Infection risk by dermatophytes during storage and after domestic laundry and their temperature-dependent inactivation

Healthy skin for children and young people with skin of colour starts with clinician knowledge and recognition: a narrative review

Skin conditions most frequently encountered in paediatric practice include infections, infestations, atopic dermatitis, and acne. Skin of colour refers to skin with increased melanin and darker pigmentation, and reflects global racial and ethnic diversity. Managing skin conditions in skin of colour requires health equity nuance, which is rarely explicitly taught. Awareness of the demographic factors, social determinants of health, and cultural practices that affect prevalence, morphological differences, and treatment of skin conditions is imperative. In this Review, we present the burden and clinical features of the common childhood skin conditions impetigo, scabies, head lice, tinea, atopic dermatitis, and acne in skin of colour. Paediatricians play an important role in diagnosis and management of these conditions to improve quality of life and prevent downstream complications, but they require education around skin of colour. We also discuss the systemic and structural racism, and the environmental and socioeconomic disadvantage, that perpetuate skin health inequity in communities with skin of colour.

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.

Comprehensive Review of Tinea Capitis in Adults: Epidemiology, Risk Factors, Clinical Presentations, and Management

Tinea capitis is a fungal infection of the scalp and hair caused by dermatophyte molds, that most often affects children and may also affect adults. Previous estimates suggest that between 3% and 11% of all tinea capitis cases worldwide occur in adults, although updated epidemiological studies are needed to reassess the prevalence of tinea capitis in adult populations specifically. Postmenopausal adult women are most often affected by tinea capitis, with African American or Black women particularly at risk. Adults who experience crowded living conditions, who live in close proximity to animals, who are immunosuppressed, and/or who live in households with affected children are at greatest risk of infection. Tinea capitis can be non-inflammatory or inflammatory in nature, and the subtype affects the extent and severity of clinical symptoms. Fungal culture and potassium hydroxide preparations are the most commonly used diagnostic tools. Trichoscopy, defined as dermoscopic imaging of the scalp and hair, is a useful adjunct to the physical examination. The mainstay of therapy is oral antifungal therapy, and topical therapy alone is not recommended. Since tinea capitis infection is uncommon in adults, there are no widely accepted treatment guidelines. Rather, the same medications used for tinea capitis infection among children are recommended for adults at varying doses, including griseofulvin, and terbinafine, and, less commonly, itraconazole and fluconazole. The prognosis for tinea capitis in adults is typically excellent when prompt and adequate treatment is administered; however, delayed diagnosis or inadequate treatment can result in scarring alopecia. Over the past decade, dermatophyte infections resistant to treatment with topical and oral antifungal agents have emerged. While tinea capitis infections resistant to antifungal therapy have been rarely reported to date, antifungal resistance is rising among superficial fungal infections in general, and antifungal stewardship is necessary to ensure that resistance to treatment does not develop among dermatophytes that cause tinea capitis.

Describing skin health and disease in urban-living Aboriginal children: co-design, development and feasibility testing of the Koolungar Moorditj Healthy Skin pilot project

BACKGROUND

Indigenous children in colonised nations experience high rates of health disparities linked to historical trauma resulting from displacement and dispossession, as well as ongoing systemic racism. Skin infections and their complications are one such health inequity, with the highest global burden described in remote-living Australian Aboriginal and/or Torres Strait Islander (hereafter respectfully referred to as Aboriginal) children. Yet despite increasing urbanisation, little is known about the skin infection burden for urban-living Aboriginal children. More knowledge is needed to inform service provision, treatment guidelines and community-wide healthy skin strategies. In this pilot study, we aimed to test the feasibility and design of larger multi-site observational studies, provide initial descriptions of skin disease frequency and generate preliminary hypotheses of association.

METHODS

This project has been co-designed with local (Noongar) Elders to provide an Australian-first description of skin health and disease in urban-living Aboriginal children. In collaboration with an urban Aboriginal Community Controlled Health Organisation (Derbarl Yerrigan Health Service), we conducted a week-long cross-sectional observational cohort study of Aboriginal children (0-18 years) recruited from the waiting room. Participants completed a questionnaire, skin examination, clinical photos, and swabs and received appropriate treatment. We assessed the feasibility and impact of the pilot study.

RESULTS

From 4 to 8 October 2021, we recruited 84 Aboriginal children of whom 80 (95%) were urban-living. With a trusted Aboriginal Health Practitioner leading recruitment, most parents (or caregivers) who were approached consented to participate. Among urban-living children, over half (45/80, 56%) of parents described a current concern with their child's skin, hair and/or nails; and one-third (26/80, 33%) reported current itchy skin. Using a research-service model, 27% (21/79) of examined urban-living participants received opportunistic same-day treatment and 18% (14/79) were referred for later review.

