Efficacy of a Newly Developed Inward Airflow Safety Cabinet to Prevent the Spread of Infected Nail Dust Particles During Mechanical Nail Reduction in Onychomycosis.

BACKGROUND: Nail thickening is a poor prognostic factor in onychomycosis. Mechanical reduction by micromotor nail grinding is an alternative treatment for onychomycosis. However, this treatment introduces a large amount of infected nail dust particles into the air and can adversely affect other patients and health-care providers. The innovative recirculating airflow safety cabinet (ASC) was developed to prevent the spread of these generated infected nail dust particles. The aim of this study was to determine the efficacy of the ASC in patients with onychomycosis or traumatic onychodystrophy. METHODS: The ASC was used during the nail-grinding process in 50 patients, including 36 onychomycosis patients and 14 traumatic onychodystrophy patients. For each patient, five Sabouraud dextrose agar plates with chloramphenicol were positioned within the working space of the ASC, and the other five plates were positioned near the area of air exit after the carbon filters within the cabinet. A total of 500 plates were incubated at 25°C and evaluated every 7 days. The results of fungal cultures were analyzed. RESULTS: In the traumatic onychodystrophy group, all fungal cultures of nail dust particles from both before and after filtration from the ASC were negative in all 14 patients. In the onychomycosis group, 52 fungal cultures (28.9%) from nail particles within the ASC working area tested positive; however, the results of fungal cultures of nail dust particles after filtration were all negative. CONCLUSIONS: The newly developed ASC was found to be effective for preventing the spread of infected nail dust particles generated by micromotor nail grinding to mechanically reduce nail thickness in patients with onychomycosis.

The March Against Onychomycosis: A Systematic Review of the Sanitization Methods for Shoes, Socks, and Textiles.

Drug-based treatment of superficial fungal infections, such as onychomycosis, is not the only defense. Sanitization of footwear such as shoes, socks/stockings, and other textiles is integral to the prevention of recurrence and reduction of spread for superficial fungal mycoses. The goal of this review was to examine the available methods of sanitization for footwear and textiles against superficial fungal infections. A systematic literature search of various sanitization devices and methods that could be applied to footwear and textiles using PubMed, Scopus, and MEDLINE was performed. Fifty-four studies were found relevant to the different methodologies, devices, and techniques of sanitization as they pertain to superficial fungal infections of the feet. These included topics of basic sanitization, antifungal and antimicrobial materials, sanitization chemicals and powder, laundering, ultraviolet, ozone, nonthermal plasma, microwave radiation, essential oils, and natural plant extracts. In the management of onychomycosis, it is necessary to think beyond treatment of the nail, as infections enter through the skin. Those prone to onychomycosis should examine their environment, including surfaces, shoes, and socks, and ensure that proper sanitization is implemented.

Disinfection trials with terbinafine-susceptible and terbinafine-resistant dermatophytes.

BACKGROUND: Treatment of tinea pedis and onychomycosis is complicated by high rates of reinfection and the emergence of terbinafine-resistant strains of Trichophyton spp. Effective disinfection of contaminated socks is an important measure. Appropriate washing reduces the risk of reinfection and is paramount in treating tinea pedis and onychomycosis. OBJECTIVES: The aim of this study was to describe the effect of commonplace disinfection methods using socks pieces inoculated with terbinafine-resistant or terbinafine-susceptible isolates of Trichophyton spp. METHODS: Sock pieces were inoculated with seven terbinafine-resistant isolates of Trichophyton spp. with known mutations in the SQLE-gene (T. rubrum (n = 3), T. interdigitale (n = 1) and T. indotineae (n = 3)) and six terbinafine-susceptible isolates of Trichophyton spp. (T. rubrum (n = 3) and T. interdigitale (n = 3)). Methods of disinfection included soaking in a quaternary ammonium (QAC) detergent (0.5, 2 and 24 h), freezing at -20°C (0.5, 12 and 24 h), domestic and steam washing (both at 40°C with detergent). Sock pieces were cultured for 4 weeks following disinfection. The primary end point was no growth at the end of week 4. RESULTS: Soaking in a QAC-detergent for 24 h procured at disinfectant rate of 100% (13/13), whilst soaking in 0.5 and 2 h had a disinfectant rate of 46.2% (6/13) and 84.6% (11/13), respectively. Domestic washing (40°C with detergent) produced a disinfectant rate of 7.7% (1/13). Freezing at -20°C (0.5, 12 and 24 h) and steam washing (40°C with detergent) had no disinfectant properties. CONCLUSIONS: Soaking in a QAC-detergent for 24 h effectively disinfected sock pieces contaminated with dermatophytes.

Tinea pedis-An embarrassing problem for health and beauty-A narrative review.

