was not different statistically from that of the untreated right fingernails. 4. Lipid analysis demonstratcd that the cholesterol content was higher in the left fingernail which had been covered with nail lacquer than in the untreated right fingernail. 5. There was no clinical adverse effect observed during application of the nail lacquer or after removal of it. CONCLUSION: According to the results of the study, nail lacquer has some occlusive effects on transonychial water evaporatior . Because increased cholesterol content may be due to perturbations of barrier function , further studies of the effect of the nail lacquer on the barrier function of the nail will be needed.

Therapeutic Efficacy of Ciclopirox Nail Lacquer in the Treatment of Onychomycoses / 대한피부과학회지

BACKGROUND: Ciclopirox 8% nail lacquer is a new topical antifungal agent which is character ized by excellent penetration into the nail plate to the infected koratin and remains there for a prolonged period. We per formed a st,udy to assess the therapeutic efficacy and safety of ciclopirox 8% nail lacquer in the treatment of onychomycoses. METHODS: We used 20 satients with onychomycoses, which was confirmed by KOH ancl fungus culture. The ciclopirox nail lacquer was applied once daily for 1 month, and followed by two times weekly for the next 5 months. The clinical observat.ion was perforrned every month for any clinical improvement and side-dffects. The involved percent of a target nail was measured by using a adhesive tape at.ached to the selected nail plate. All involved nails(n=68) were also evaluated by a severity score(sever>50%. moderate 25-50%, mild50%) in all 68 involved nails was also decreased from 56% at baseline to 7% by the end of the treatment The mycologieal cure rate was 82.4% by the end of the treatment. The overall efficaor assessed by the physician and patients was improvement by 82.4% Tolerability was excellent or good in all patients, but cosmetic acceptance was good or excellen by 53%. Only one patient complained of a prickling sensation, but no systemic adverse effect were found. CONCLUSION: These data suggest that ciclopirox 8% nail lacquer may be safe and effective ir the treatment of onychomvcoses.

Amorolfine Nail Lacquer 5 % Once Weekly in Onychomycosis of Fingers and / or Toes / 대한피부과학회지

BACKGROUND: Amorolfine is a new topical antifungal drug of the morpholine class has broad spectrum fungicidal activity. Amorolfine nail lacquer 5% is a transungual delivery system which can penetrate well through the nail plate to the infected keratin and remain there for a prolonged period. OBJECTIVE: The aim of this study is to assess the efficacy and tolerability of 5% amorolfine nail lacquer given once weekly to the patients with onychomycosis. METHODS: 29 patients with onychomycosis affecting not more than 80% of the surface of nail were treated once weekly for up to 9 months with amorolfine nail lacquer 5%. Clinical and mycological examination were performed before treatment and 3, 6, 9 months after start of treatment. Final evaluation was done 3 months after the end of treatment. RESULTS: Average affected area(%) and average score of clinical signs-thickening, splitting, discoloration-were significantly decreased 3 months after start of treatment. Mycological cure rate was continuously increased according to the treatment duration reaching 75.9% at 3 months after treatment. Overall efficacy assessed by the investgators were cure in 31.0% and improvement in 41.4%. Tolerability, mode and frequency of treatment, and formulation were evaluated as good or excellent by most of the patients.No systemic or local side effect was observed. CONCLUSION: Amorolfine nail lacquer 5% used once weekly up to 9 months was relatively effective and safe for the treatment of onychomycosis.