CONCLUSIONS

This co-designed pilot study to understand skin health in urban-living Aboriginal children was feasible and acceptable, with high study participation and subsequent engagement in clinical care observed. Co-design and the strong involvement of Aboriginal people to lead and deliver the project was crucial. The successful pilot has informed larger, multi-site observational studies to more accurately answer questions of disease burden and inform the development of healthy skin messages for urban-living Aboriginal children.

Strategies to improve the diagnosis and clinical treatment of dermatophyte infections

INTRODUCTION

Significant problems are associated with the diagnosis and treatment of dermatophyte infections, which constitute the most common fungal infections of the skin. Although this is a common problem in the community, there are no adequate guidelines for the management of all forms of dermatophyte infections. Even if dermatophytes are correctly diagnosed, they sometimes exhibit poor susceptibility to several antifungal compounds. Therefore, long-term treatment may be needed, especially in immunosuppressed patients, for whom antifungal pharmacotherapy may be inconvenient owing to allergies and undesirable drug interaction-related effects.

AREAS COVERED

In this review article, problems related to the diagnosis and treatment of dermatophyte infections have been discussed, and suggestions to resolve these problems have been presented.

EXPERT OPINION

Pretreatment microscopic or mycological examinations should be performed for dermatophyte infections. In treatment-refractory cases, antifungal-resistant strains should be determined using antifungal susceptibility testing or via molecular methods. Natural herbal, laser, and photodynamic treatments can be used as alternative treatments in patients who cannot tolerate topical and systemic antifungal treatments.

Updated Perspectives on the Diagnosis and Management of Onychomycosis

Onychomycosis is the most common nail disease encountered in clinical practice and can cause pain, difficulty with ambulation, and psycho-social problems. A thorough history and physical examination, including dermoscopy, should be performed for each patient presenting with nail findings suggestive of onychomycosis. Several approaches are available for definitive diagnostic testing, including potassium hydroxide and microscopy, fungal culture, histopathology, polymerase chain reaction, or a combination of techniques. Confirmatory testing should be performed for each patient prior to initiating any antifungal therapies. There are several different therapeutic options available, including oral and topical medications as well as device-based treatments. Oral antifungals are generally recommended for moderate to severe onychomycosis and have higher cure rates, while topical antifungals are recommended for mild to moderate disease and have more favorable safety profiles. Oral terbinafine, itraconazole, and griseofulvin and topical ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the Food and Drug Administration for treatment of onychomycosis in the United States and amorolfine 5% nail lacquer is approved in Europe. Laser treatment is approved in the United States for temporary increases in clear nail, but clinical results are suboptimal. Oral fluconazole is not approved in the United States for onychomycosis treatment, but is frequently used off-label with good efficacy. Several novel oral, topical, and over-the-counter therapies are currently under investigation. Physicians should consider the disease severity, infecting pathogen, medication safety, efficacy and cost, and patient age, comorbidities, medication history, and likelihood of compliance when determining management plans. Onychomycosis is a chronic disease with high recurrence rates and patients should be counseled on an appropriate plan to minimize recurrence risk following effective antifungal therapy.

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.

Virucidal Efficacy of Laundering

Viruses contribute significantly to the burden of infectious diseases worldwide. Although there are multiple infection routes associated with viruses, it is important to break the chain of infection and thus consider all possible transmission routes. Consequently, laundering can be a means to eliminate viruses from textiles, in clinical settings well as for domestic laundry procedures. Several factors influence the survival and inactivation of microorganisms, including viruses on hard surfaces and textiles. Therefore, textiles should be regarded as potential fomites. While in clinical and industrial settings laundry hygiene is ensured by standardized processes, temperatures of at least 60 °C and the use of oxidizing agents, domestic laundry is not well defined. Thus, the parameters affecting viral mitigation must be understood and prudently applied, especially in domestic laundering. Laundering can serve as a means to break the chain of infection for viral diseases by means of temperature, time, chemistry and mechanical action.

Decontamination Efficiency of Thermal, Photothermal, Microwave, and Steam Treatments for Biocontaminated Household Textiles

With the outbreak of the COVID-19 pandemic, textile laundering hygiene has proved to be a fundamental measure in preventing the spread of infections. The first part of our study evaluated the decontamination efficiency of various treatments (thermal, photothermal, and microwave) for bio contaminated textiles. The effects on textile decontamination of adding saturated steam into the drum of a household textile laundering machine were investigated and evaluated in the second part of our study. The results show that the thermal treatment, conducted in a convection heating chamber, provided a slight reduction in efficiency and did not ensure the complete inactivation of Staphylococcus aureus on cotton swatches. The photothermal treatment showed higher reduction efficiency on contaminated textile samples, while the microwave treatment (at 460 W for a period of 60 s) of bio contaminated cotton swatches containing higher moisture content provided satisfactory bacterial reduction efficiency (more than 7 log steps). Additionally, the treatment of textiles in the household washing machine with the injection of saturated steam into the washing drum and a mild agitation rhythm provided at least a 7 log step reduction in S. aureus. The photothermal treatment of bio contaminated cotton textiles showed promising reduction efficiency, while the microwave treatment and the treatment with saturated steam proved to be the most effective.