Fungal infections present with a broad spectrum of diseases in humans (from relatively mild superficial infections of the skin and mucous membranes to the invasive or chronic infections of internal organs, which have a high mortality rate). Globally, up to 1.6 million people die each year as a result of various types of mycoses. Currently, many scientific studies focus on the best possible understanding of the aspects of the epidemiology and pathogenesis of invasive mycoses and effective methods to combat them. However, mycoses of the skin and its appendages remain a relatively less explored area. In some communities, superficial mycoses are a frequent problem as they affect nearly 70% of the population, an example of which is the athlete's foot. It involves the nails (onychomycosis) and skin (tinea pedis). It is mainly caused by keratin-decomposing dermatophyte fungi. Less often, infections are caused by non-dermatophyte moulds (Fusarium, Aspergillus, Scopulariopsis) or yeasts. Several factors have been listed as having substantial influence on the development of dermatophytosis, including those related to climate, season, geographical region, as well as to demography, socioeconomic and cultural customs, professions or contact with animals. In this review, we summarise the current knowledge about aetiology, epidemiology, diagnostics and therapy of tinea pedis with a special focus to the role of podologic management in spreading, prevention and therapy of mycoses. The article presents up-to-date knowledge on the management of the patient from the diagnosis, treatment and skincare, to counselling on how to prevent fungal skin infections in the long term.

Onychomycosis: Diagnosis, Treatment, and Prevention.

Toenail disorders account for the majority of foot complaints for which adults seek medical care. Onychomycosis, a fungal nail infection, is the most prevalent. Dermatophytes are responsible for the majority of nail infections and cause varying degrees of nail deformities. While several treatment strategies are available, no one approach (topical, systemic, or mechanical) is highly curative. This article reviews causes, diagnosis, and treatment options for onychomycosis and provides patient education tips to prevent and limit the spread of the disease.

Onychomycosis in Athletes.

Onychomycosis is a common disorder that is difficult to cure. Prevalence is lower in children (0.7%), but athletes are 2.5-fold more likely to develop the disease, with infections of the toenails seven times more prevalent than those of the fingernails. This is a concern for athletes as it can interfere with their performance. The risk of developing onychomycosis is increased by the warm environment of many sports activities; the use of occlusive footwear; the warm, moist environment associated with socks and sweating; shared, close quarters among athletes; and trauma to the foot and toenail. Once infected, onychomycosis treatment requires a long duration of treatment with strict compliance, a potential problem for younger patients. Treatment carries the risk of significant side effects, and recurrence rates remain high. Avoiding infection can be a potent first line of defense and may circumvent the need for treatment. Preventive recommendations such as keeping toenails short and proper washing of laundry, to name a few, can be effective and are discussed here. Technological improvements such as synthetic, moisture-wicking socks and well-ventilated, mesh shoes have also been shown to reduce moisture and injury. Education about preventing fungal spread and improving hygiene in the locker room, gym, and pool are of critical importance. This overview of onychomycosis focuses primarily on the preventive measures and innovative changes in athletic gear. It also provides a compact step-by-step guide to prevention intended to be useful for both the general public and the professional. It can be reproduced to use as a handout for athletes, trainers, and coaches.

A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level.

Onychomycosis is a fungal nail infection caused by dermatophytes, non-dermatophyte molds, and yeasts. Treatment of this infection can be difficult, with relapse likely to occur within 2.5 years of cure. The objective of this article is to review factors that can impact cure and to suggest practical techniques that physicians can use to maximize cure rates. Co-morbidities, as well as disease severity and duration, are among the many patient factors that could influence the efficacy of antifungal therapies. Furthermore, organism, treatment, and environmental factors that may hinder cure include point mutations, biofilms, affinity for non-target enzymes, and exposure to fungal reservoirs. To address patient-related factors, physicians are encouraged to conduct confirmatory testing and treat co-morbidities such as tinea pedis early and completely. To combat organism-focused factors, it is recommended that disruption of biofilms is considered, and drugs with multiple routes of delivery and unique mechanisms of action are prescribed when traditional agents are not effective. Extending follow-up periods, using combination treatments, and considering pulse regimens may also be of benefit. Through these practical techniques, physicians can maximize cure and limit the risk of relapse and re-infection.

Onychomycosis: Treatment and prevention of recurrence.

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.

Onicomadesis: un signo de alarma inusual en el anciano / Onychomadesis: an unusual sign of alarm in the elderly

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Concepts in Onychomycosis Treatment and Recurrence Prevention: An Update.

