Pilot study to evaluate a plasma device for the treatment of onychomycosis.

Onychomycosis is a fungal infection of the nail unit, and is the most common of the nail disorders. Current therapies for onychomycosis have less than ideal efficacy and have the potential for adverse effects. As previous studies have shown that nonthermal plasma inhibits the in vitro growth of Trichophyton rubrum, we conducted a pilot study on 19 participants with toenail onychomycosis. The primary endpoint was safety of the device, and secondary outcome measures were clinical efficacy and mycological cure. Patient satisfaction was measured using questionnaires at the completion of the study. All but one patient met the primary endpoint of safety and there were no long-term sequelae. The overall clinical cure was 53.8% and the mycological cure was 15.4%. The majority of patients were satisfied with the treatment. Our conclusions are that nonthermal plasma is a safe treatment and may have a beneficial effect on toenail onychomycosis.

Onychomycosis in clinical practice: factors contributing to recurrence.

The treatment of onychomycosis has improved in recent years and many patients can now expect a complete and lasting cure. However, for up to 25% of patients, persistent disease remains a problem, thus presenting a particular challenge to the clinician. For these patients, it is obviously important to ensure that a correct diagnosis of onychomycosis has been made, as misdiagnosis will inevitably jeopardize the perception of therapeutic effectiveness. Although onychomycosis accounts for about 50% of all nail diseases seen by physicians, nonfungal causes of similar symptoms include repeated trauma, psoriasis, lichen planus, local tumours vascular disorders and inflammatory diseases. Predisposing factors that contribute to a poor response to topical and/or oral therapy include the presence of a very thick nail, extensive involvement of the entire nail unit, lateral nail disease and yellow spikes. However, poor penetration of systemic agents to the centre of infection, or the inability of topical agents to diffuse between the surface of the nail plate and the active disease below, probably contributes to this. Other factors contributing to recurrence may be related to the patient's family history, occupation, lifestyle or underlying physiology. In addition, patients with concomitant disease (e.g. peripheral vascular disease, diabetes) or patients who are immunosuppressed (e.g. those with human immunodeficiency virus/acquired immunodeficiency syndrome) are more susceptible to onychomycosis. In the elderly, the prevalence of onychomycosis may be as high as 60%, and increases with age; in this population, physical trauma plays a major role in precipitating recurrence, especially in patients with faulty biomechanics due to underlying arthritis and bone abnormalities. It is also possible that recurrence in some cases is due to early termination of treatment or use of an inappropriate dose, and these possibilities should be eliminated before further investigations are undertaken. There is good evidence to suggest that a combination of oral and topical therapies, when given at the same time, yield excellent clinical outcomes, although there remains a need for more effective topical agents with greater nail penetration and more effective oral antifungal agents.

A psychometric study of patients with nail dystrophies.

BACKGROUND: Survey studies suggest that patients with various dermatologic conditions experience concomitant psychologic distress. OBJECTIVE: The purpose of this study was to determine which types of psychologic distress may be correlated with dystrophic disease of the nail in nonpsychiatric patients. METHODS: Fifty-seven adult subjects presenting for treatment of nail dystrophies completed a survey instrument, which included 5 psychometric measures. RESULTS: On average, patients rated the severity of their nail dystrophy and functional deficit higher (7.40/10 and 6.00, respectively) than investigators (6.15 and 3.75, respectively). Compared with age- and sex-matched nonpsychiatric patients, subjects in the study were moderately more anxious and minimally to mildly more depressed. Subjects had moderately depressed total self-concept, but their body image was approximately normal. Overall, subjects exhibited markedly more severe psychologic symptoms (84th percentile) than the normal sample, with the scores on the psychoticism, obsessive-compulsive, and paranoid ideation subscales being the most elevated. CONCLUSION: The subjects with nail dystrophy had markedly exacerbated psychologic symptoms compared with age- and sex-matched nonpsychiatric patients.

Complications of nail surgery: a review of the literature.

BACKGROUND: The realm of nail unit surgery encompasses the dermatologist as well as the hand surgeon. Nail surgery complications may include allergy to anesthetic, infection, hematoma, nail deformity, and persistent pain and swelling. OBJECTIVE: To review the pertinent literature regarding nail unit surgery complications. METHODS: A Medline literature search was performed for relevant publications. RESULTS: Nail unit surgery complications appear to be relatively infrequent. The majority of postoperative nail deformity complications result from nail matrix damage. CONCLUSION: Complications may be reduced to a minimum by preventive measures, such as careful patient selection, sterile technique, and gentle treatment of the nail matrix.

Systemic antifungal therapy.

Systemic antifungal therapy for superficial mycoses has advanced greatly since the introduction of griseofulvin in 1958. The discovery of the azole antifungal compounds, ketoconazole, itraconazole, and fluconazole, allowed for a broader spectrum of treatment and a shorter treatment duration. Terbinafine, through a unique mechanism of action, has a fungicidal power not seen previously in the other antifungals. It is important to use our knowledge of the pharmacology in combination with clinical experience and cost of therapy in order to select the proper drug. The search to identify new oral antifungal agents should continue, since none of the five currently used drugs fulfill the criteria of the "ideal" antifungal.

Tazarotene 0.1% gel in the treatment of fingernail psoriasis: a double-blind, randomized, vehicle-controlled study.

A double-blind, randomized, vehicle-controlled, parallel-group trial was performed to compare the efficacy and tolerability of tazarotene 0.1% gel and vehicle gel in 31 patients with fingernail psoriasis. Patients were randomized to receive tazarotene or vehicle gel, which they applied each evening for up to 24 weeks to 2 target fingernails, one under occlusion and one unoccluded. The tazarotene treatment resulted in a significantly greater reduction in onycholysis in occluded nails (P < or = .05 at weeks 4 and 12) and a significantly greater reduction in onycholysis in nonoccluded nails (P < or = .05 at week 24). Tazarotene also resulted in a significantly greater reduction in pitting in occluded nails (P < or = .05 at week 24). There were no other significant between-group differences in pitting, subungual hyperkeratosis, leukonychia, nail plate crumbling/loss, splinter hemorrhage, or nail growth rate. Tazarotene 0.1% gel was well tolerated with only 5 of the 21 tazarotene-treated patients reporting a treatment-related adverse event (all mild or moderate). In conclusion, tazarotene 0.1% gel can significantly reduce onycholysis (in occluded and nonoccluded nails) and pitting (in occluded nails) and is well tolerated in the treatment of nail psoriasis.