Effect of Household Laundering, Heat Drying, and Freezing on the Survival of Dermatophyte Conidia

Dermatomycoses are one of the most common dermatological infectious diseases. Dermatophytoses, such as tinea pedis (athlete’s foot) in adults and tinea capitis in children, are the most prevalent fungal diseases caused by dermatophytes. The transmission of anthropophilic dermatophytoses occurs almost exclusively through indirect contact with patient-contaminated belongings or environments and, subsequently, facilitates the spread of the infection to others. Hygienic measures were demonstrated to have an important role in removing or reducing the fungal burden. Herein, we evaluated the effectiveness of physical-based methods of laundering, heat drying, and freezing in the elimination of Trichophyton tonsurans, T. rubrum, and T. interdigitale conidia in diverse temperatures and time spectra. Based on our findings, laundering at 60 °C was effective for removing the dermatophyte conidia from contaminated linens. On the contrary, heat drying using domestic or laundromat machines; freezing at −20 °C for 24 h, 48 h, or one week; and direct heat exposure at 60 °C for 10, 30, or 90 min were unable to kill the dermatophytes. These results can be helpful for clinicians, staff of children’s communities, and hygiene practitioners for implementing control management strategies against dermatophytoses caused by mentioned dermatophyte species.

Onychomycosis in Older Adults: Prevalence, Diagnosis, and Management

The risk of having onychomycosis increases with age. Data suggest that the prevalence of onychomycosis may be ≥ 20% in subjects aged ≥ 60 years and ≥ 50% in those aged ≥ 70 years. Older males are 2.1 times more prone to onychomycosis than are females. Although most nail dystrophies (approximately 50%) are caused by onychomycosis, proper clinical assessment followed by mycological examination is recommended to exclude other conditions such as nail trauma, lichen planus, and psoriasis. The US FDA-approved onychomycosis treatments are systemic antifungals (terbinafine and itraconazole) for severe onychomycosis and topical antifungals (ciclopirox 8%, efinaconazole 10%, and tavaborole 5%) for mild-to-moderate onychomycosis. Oral fluconazole is used off-label, and itraconazole may be considered for non-dermatophyte onychomycosis. Recently, fosravuconazole was approved in Japan for onychomycosis treatment. Although the treatment options and durations are the same for older patients as for other age groups, a clinical decision should take into account various age-related factors such as comorbidities, polypharmacy, hepatic and renal insufficiency, and noncompliance. Clinicians should also consider possible drug interactions and side effects when choosing a particular antifungal. Since the recurrence rate of onychomycosis is high, older patients should practice sanitization techniques, consider lifestyle changes, and perhaps consider using a topical antifungal as long-term maintenance therapy one to three times per week to prevent the recurrence of onychomycosis or to treat early disease.

Transmission of Onychomycosis and Dermatophytosis between Household Members: A Scoping Review

Onychomycosis is a common fungal infection of the nail, caused by dermatophytes, non-dermatophytes, and yeasts. Predisposing factors include older age, trauma, diabetes, immunosuppression, and previous history of nail psoriasis or tinea pedis. Though many biological risk factors have been well characterized, the role of the environment has been less clear. Studies have found evidence of transmission in 44% to 47% of households with at least one affected individual, but the underlying mechanisms and risk factors for transmission of onychomycosis between household members are incompletely understood. A scoping literature review was performed to characterize and summarize environmental risk factors involved in the transmission of onychomycosis within households. A total of 90 papers met the inclusion criteria, and extracted data was analyzed in an iterative manner. Shared household surfaces may harbor dermatophytes and provide sources for infection. Shared household equipment, including footwear, bedding, and nail tools, may transmit dermatophytes. The persistence of dermatophytes on household cleaning supplies, linen, and pets may serve as lasting sources of infection. Based on these findings, we provide recommendations that aim to interrupt household transmission of onychomycosis. Further investigation of the specific mechanisms behind household spread is needed to break the cycle of transmission, reducing the physical and social impacts of onychomycosis.

Pathogenesis, Immunology and Management of Dermatophytosis

Dermatophytic infections of the skin and appendages are a common occurrence. The pathogenesis involves complex interplay of agent (dermatophytes), host (inherent host defense and host immune response) and the environment. Infection management has become an important public health issue, due to increased incidence of recurrent, recalcitrant or extensive infections. Recent years have seen a significant rise in incidence of chronic infections which have been difficult to treat. In this review, we review the literature on management of dermatophytoses and bridge the gap in therapeutic recommendations.