In considering therapy for onychomycosis, the most important factor to take into account is patient selection rather than treatment selection. Patients should be screened and evaluated for the extent of nail involvement, the amount of subungual debris, the degree of dystrophy, their ability and willingness to follow the regimen, and whether comorbidities are present that may affect the efficacy and/or safety of one or more therapies. Onychomycosis is a chronic disease with a high recurrence rate. Commonsense measures to reduce the risk for reinfection include patient education and a clinician-patient team approach to long-term management.

Onychomycosis: Strategies to Minimize Recurrence.

Recurrence (relapse or re-infection) in onychomycosis is common, occurring in 10% to 53% of patients. However, data on prevalence is limited as few clinical studies follow patients beyond 12 months. It has been suggested that recurrence after continuous terbinafine treatment may be less common than with intermittent or continuous itraconazole therapy, probably due to the fungicidal activity of terbinafine, although these differences tended not to be significant. Relapse rates also increase with time, peaking at month 36. Although a number of factors have been suggested to play a role in recurrence, only the co-existence of diabetes has been shown to have a significant impact. Data with topical therapy is sparse; a small study showed amorolfine prophylaxis may delay recurrence. High concentrations of efinaconazole have been reported in the nail two weeks' post-treatment suggesting twice monthly prophylaxis with topical treatments may be a realistic option, and may be an important consideration in diabetic patients with onychomycosis. Data suggest that prophylaxis may need to be continued for up to three years for optimal effect. Treating tinea pedis and any immediate family members is also critical. Other preventative strategies include avoiding communal areas where infection can spread (such as swimming pools), and decontaminating footwear.

Onychomycosis to Fungal Superinfection: Prevention Strategies and Considerations.

Onychomycosis is the most common fungal skin infection, and it is frequently seen in the setting of other concomitant fungal infections, the most common being tinea pedis. Infected nails become a reservoir of fungal organisms that may infect the skin, and vice versa. Early, effective treatment of the nails is necessary for preventing not only permanent structural damage but also the spread and superinfection of the surrounding skin and soft tissue. Moreover, treatment of the skin is important for preventing re-infection of the nails.

Onychomycosis Diagnosis and Management: Perspectives from a Joint Dermatology-Podiatry Roundtable.

Onychomycosis prevalence is expected to rise as the population ages and the prevalence of diabetes, peripheral vascular disease, and other significant risk factors rise. Until recently, treatment options were limited due to safety concerns with oral antifungals and low efficacy with available topical agents. Efinaconzole and tavaborole were approved by the FDA in 2014 for onychomycosis treatment and provide additional effective topical treatment options for patients with mild-to-moderate disease. Dermatologists and podiatrists both regularly treat onychomycosis, yet there are striking differences between specialties in approach to diagnosis and treatment. In order to explore these differences a joint dermatology-podiatry roundtable of onychomycosis experts was convened. Although it has little effect on mycologic cure, debridement may be a valuable adjunct to oral or topical antifungal therapy, especially in patients with greater symptom burden. However, few dermatologists incorporate debridement into their treatment plans and referral to podiatry may be appropriate for some of these patients. Furthermore, podiatrists may be better equipped to manage patients with concurrent diabetes or peripheral vascular disease and elderly patients who are unable to maintain proper foot hygiene. Once cure is achieved, lifestyle and hygiene practices, maintenance/prophylactic onychomycosis treatment, and proactive tinea pedis treatment in patients and family members may help to maintain patients' cured status.

Onicomicosis distrófica total en ambos pies por Tricophyton rubrum / Total dystrophic onychomycosis in both feet by Tricophyton rubrum

Las onicomicosis son una patología infrecuente en la edad pediátrica. De presentarse, suelen afectar a las uñas de los pies, principalmente a las uñas del primer y quinto dedo, y ocasionalmente se asocia a una tinea pedis. Presentamos un caso de onicomicosis distrófica total por Tricophyton rubrum en ambos pies en un paciente varón de siete años, con evolución favorable tras tratamiento sistémico y tópico. El interés del caso radica en la baja prevalencia de las onicomicosis en esta franja etaria, así como una presentación clínica (distrófica total) poco frecuente. El aislamiento de las levaduras es, en ocasiones, dificultoso, pero en este caso el cultivo resultó positivo (AU)

Onychomycosis is an uncommon condition in children. When it appears, it usually affects toenails, mainly the first and fifth toenails, and occasionally it is associated to tinea pedis. We report a case of total dystrophic onychomycosis by Tricophyton rubrum in both feet in a male patient seven years old, with favorable outcome after systemic and topical treatment. The interest of this case report lies in the low prevalence of onychomycosis at this age, as well as in an uncommon (total dystrophic) clinical presentation. Fungal isolation is sometimes challenging, but the culture proved positive in this case (AU)

Perfil de sensibilidad antifúngica in vitro de Scopulariopsis brevicaulis aislados de onicomicosis / In vitro antifungal susceptibility profile of Scopulariopsis brevicaulis isolated from onychomycosis

