Health-related quality of life in patients with nail disorders

JAK Inhibitors and Inflammatory Nail Disorders: A Systematic Review of Clinical Outcomes and Therapeutic Potential

BACKGROUND

Inflammatory nail disorders can have a significant impact on patients' quality of life owing to aesthetic and functional concerns. They are also challenging to treat because the therapeutic armamentarium is quite limited. This systematic review aims to report the efficacy and safety of Janus kinase and Tyrosine kinase 2 inhibitors in treating these conditions.

METHODS

We conducted a comprehensive search on PubMed, Cochrane, and Embase Library to find eligible case reports, case series, single-arm clinical trials, and randomized controlled trials. We used the following search terms from inception until 15 December, 2024: "nail" AND "jak inhibitors" OR "tofacitinib" OR "baricitinib" OR "abrocitinib" OR "ruxolitinib" OR "deuruxolitinib" OR "upadacitinib" OR "ritlecitinib" OR "deucravacitinib" (nine searches in total).

RESULTS

Of 441 articles found, 31 were included in this study. The most extensively studied drug was tofacitinib, followed by baricitinib, deucravacitinib, upadacitinib, and abrocitinib. Janus kinase/Tyrosine kinase 2 inhibitors demonstrated improvements in inflammatory nail conditions, with generally mild adverse events (nasopharyngitis and transient laboratory abnormalities being most common). The topical formulation of tofacitinib, the only one studied in these nail diseases, also demonstrated promising results with minimal systemic absorption and no side effects.

CONCLUSIONS

This review highlights Janus kinase/Tyrosine kinase 2 inhibitors as a valuable addition to the therapeutic arsenal for inflammatory nail disorders while emphasizing the importance of safety assessments and tailored treatment approaches. The long-term safety of Janus kinase/Tyrosine kinase 2 inhibitors still needs further investigation and the potential for adverse events emphasizes the need for tailored therapeutic strategies, including more studies on topical formulations.

"Unveiling onychomycosis: Pathogenesis, diagnosis, and innovative treatment strategies"

Onychomycosis, a widespread fungal nail infection, manifests as discoloration, thickening, and detachment of nails, often affecting the surrounding skin. While dermatophytes were historically considered the primary causative agents, recent studies reveal a rise in non-dermatophyte mold (NDM) infections, particularly in warmer climates. Dermatophytes dominate toenail infections, while yeasts and molds also contribute to fingernail infections, with certain molds like Fusarium spp. and Scytalidium spp being notable culprits. Diagnostic challenges arise from elevated false-negative rates in conventional methods like microscopy and culture, particularly with NDM infections. Histology and polymerase chain reaction (PCR) offers higher accuracy, albeit requiring multiple confirmations due to contamination risks. Treatment options encompass oral antifungals with higher cure rates but significant side effects and topical treatments with milder side effects but inferior efficacy. Several ongoing research aims to enhance transungual delivery through various approaches for the treatment of onychomycosis. Recurrence rates underscore the importance of prompt treatment, footwear hygiene, and preventive measures like topical treatments to mitigate the risk of reinfection. Understanding the evolving fungal landscape in onychomycosis is critical for effective management and recurrence prevention strategies.

Nail psoriasis in China: A prospective multicentre study

BACKGROUND

Data on nail psoriasis (PsO) in China are scarce.

OBJECTIVES

To provide nail PsO-related data regarding epidemiologic characteristics, manifestations, fungal infections, arthritic complaints and treatments that may facilitate improved patient management globally.

METHODS

From August 2021 to August 2022, patients with nail PsO were enrolled in a prospective multicentre observational study at 25 hospitals in China. We collected and analysed data concerning nail PsO demography, clinical signs, fungal detection, arthritic symptoms and treatment.