A Paradigm Shift in the Treatment and Management of Onychomycosis

There is an increase in the incidence of onychomycosis, especially in at-risk populations. Onychomycosis is difficult to treat, as the efficacy of most antifungal agents is relatively low. Nondermatophyte molds (NDMs) and mixed infection (dermatophyte plus NDM) onychomycosis are contributing to growing antifungal resistance, as they are often underestimated and ignored due to incorrect diagnosis. There is a need for a paradigm shift in the management of onychomycosis to a patient-centered, holistic approach with an emphasis on laboratory diagnosis prior to initiating treatment, which enables the rational choice of the antifungal agent. Additionally, in the case of resistant infections, antifungal susceptibility testing is recommended. Strategies for effective management of onychomycosis include disinfection of fungal reservoirs in shoes and socks and prophylaxis posttreatment using topical antifungal agents. These measures may reduce the recurrence of onychomycosis and improve long-term clinical success.

Laundry Hygiene and Odor Control: State of the Science

Laundering of textiles—clothing, linens, and cleaning cloths—functionally removes dirt and bodily fluids, which prevents the transmission of and reexposure to pathogens as well as providing odor control. Thus, proper laundering is key to controlling microbes that cause illness and produce odors. The practice of laundering varies from region to region and is influenced by culture and resources. This review aims to define laundering as a series of steps that influence the exposure of the person processing the laundry to pathogens, with respect to the removal and control of pathogens and odor-causing bacteria, while taking into consideration the types of textiles. Defining laundering in this manner will help better educate the consumer and highlight areas where more research is needed and how to maximize products and resources. The control of microorganisms during laundering involves mechanical (agitation and soaking), chemical (detergent and bleach), and physical (detergent and temperature) processes. Temperature plays the most important role in terms of pathogen control, requiring temperatures exceeding 40°C to 60°C for proper inactivation, while detergents play a role in reducing the microbial load of laundering through the release of microbes attached to fabrics and the inactivation of microbes sensitive to detergents (e.g., enveloped viruses). The use of additives (enzymes) and bleach (chlorine and activated oxygen) becomes essential in washes with temperatures below 20°C, especially for certain enteric viruses and bacteria. A structured approach is needed that identifies all the steps in the laundering process and attempts to identify each step relative to its importance to infection risk and odor production.

Inhibition of microbial production of the malodorous substance isovaleric acid by 4,4' dichloro 2-hydroxydiphenyl ether (DCPP)

Human body malodour is a complex phenomenon. Several types of sweat glands produce odorless secretions that are metabolized by a consortium of skin‐resident microorganisms to a diverse set of malodorous substances. Isovaleric acid, a sweaty‐smelling compound, is one major malodorous component produced by staphylococci with the skin‐derived amino acid L‐leucine as a substrate. During wearing, fabrics are contaminated with sweat and microorganisms and high humidity propagates growth and microbial malodour production. Incomplete removal of sweat residues and microorganisms from fabrics during laundry with bleach‐free detergents and at low temperatures elevate the problem of textile malodour. This study aimed to analyze the inhibitory effect of the antimicrobial 4,4ʹ dichloro 2‐hydroxydiphenyl ether (DCPP) on the formation of isovaleric acid on fabrics. Therefore, GC‐FID‐ and GC–MS‐based methods for the analysis of isovaleric acid in an artificial human sweat‐mimicking medium and in textile extracts were established. Here, we show that antimicrobials capable to deposit on fabrics during laundry, such as DCPP, are effective in growth inhibition of typical malodour‐generating bacteria and prevent the staphylococcal formation of isovaleric acid on fabrics in a simple experimental setup. This can contribute to increased hygiene for mild laundry care approaches, where bacterial contamination and malodour production represent a considerable consumer problem.

S1 guidelines: Tinea capitis

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Biological and Chemical Processes that Lead to Textile Malodour Development

The development of malodour on clothing is a well-known problem with social, economic and ecological consequences. Many people still think malodour is the result of a lack of hygiene, which causes social stigma and embarrassment. Clothing is washed more frequently due to odour formation or even discarded when permastink develops. The malodour formation process is impacted by many variables and processes throughout the textile lifecycle. The contact with the skin with consequent transfer of microorganisms, volatiles and odour precursors leads to the formation of a distinctive textile microbiome and volatilome. The washing and drying processes further shape the textile microbiome and impact malodour formation. These processes are impacted by interindividual differences and fabric type as well. This review describes the current knowledge on the volatilome and microbiome of the skin, textile and washing machine, the multiple factors that determine malodour formation on textiles and points out what information is still missing.