Se ha estudiado el perfil de actividad antifúngica in vitro de amorolfina (AMR), bifonazol (BFZ), clotrimazol (CLZ), econazol (ECZ), fluconazol (FNZ), itraconazol (ITZ), ketoconazol (KTZ), miconazol (MNZ), oxiconazol (OXZ), tioconazol (TCZ) y terbinafina (TRB) frente a 26 aislamientos clínicos de Scopulariopsis brevicaulis obtenidos de muestras clínicas de pacientes con onicomicosis, por medio de un método estandarizado de microdilución. A pesar de que este hongo filamentoso ha sido descrito como resistente frente a un amplio espectro de antifúngicos, los datos obtenidos muestran una mejor actividad fungistática in vitro de AMR, OXZ y TRB (0,08; 0,3 y 0,35 mg/L, respectivamente) en comparación con la de CLZ (0,47 mg/L), ECZ (1,48 mg/L), MNZ (1,56 mg/L, BFZ (2,8 mg/L), TCZ (3,33 mg/L), KTZ (3,73 mg/L). FNZ (178,47 mg/L) e ITZ (4,7 mg/L) mostraron una reducida actividad antifúngica in vitro. Las CMIs obtenidas muestran la reducida sensibilidad in vitro en general de S. brevicaulis a los antifúngicos utilizados y que son de posible uso para el tratamiento de las onicomicosis con la excepción de AMR, OXZ y TRB (AU9

We studied the in vitro antifungal activity profile of amorolfine (AMR), bifonazole (BFZ), clotrimazole (CLZ), econazole (ECZ), fluconazole (FNZ), itraconazole (ITZ), ketoconazole (KTZ), miconazole (MNZ), oxiconazole (OXZ), tioconazole (TCZ) and terbinafine (TRB) against 26 clinical isolates of Scopulariopsis brevicaulis from patients with onychomycosis by means of an standardized microdilution method. Although this opportunistic filamentous fungi was reported as resistant to several broad-spectrum antifungals agents, obtained data shows a better fungistatic in vitro activity of AMR, OXZ and TRB (0.08, 0.3, and 0.35 mg/L, respectively) in comparison to that of CLZ (0.47 mg/L), ECZ (1.48 mg/L), MNZ (1.56 mg/L, BFZ (2.8 mg/L), TCZ (3.33 mg/L), KTZ (3.73 mg/L). FNZ (178.47 mg/L) and ITZ (4.7 mg/L) showed a reduced in vitro antifungal activity against S. brevicaulis. Obtained MICs show the low in vitro antifungal susceptibility of S. brevicaulis to topical drugs for onychomycosis management, with exceptions (AMR, OZX and TRB) (AU)

Ability of hydroxypropyl chitosan nail lacquer to protect against dermatophyte nail infection.

The development of a topical agent that would strengthen the nail, improve the natural barrier, and provide better drug penetration to the nail bed is needed. In this study, we examined the effects of a hydroxypropyl chitosan (HPCH)-based nail solution using a bovine hoof model. Following application of the nail solution, changes in the hardness of the hoof samples were measured using the Vickers method. Tensile and flexural strengths were tested by stretching or punching the samples, respectively. The ultrastructure was examined using scanning electron microscopy (SEM), and samples stained with periodic acid-Schiff (PAS) stain were used to determine the fungal penetration depth. The comparators included 40% urea and 70% isopropyl alcohol solutions. The HPCH nail solution increased hoof sample hardness in comparison to the untreated control sample (mean, 22.3 versus 19.4 Vickers pyramid number [HV]). Similarly, the HPCH solution increased the tensile strength (mean, 33.07 versus 28.42 MPa) and flexural strength (mean, 183.79 versus 181.20 MPa) compared to the untreated control. In contrast, the comparators had adverse effects on hardness and strength. SEM showed that the HPCH solution reduced the area of sample crumbling following abrasion compared to the untreated control (7,418 versus 17,843 pixels), and the PAS-stained images showed that the HPCH solution reduced penetration of the dermatophyte hyphae (e.g., penetration by Trichophyton mentagrophytes was <25 µm at day 9 versus 275 µm in the untreated control). Unlike chemicals normally used in cosmetic treatments, repeated application of the HPCH nail solution may help prevent the establishment of new or recurring fungal nail infection.

Promoting and maintaining or restoring healthy nails: practical recommendations for clinicians and patients.

The American Academy of Dermatology guidelines for managing patients with onychomycosis, published almost 2 decades ago, provide sound, basic recommendations for clinicians. This article provides a quick reference for clinicians and includes a handout for patients to support the health care provider's educational efforts.