RESULTS

A total of 817 patients with nail PsO were involved, with a mean body mass index of 24.13 ± 2.93. In addition, 71.41% of the patients were male. The Nail PsO Severity Index score was weakly positively correlated with body surface area. The percentage of nail involvement was 95.29% for fingernails and 57.18% for toenails, with pitting (67.11%) and subungual hyperkeratosis (60.40%) being the most prevalent manifestations, respectively. Toenails showed a significantly higher frequency of nailfold scales, subungual hyperkeratosis and nail plate crumbling and a lower frequency of splinter haemorrhages, pitting and erythema of the lunula. A total of 13.26% of the PsO patients had onychomycosis, and 77.08% were observed in the toenails. Articular symptoms were reported by 12.17% of the patients, with the peripheral type being predominant. Significant associations between articular symptoms and nailfold swelling, subungual hyperkeratosis, nailfold scales, onycholysis and longitudinal ridges were found. Only 2.30% (20 out of 871) of patients with nail PsO received treatment. The most frequently employed therapy for cutaneous PsO with nail involvement was biologic therapy (n = 366).

CONCLUSIONS

PsO showed distinct manifestations in the toenails and fingernails. Additionally, toenail PsO combined with onychomycosis requires special attention. Articular symptoms in psoriatic patients are associated with specific nail changes. It is important to research and advocate for more potent treatments for nail PsO.

Azorean Black Tea (Camellia sinensis) Antidermatophytic and Fungicidal Properties

The treatment of dermatophytoses, the most common human fungal infections, requires new alternatives. The aim of this study was to determine the antidermatophytic activity of the aqueous Azorean Black Tea extract (ABT), together with an approach to the mechanisms of action. The phytochemical analysis of ABT extract was performed by HPLC. The dermatophytes susceptibility was assessed using a broth microdilution assay; potential synergies with terbinafine and griseofulvin were evaluated by the checkerboard assay. The mechanism of action was appraised by the quantification of the fungal cell wall chitin and β-1,3-glucan, and by membrane ergosterol. The presence of ultrastructural modifications was studied by Transmission Electron Microscopy (TEM). The ABT extract contained organic and phenolic acids, flavonoids, theaflavins and alkaloids. It showed an antidermatophytic effect, with MIC values of 250 µg/mL for Trichophyton mentagrophytes, 125 µg/mL for Trichophyton rubrum and 500 µg/mL for Microsporum canis; at these concentrations, the extract was fungicidal. An additive effect of ABT in association to terbinafine on these three dermatophytes was observed. The ABT extract caused a significant reduction in β-1,3-glucan content, indicating the synthesis of this cell wall component as a possible target. The present study identifies the antidermatophytic activity of the ABT and highlights its potential to improve the effectiveness of conventional topical treatment currently used for the management of skin or mucosal fungal infections.

Updates in treatment and impact of nail psoriasis

INTRODUCTION

Nail psoriasis is an inflammatory disorder without a potential scarring outcome, but the nail signs, even the milder ones, can cause discomfort to patients and severely affect their quality of life. Nail psoriasis may be associated with psoriatic arthritis and when it starts during infancy, it may be a predictor of a more severe disease course in adulthood. All these issues contribute to the high economic burden of psoriasis.

AREAS COVERED

Nail psoriasis is notoriously difficult to treat, even though new treatments are in continuous development. This paper provides an update on new treatments and address the current gaps in care of nail psoriasis.

EXPERT OPINION

A better understanding of the disease pathogenesis and more 'real-life' studies will definitely be helpful to improve treatment results. A lower level of heterogeneity should be advisable among trials when evaluating nail psoriasis. Moreover, the relationship between nail psoriasis and psoriatic arthritis should be the focus of unbiased studies in order to better define the real risk that nail psoriasis patients have to develop arthritis.

Psoriasis Management Challenges Regarding Difficult-to-Treat Areas: Therapeutic Decision and Effectiveness

Psoriasis is not optimally controlled in spite of newly developed treatments, possibly due to the difficulty of objectively quantifying the disease's severity, considering the limitations of the clinical scores used in clinical practice. A major challenge addresses difficult-to-treat areas, especially in the absence of significant body surface involvement. It is controversial whether the severity evaluation of patients with several affected areas (having at least one difficult-to-treat area) should be done differently from current methods. Scores used for special areas (PSSI, NAPSI and ESIF) allow an accurate assessment of disease severity in difficult-to-treat areas, but the issue of whether to integrate these scores into PASI, BSA or DLQI remains. The review's purpose resides in providing an overview of the main current issues in determining psoriasis severity in patients with psoriasis in difficult-to-treat areas and suggesting possible solutions for the optimal integration of the area assessment in current scores: severity can be either established according to the highest calculated score (PASI or PSSI or NAPSI or ESIF) or by adding a correction factor in the calculation of PASI for special areas.