Onychomycosis in children - review on treatment and management strategies

BACKGROUND

Onychomycosis is an uncommon condition in children with increasing global prevalence. Health practitioners should confirm the diagnosis through mycology examination and examine family members of affected individuals for onychomycosis and tinea pedis.

OBJECTIVE

To comprehensively summarize the treatment and management strategies for pediatric onychomycosis.

METHODS

We performed a comprehensive literature search in the PubMed database to identify clinical studies on treatment for mycologically-confirmed dermatophyte onychomycosis in children <18 years. The exclusion criteria were combination therapy, case reports, reviews, systematic reviews and duplicate studies.

RESULTS

Per-weight dosing regimens of systemic antifungal agents such as terbinafine, itraconazole, and fluconazole are found to be safe in children and are used off-label for the treatment of pediatric onychomycosis with high efficacy. Topical antifungal agents such as ciclopirox, efinaconazole, and tavaborole have established safety and efficacy in children. Children respond better than adults to topical therapy due to their thinner, faster growing nails. There is no data on the efficacy of medical devices for onychomycosis in children.

CONCLUSION

Efinaconazole topical solution 10% and tavaborole topical solution 5% are FDA approved for the treatment of onychomycosis in children ≥6 years; ciclopirox topical solution 8% nail lacquer is approved in children ≥12 years.

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT)

Background and Aims:

Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India.

Methods:

Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either “agree” or “disagree” to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs.

Results:

Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis.

Conclusion:

Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.

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.

Laundry and textile hygiene in healthcare and beyond

The elimination of microbial contaminations from textile is an important aspect of laundering apart from the removal of stains and dirt from used and worn textiles. Although the framework for institutional laundering is well regulated to ensure hygienic cleanliness via the use of e.g. high temperatures and bleaching agents, there are several open points, especially in domestic laundering. In both cases, energy efficiency of appliances is a main driver for innovation and has resulted in a general decrease in washing temperatures which in turn can impact the antimicrobial efficacy of laundering. Thus, the different factors influencing the input and removal of microbial cells in the laundering process and possible adverse effects of microbial contaminants in the washing machine and on the textiles as well as suitable counteractions are discussed in this article, focusing on the clinical area but also considering the domestic environment, which will gain importance in the future, e.g. by the increase of elderly and ill persons being cared for at home.

Clothing-Mediated Exposures to Chemicals and Particles

A growing body of evidence identifies clothing as an important mediator of human exposure to chemicals and particles, which may have public health significance. This paper reviews and critically assesses the state of knowledge regarding how clothing, during wear, influences exposure to molecular chemicals, abiotic particles, and biotic particles, including microbes and allergens. The underlying processes that govern the acquisition, retention, and transmission of clothing-associated contaminants and the consequences of these for subsequent exposures are explored. Chemicals of concern have been identified in clothing, including byproducts of their manufacture and chemicals that adhere to clothing during use and care. Analogously, clothing acts as a reservoir for biotic and abiotic particles acquired from occupational and environmental sources. Evidence suggests that while clothing can be protective by acting as a physical or chemical barrier, clothing-mediated exposures can be substantial in certain circumstances and may have adverse health consequences. This complex process is influenced by the type and history of the clothing; the nature of the contaminant; and by wear, care, and storage practices. Future research efforts are warranted to better quantify, predict, and control clothing-related exposures.

The Role of Shoe and Sock Sanitization in the Management of Superficial Fungal Infections of the Feet

Because of the ubiquitous nature of dermatophytes and a lack of an adaptive immune response in the nail plate, recurrence and relapse rates associated with superficial fungal infections are high (10%-53%). Cured or improved dermatophytosis patients could become reinfected if exposed to fungal reservoirs, such as an infected shoe, sock, or textile. To prevent this, footwear, sock, and textile sanitization methods can be used. To provide insight into effective sanitization options, the focus of this article is to review footwear, sock, and textile sanitization studies conducted throughout history (1920-2016). Thirty-three studies are covered in this review, encompassing techniques ranging from formaldehyde fumigation and foot powder application, to more modern approaches such as UV light and silver-light irradiation technologies. Older sanitization methods (eg, boiling, use of chlorine and salts) are quite limited in their practicality, as they can result in health complications and ruin shoe integrity. Newer approaches to shoe and sock sanitization, such as ozone application and UV irradiation, have shown very promising results. Further research is still needed with these modern techniques, as knowledge gaps and cost prevent the creation of standardized parameters for successful use. By combining sanitization methods with other preventative measures, protection against reinfection may be enhanced.

Laundry Hygiene and Visible Cleanliness: An Attempt to Predict the Antimicrobial Efficacy of Laundering Processes by its Cleaning Performance

Insufficiently decontaminated textiles could lead to transmission of infections. Thus, laundry hygiene is of particular interest and investigated in numerous studies. However, laundering experiments that use microorganisms to investigate the reduction of microbial loads on textiles are particularly time-consuming and material-intensive and the handling of pathogenic microorganisms is subject to legal regulations. Therefore, alternative methods of investigation are desired. So far, there is no satisfactory solution to assess the antimicrobial efficacy of a laundering process without expensive microbiological investigations. This study introduces an approach to predict the antimicrobial performance of a laundering process by its cleaning performance. It is not possible to conclude immediately from the cleaning index of a washing process to its antimicrobial effect based on stain types used in this study. Also in washing processes with low cleaning indices a high microbial reduction can be achieved. For bleach free liquid detergent, strong, time dependent, positive correlations between microbial reduction and cleaning index for cocoa, soot, and sebum were identified.

Onychomycosis in children: Safety and efficacy of antifungal agents

Onychomycosis is an uncommon condition in childhood, but prevalence in children is increasing worldwide.The objective was to review the efficacy and safety of systemic and topical antifungal agents to treat onychomycosis in children. Databases (Pubmed, OVID, Scopus, clinicaltrials.gov, Cochrane Library) were searched. Seven studies were selected for inclusion. Only one was a randomized controlled trial. In total, 208 children were administered antifungal agents for the treatment of onychomycosis. Four reports of mild adverse events were documented (1.9% of treated children), one of which discontinued treatment (0.5%). Limitations of this review are the lack of randomized controlled trials available in pediatric onychomycosis. These findings suggest that antifungal therapies used to treat onychomycosis in children are associated with a low incidence of adverse events. Current dosing regimens for antifungal drugs are effective and appear safe to use in children, notwithstanding that the Food and Drug Administration has not approved any of these agents for the treatment of onychomycosis in children. To our knowledge, this review is the most up-to-date, comprehensive summary of pediatric onychomycosis treatment.

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.

Laundry hygiene-how to get more than clean

Although laundering should mainly remove stains and dirt from used and worn textiles, the elimination of microbial contamination is an important aim of the laundry process as well. While industrial and institutional laundering employs standardized processes using high temperatures (i.e. 60°C and above) and bleaching agents to ensure a sufficient hygienic reconditioning of textiles, domestic laundering processes are less defined and not always led by purposeful aims. The strive for energy efficiency of household appliances has resulted in a decrease in washing temperatures in Europe during the last decades and convenience aspects led to an increased use of liquid detergents that do not contain bleach which in turn impacts the antimicrobial efficacy of domestic laundering. This review compiles the different factors that influence the input and removal of micro-organisms in the laundering process and discusses the possible adverse effects of microbial contaminants in the washing machine and on the textiles as well as suitable counteractions.

Antimicrobial Efficacy of Laundry Detergents with Regard to Time and Temperature in Domestic Washing Machines

In times of low-temperature washing, laundry hygiene gains importance, as microbial contaminations on textiles can cause infection transmission and malodour formation. This study systematically investigated the antimicrobial effect of laundry detergents (solid and liquid market detergents) with regard to time and temperature in domestic washing machines. To evaluate the microbial reduction, cotton swatches contaminated with Staph. aureus, Ent. hirae, Ps. aeruginosa, C. albicans and T. mentagrophytes were washed at 20 to 60 °C, varying the washing time, with and without detergent. All tested washing factors affected the antimicrobial effect of to a varying extend, depending on the germ. The used solid market detergent containing activated oxygen bleach provided a way to achieve high microbial reductions in low temperature washing.

Onychomycosis: Practical Approaches to Minimize Relapse and Recurrence

INTRODUCTION

Toenail onychomycosis is a common disease in which treatment options are limited and treatment failures and disease recurrence are frequently encountered. It usually requires many months of treatment, and recurrence may occur in more than half of the patients within 1 year or more after the infection has been eradicated. Data on long-term treatment, follow-up and recurrence are limited.

OBJECTIVE

Our objective is to interpret these data and recommend practical approaches that should minimize recurrence based on our clinical experience.

RESULTS

Several factors have been suggested to play a role in the high incidence of recurrence, but only the extent of nail involvement and co-existing diabetes mellitus have been shown to have a significant impact.

CONCLUSION

The use of topical antifungals to prevent recurrences after complete cure was achieved has been suggested by various workers and used successfully in our practice. However, it has never been validated through clinical studies. Topical prophylaxis once weekly or twice monthly would seem appropriate in those patients most at risk. Prompt treatment of tinea pedis is essential, as is ensuring family members are free from disease. Patient education and pharmacologic intervention are equally important, and there are a number of simple strategies patients can employ. Managing onychomycosis is a significant long-term commitment for any patient, and minimizing recurrence is critical to meet their expectations.

New Antifungal Agents and New Formulations Against Dermatophytes

A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353-67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.