Relevant insights into onychomycosis' pathogenesis related to the effectiveness topical treatment

Onychomycosis (OM) is a fungal infection, responsible for about 50% of nail diseases. OM has been attributed to the ability of fungi to naturally organize themselves into biofilms on nail surfaces. However, little is known about the exact role of the biofilm in the etiopathogenesis of OM, as well as its influence in the permeation of a topical treatment. The objectives of this study were to review the literature for topical OM treatments in clinical trials, assess the efficiency of these treatments, and discuss factors that could affect the success of these treatments. First, a systematic search of articles published in the MEDLINE database (PubMed) between January 2010 and December 2019 was conducted, focusing on drugs under clinical trials for the topical treatment of OM. Of the publications selected, it was clear that none of them had considered the fungi organized in biofilm. Therefore, we reflected on some important variables involved in OM, such as the nail structure and the mechanism of fungal invasion. Some methods, such as histopathologic analysis and spectroscopy techniques, were found to be effective in the detection of nail biofilm, and could be used in future drug permeation studies. This review allowed us to conclude that novel antifungals for the topical treatment of OM must consider the drug to permeate through biofilm. Natural products, such as propolis, seem strong candidates in this respect.

Chronic Plaque Psoriasis in Poland: Disease Severity, Prevalence of Comorbidities, and Quality of Life

The epidemiology of psoriasis has not been widely assessed in Polish population so far. This study aimed to investigate psoriasis epidemiological situation by evaluating disease course and severity, management, comorbidities, environmental factors, and knowledge about this disorder among psoriatic patients in Poland. A cross-sectional cohort population-based study enrolled 1080 psoriatic patients and 1200 controls. The mean age of psoriasis onset was 27.6 years; 78.24% had type I psoriasis. Positive family history of psoriasis was reported in 44.81% of patients, whereas itch was reported in vast majority of patients (83.33%). Based on PASI score moderate psoriasis was the most common in studied group (mean 12.63 ± 9.33, range 0−67.2). The DLQI score (12.01 ± 7.41, range 0−30.0) indicated a very large effect of psoriasis on the quality of life. Hypertension was the most prevalent comorbidity (33.80%), followed by obesity (16.85%) and dyslipidemia (11.85%). Stress was the foremost cause of disease exacerbation (66.20%); however, infections (44.07%) and seasonal changes (45.09%) had also an impact on the course of psoriasis. Psoriatic patients were more often smokers (37.59%) vs. general population (27.50%; p < 0.0001). In conclusion, epidemiological studies help clinicians in better disease and patient understanding, which may translate into better management and patient compliance.

Treatment of nail diseases in the emergency department

BACKGROUND

Although Americans seek care for their nail diseases on an outpatient basis, they also seek nail care in the setting of the emergency department (ED).

PURPOSE

This study aims to characterize the treatment of nail diseases at ED visits in the United States from 2009-2018.

METHODS

Data from 2009-2018 was collected from the National Hospital Ambulatory Medical Care Survey for EDs.

RESULTS

There was an estimated 1.54 (95% CI [1.35, 1.74]) million nail visits to the ED from 2009-2018. Whites accounted for the most visits (57%), followed by African Americans (21%). 25-44-year-olds was the age group with the most visits. The South was the region with the most visits (33%). The most common diagnosis was paronychia (42%). Treatments for paronychia included oral antibiotics, incision and drainage, or both.

LIMITATIONS

The accuracy of reporting the correct diagnosis remains the biggest limitation.

CONCLUSIONS

Nail disease visits accounted for over a million visits to the ED from 2009-2018. All ages and sexes were represented in these visits. Paronychia made up the largest portion of visits and was treated with oral antibiotics, incision and drainage, or both.

The Impact of Nail Psoriasis and Treatment on Quality of Life: A Systematic Review

At least 80% of patients with psoriasis will have nail involvement during their lifetimes. Understanding quality of life (QoL) impact of this condition and associated treatments is of utmost importance. Study objectives were to review the available literature describing patient-reported QoL outcomes in nail psoriasis and relationship with disease severity and treatment. A literature search was performed for English-language articles published prior to August 1, 2020. Articles were included in the review if primary data and validated patient-reported outcome measures assessing QoL were presented, and nail involvement was specifically examined. Fifteen studies were included in the final analysis. Patients with nail psoriasis had higher Psoriasis Area Severity Index and Dermatology Life Quality Index scores than those with psoriasis without nail involvement. The largest percent improvement in QoL score was associated with adalimumab. Studies investigating topicals, intralesionals, and systemic treatments were excluded since only biologic studies utilized validated patient-reported outcome measures. This review affirms that nail psoriasis is physically and emotionally distressing, warranting prompt treatment. Increased efforts are needed to address the impact of treatment on patient QoL using validated outcome measures that assess cosmetic, physical, and social problems.

Assessment of work-related symptoms, perceived knowledge, and attitude among nail salon technicians

OBJECTIVES

Beauty is a Lebanese stereotype, as Lebanese women often feel urged to decorate themselves. Recent studies have raised concerns about nail salon technicians' (NSTs) health and safety issues. The aim of our study was to evaluate the occupational symptoms reported by NSTs, to assess their knowledge and document their awareness regarding hazardous chemicals found in nail cosmetics.

METHODS

NSTs completed a researcher-administered questionnaire. Data were gathered on sociodemographic characteristics, perceived knowledge, and safety issues. Work-related symptoms reported by NSTs were evaluated, and their responses were compared to those of the office employees.

RESULTS

A total of 120 NSTs and 120 office employees were interviewed. Compared to the control group, NSTs reported a higher prevalence of work-related respiratory, dermal, and irritative symptoms, all significantly associated with smoking and a poor ventilation system. In addition, musculoskeletal complaints were common among NSTs and significantly linked to a poor ventilation system, an increased number of customers per day, and a longer service duration. Furthermore, a longer career duration was significantly associated with an increased prevalence of irritative symptoms. When a binary logistic regression was carried out, it demonstrated a 25 times higher prevalence of work-related symptoms among NSTs compared to the office employees. Interestingly, 84% of the respondents had an inaccurate knowledge of nail cosmetics' risks with their educational level acting as key factor.

CONCLUSIONS

Based on these findings, it is warranted to perform a clinical assessment, implement a stringent regulatory framework, and improve knowledge toward nail cosmetics' risk.

Foot care knowledge and practices among Japanese nurses and care workers in home care and adult service center: a cross- sectional study

Background

Foot care knowledge and practices among nurses and care workers in the community greatly impact foot health maintenance and prevention of foot-related problems among older people. This study aimed to explore and examine the current foot care knowledge, practices, and perceptions among nurses and care workers at home care and adult day service center, along with their demographic characteristics and daily care for clients.

Methods

This study analyzed 232 randomly selected front-line nurses and care workers working at home care or adult day service center in one of the selected cities, Aichi Prefecture, Japan. Data were obtained using questionnaires and subsequently analyzed using descriptive statistics, t-tests, Chi-square tests, Wilcoxon rank-sum tests, and Spearman's rank correlation tests.

Results

Among the 305 surveyed, 232 (62 nurses; 170 care workers) provided data. Although 57 nurses (91.9%) and 142 care workers (83.5%) showed interest in foot care, 33 nurses (53.2%) and 133 care workers (78.2%) stated that foot care education was insufficient. Knowledge and practice scores were associated with working status.Higher accuracy differences in the early detection of foot problems and skin tears on lower limbs in knowledge category were observed between nurses and care workers. The nurses as well as the care workers had low accuracy rates of knowledge questions regarding the use of shoes and socks subscale.For practice, both nurses and care workers had low mean scores for checking client's shoes (2.0/5.0 and 2.1/5.0, respectively), method for reducing ingrown nail pain (2.6/5.0 and 1.9/5.0, respectively), and opportunity for discussing foot care with others (2.7/5.0 and 2.2/5.0, respectively). A significant correlation between knowledge and practice scores was observed among nurses (0.331, p < 0.05) and care workers (0.339, p < 0.001).