Onychomycosis: Evaluation, Treatment Options, Managing Recurrence, and Patient Outcomes

Onychomycosis is the most common nail disease seen in podiatric practice. Effective long-term management remains problematic. We need to treat onychomycosis effectively to prevent its progression into a severe, debilitating, and painful condition, and to manage recurrence. With new agents now available and greater discussion on management strategies, this article reviews the appropriate evaluation of the disease, treatment options, and optimal patient outcomes.

Decontamination of laundry exposed to Microsporum canis hairs and spores

OBJECTIVES

The objective of this study was to determine the efficacy of decontamination of fabric exposed to Microsporum canis hairs and spores by mechanical washing using hot or cold water with or without a sodium hypochlorite additive, and to field test a washing protocol for terry cloth and denim exposed to M canis via direct contact with infected cats.

METHODS

Cotton, terry cloth and denim fabric swatches were contaminated with isolated infective spores and hairs and then washed in water at temperatures of 30°C and 60°C, with and without a sodium hypochlorite additive, and with and without mechanical drying. Terry cloth and denim were contaminated by direct contact with infected kittens and washed at 30°C until culture-negative.

RESULTS

All prelaundering samples had >300 colony forming units (cfu)/plate. Experimentally contaminated fabrics were culture-negative, regardless of fabric type, water temperature, the presence or absence of sodium hypochlorite, or tumble drying after one wash. After one wash, 22/34 (65%) of terry cloth towels and 12/20 (60%) denim fabric squares were culture-positive, but the infective load was minimal (1-5 cfu/plate). After two washes in cold water there was no detectable contamination of fabric. The rinse water was not contaminated with spores. The laundry tub was easily decontaminated via mechanical cleaning followed by use of a disinfectant.

CONCLUSIONS AND RELEVANCE

Washable textiles exposed to M canis can be decontaminated via mechanical washes in cold water without the addition of bleach. Two washes are recommended to ensure removal of spores. Laundry can be effectively decontaminated by washing twice in cold water on a long wash cycle (for ⩾14 mins). It is important to ensure maximal agitation (ie, the machine should not be overloaded).

Experimental Evaluation of Hygienic Conditions in Domestic Dishwashers

Rising environmental concerns lead to use of lower temperatures and to reduced water consumption in domestic dishwashing. The development of new dishwashers with reservoir for reusage of water from the final rinse seeks to reduce the costs per cleaning cycle, but leads to concerns about the hygienic conditions of domestic dishwashers, as the presence of stable communities of microorganisms has been reported. This study investigates the hygienic conditions of different types of domestic dishwashers and the long-term effect of process parameters on the hygiene in dishwashers with water reservoirs.

Candida and Fusarium species known as opportunistic human pathogens from customer-accessible parts of residential washing machines

Energy constraints have altered consumer practice regarding the use of household washing machines. Washing machines were developed that use lower washing temperatures, smaller amounts of water and biodegradable detergents. These conditions may favour the enrichment of opportunistic human pathogenic fungi. We focused on the isolation of fungi from two user-accessible parts of washing machines that often contain microbial biofilms: drawers for detergents and rubber door seals. Out of 70 residential washing machines sampled in Slovenia, 79% were positive for fungi. In total, 72 strains belonging to 12 genera and 26 species were isolated. Among these, members of the Fusarium oxysporum and Fusarium solani species complexes, Candida parapsilosis and Exophiala phaeomuriformis represented 44% of fungi detected. These species are known as opportunistic human pathogens and can cause skin, nail or eye infections also in healthy humans. A machine learning analysis revealed that presence of detergents and softeners followed by washing temperature, represent most critical factors for fungal colonization. Three washing machines with persisting malodour that resulted in bad smelling laundry were analysed for the presence of fungi and bacteria. In these cases, fungi were isolated in low numbers (7.5 %), while bacteria Micrococcus luteus, Pseudomonas aeruginosa, and Sphingomonas species prevailed.

Impact of wash cycle time, temperature and detergent formulation on the hygiene effectiveness of domestic laundering

AIMS

Investigation of the effect of temperature and duration of the laundering process with and without activated oxygen bleach (AOB)-containing detergent on the hygienic effectiveness of laundering.

METHODS AND RESULTS

Cotton test swatches were contaminated with Staphylococcus aureus, Enterococcus hirae, Pseudomonas aeruginosa, Candida albicans and Trichophyton mentagrophytes and were washed in a household washing machine using temperatures between 20 and 60°C and different wash cycle times. The logarithmic microbial reduction factor and cross-contamination (i.e. transfer from contaminated to sterile swatches) were used to indicate the hygienic effectiveness of the washing process. For all tested micro-organisms, the temperature needed for decontamination depended on washing time and detergent type. Hygiene effectiveness of laundering was enhanced by inclusion of AOB even at lowest temperatures, except for C. albicans, which was virtually unaffected by AOB. The use of AOB-containing detergents as well as high washing temperatures reduced cross-contamination to sterile swatches included in the load.

CONCLUSIONS

Depending on the type of organism, longer wash cycle times or the use of AOB-containing detergents can be used to enhance the hygiene effectiveness of laundering.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study demonstrates that it is possible to compensate for the loss of hygiene effectiveness of laundering at lower temperatures using detergents with activated oxygen bleach or by extending the wash cycle time.

Tinea pedis: the etiology and global epidemiology of a common fungal infection

Tinea pedis, which is a dermatophytic infection of the feet, can involve the interdigital web spaces or the sides of the feet and may be a chronic or recurring condition. The most common etiological agents are anthropophiles, including Trichophyton rubrum sensu stricto, which is the most common, followed by Trichophyton interdigitale and Epidermophyton floccosum. There has been a change in this research arena, necessitating a re-evaluation of our knowledge on the topic from a multidisciplinary perspective. Thus, this review aimed to provide a solid overview of the current status and changing patterns of tinea pedis. The second half of the twentieth century witnessed a global increase in tinea pedis and a clonal spread of one major etiologic agent, T. rubrum. This phenomenon is likely due to increases in urbanization and the use of sports and fitness facilities, the growing prevalence of obesity and the aging population. For optimal patient care and management, the diagnosis of tinea pedis should be verified by microbiological analysis. In this review, we discuss the epidemiology, clinical forms, complications and mycological characteristics of tinea pedis and we highlight the pathogenesis, prevention and control parameters of this infection.

Antimicrobial Efficacy of Hygiene Rinsers under Consumer-Related Conditions

In domestic laundry, the question how to achieve a sufficient germ reduction gains importance since the trend towards lower washing temperatures and the incremental use of bleach-free liquid detergents does not ensure a sufficient hygiene by the means of temperature and bleach any longer. Hygiene rinsers as products being added to the rinse cycle offer further antimicrobial efficacy and seem to provide an adequate solution for this challenge. However, their regular application is debated due to the used ingredients and it is still unclear whether they are able to exhibit an additional antimicrobial efficacy. This study investigates the germ reduction by a supplementary use of hygiene rinsers under conditions that are close to the parameters found in the household to evaluate the benefit of these products for the hygienic reconditioning of laundry.

The effect of domestic laundry processes on fungal contamination of socks

Tinea pedis is a common chronic skin disease. The role of contaminated clothes as a possible source of reinfection is not fully understood. This study was conducted to evaluate the efficacy of domestic laundering at different temperatures in the eradication of fungal pathogens from contaminated socks. Samples from 81 socks worn by patients suffering from tinea pedis underwent domestic laundering at either 40 °C or 60 °C. The socks were dried at room temperature; fungal cultures were taken from two samples from, respectively, the toe and heel areas of the socks. Samples from socks washed at 40 °C revealed 29 (36%) positive fungal cultures, of which 14 came from the toe and 15 from the heel areas of socks. Trichophyton rubrum was isolated in four specimens, and Aspergillus spp. were found in 20 (70%) specimens. Samples from the same socks washed at 60 °C revealed five (6%) positive fungal cultures, of which three came from the toe and two from the heel areas of socks. Only Aspergillus spp. were detected. Yeasts were eradicated at 40 °C. Contravening current trends for energy saving and environmental protection, laundering at low temperatures is not effective in eradicating fungal pathogens, which requires high-temperature laundering at 60 °C.

A model of the transmission of micro-organisms in a public setting and its correlation to pathogen infection risks

AIM

Gastro-intestinal infections are widespread in the community and have considerable economic consequences. In this study, we followed chains of infection from a public toilet scenario, looking at infection risks by correlating the transmission of bacteria, fungi and viruses to our current knowledge of infectious doses.

METHODS AND RESULTS

Transmission of Escherichia coli, Bacillus atrophaeus spores, Candida albicans and bacteriophage MS2 from hands to surfaces was examined in a transmission model, that is toilet brush, door handle to water tap. The load of viable pathogens was significantly reduced during transfer from hands to objects. Nevertheless, it was shown that pathogens were successfully transferred to other people in contagious doses by contact with contaminated surfaces.

CONCLUSIONS

Our results suggest that infection risks are mainly dependent on current infectious doses of pathogens. For enteritic viruses or bacteria, for example Norovirus or EHEC, only a few particles or cells are sufficient for infection in public lavatories, thus bearing a high risk of infection for other persons. However, there seems to be only a low probability of becoming infected with pathogens that have a high infectious dose whilst sharing the same bathroom.

SIGNIFICANCE AND IMPACT OF THE STUDY

The transmission model for micro-organisms enables a risk assessment of gastro-intestinal infections on the basis of a practical approach.