Conclusions

Despite the presence of several barriers toward enhanced care delivery to clients needing it most, nurses and care workers clearly understood the importance of foot care. These findings indicate that foot care should be focused by nurses and care workers to improve the knowledge and practice of foot care and to suggest future implications that efficient and understandable tools are needed considering their current working situation.

The Impact of Onychopathies on Quality of Life: A Hospital-based, Cross-sectional Study

Background:

Onychopathies or nail disorders are associated with social stigma and causes limitation of daily activities by hampering the function of both fingers and toes.

Aim:

To evaluate the impact of onychopathies on quality of life (QoL) and compare the severity of impact on QoL in various nail disorders.

Materials and Methods:

A hospital-based cross-sectional study consisting of 540 patients with onychopathies was conducted in the dermatology outpatient department. Patients were requested to complete a nail-specific QoL questionnaire consisting of 24 and 16 questions, respectively, for fingernails (group F) and toenails (group T) with five possible responses to each question. A score of 1-5 was given to each response. Statistical analysis was done to compare the impact of QoL on the different types of onychopathies.

Results:

We found that onychopathies have a significant impact on QoL. QoL was significantly more affected when multiple nails were involved (P = 0.020 for group F and P = 0.001 for group T). QoL impact was statistically more significant in women (P = 0.038 for group F and P < 0.001 for group T) and in younger people aged <20 years in group F and 20-39 years in group T (P < 0.001 for both groups F and T). Patients with onychomycosis, structural nail defects, and psoriasis had a more significant impact than other diseases (P < 0.001 for both groups F and T).

Conclusion:

Onychopathies have a significant adverse effect on QoL because of their serious physical, psychological and social impact. Hence, clinicians should treat the nail disorders with utmost seriousness.

Epidemiology of psoriasis in hard-to-treat body locations: data from the Danish skin cohort

BACKGROUND

Having psoriasis in hard-to-treat areas, i.e. the scalp, face, palms, soles, nails, and genitals, respectively, can impair patients' quality of life. We investigated the prevalence of hard-to-treat body locations of psoriasis, and described patients' clinical and demographic characteristics, and quality of life impacts in a population-based cohort.

METHODS

We performed a cross-sectional study using a total of 4016 adults (≥18 years) with psoriasis from the Danish Skin Cohort. Groups were compared to patients without involvement of hard-to-treat areas.

RESULTS

The most frequently affected hard-to-treat area was the scalp (43.0%), followed by the face (29.9%), nails (24.5%), soles (15.6%), genitals (14.1%), and palms (13.7%), respectively. Higher prevalence was generally seen with increasing psoriasis severity. Among all patients 64.8, 42.4, and 21.9% of patients had involvement of ≥1, ≥2, or ≥ 3 hard-to-treat areas. Those with involvement of certain hard-to-treat areas such as hands, feet, and genitals had clinically relevant DLQI impairments. Having involvement of one hard-to-treat area was significantly associated with other hard-to-treat areas affected even after adjusting for age, sex, and psoriasis severity.

CONCLUSION

Psoriasis commonly affects hard-to-treat locations, even in patients with mild disease. For some of these areas, patient-reported disease burden, e.g. as measured by DLQI, is impaired.

Topical and device-based treatments for fungal infections of the toenails

BACKGROUND

Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails.

OBJECTIVES

To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis.

SEARCH METHODS

We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events.

MAIN RESULTS

We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment.

AUTHORS' CONCLUSIONS

Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.

Dermatologic conditions in women receiving systemic cancer therapy

As advances in cancer therapies have improved cancer-related survival, novel therapeutics have also introduced a variety of dermatologic toxicities, and an increased number of patients are living with these sequalae. Women with cancer in particular experience a spectrum of dermatologic conditions that affect their skin, hair, nail, and mucosal surfaces. Studies have shown that these toxic effects can significantly affect quality of life and alter a woman's self-image, cultural identity, femininity, sexuality, and mental health. In severe instances, dermatologic toxicities may even disrupt cancer therapy and can therefore affect overall survival and treatment response. In this article, we review the dermatologic adverse effects from traditional chemotherapy, targeted therapy, immune checkpoint inhibitors, and endocrine therapy that disproportionately affect women. The timely diagnosis and management of these dermatologic conditions is crucial in the multidisciplinary care of women with cancer.

The Impact of Onychomycosis on Quality of Life: A Systematic Review of the Available Literature

Purpose

Onychomycosis is a nail disorder that is increasing in prevalence worldwide. The psychological and social limitations caused by onychomycosis can potentially undermine the work and social lives of those experiencing these negative effects. This review aimed to evaluate the randomized controlled trials (RCTs) available in the current literature on the impact onychomycosis has on quality of life (QoL).

Methods

A systematic review was performed using the databases PubMed, PsycINFO, Scopus, ClinicalTrials.gov, and Cochrane Library on July 18, 2017. Only RCTs with clinical effects described in English were included for review.

Results

Ten RCTs reported QoL outcomes for patients suffering from onychomycosis. Treatment satisfaction was statistically significant from baseline to end of treatment in 100.0% (4/4) measures which reported on satisfaction with treatment; mental health was also significant in 100.0% (3/3), symptoms index rating in 100.0% (2/2), symptom frequency in 75.0% (3/4), overall problems in 75.0% (3/4), functional activities in 75.0% (6/8), appearance problems in 66.7% (2/3), symptom distress in 57.1% (4/7), and stigma in 40.0% (2/5). The OnyCOE-t^TM and the NailQoL were the most used common outcome measures to describe QoL.

Conclusion

The study sanctions that onychomycosis physically and psychologically distresses patients' lives. Further research should include validated outcome measures to more effectively treat onychomycosis.

Potential of Ravuconazole and its Prodrugs as the New OralTherapeutics for Onychomycosis

Onychomycosis is a fungal infection of the nail apparatus caused by dermatophytes, Candida and non-dermatophytic molds. It is highly prevalent in the general population worldwide and also responsible for significant morbidity and complications and does not usually cure itself. Thus, the condition needs to be treated in view of physical and psychological problems produced. Currently, oral medications using terbinafine are the most effective therapy, but it has relatively limited therapeutic success, particularly for long-term management. Such existing oral therapies are associated with high recurrence rates and treatment failure, as well as with potential adverse events and drug-drug interactions. In the light of these issues, development of more efficacious and safer alternatives for the treatment of onychomycosis is warranted.Ravuconazole and its prodrugs are promising new drug candidates for oral therapy of onychomycosis, among which a water-soluble prodrug, mono-lysine phosphoester derivative (E1224 or BFE1224) is in the most advanced stage of clinical development; a Phase II dose-finding study has been successfully completed and Phase III comparative studies are in progress in Japan.This review aims to summarize our current status of knowledge and information on ravuconazole and its prodrugs, particularly BFE1224, as the potential oral treatment option for onychomycosis. It also summarize the clinical features of onychomycosis with particular stress on its etiology, epidemiology, and current therapeutic options and their limitations. Given its clinical usefulness, BFE1224 may become a valuable addition to the current armamentarium for the treatment of onychomycosis.

Photobiomodulation with non-thermal lasers: Mechanisms of action and therapeutic uses in dermatology and aesthetic medicine

BACKGROUND

Non-thermal laser therapy in dermatology, is a growing field in medical technology by which therapeutic effects are achieved by exposing tissues to specific wavelengths of light.

OBJECTIVES

The purpose of this review was to gain a better understanding of the science behind non-thermal laser and the evidence supporting its use in dermatology.

METHODS

A group of dermatologists and surgeons recently convened to review the evidence supporting the use of non-thermal laser for body sculpting, improving the appearance of cellulite, and treating onychomycosis.

RESULTS

The use of non-thermal laser for body sculpting is supported by three randomized, double-blind, sham-controlled studies (N = 161), one prospective open-label study (N = 54), and two retrospective studies (N = 775). Non-thermal laser application for improving the appearance of cellulite is supported by one randomized, double-blind, sham-controlled study (N = 38). The use of non-thermal laser for the treatment of onychomycosis is supported by an analysis of three non-randomized, open-label studies demonstrating clinical improvement of nails (N = 292).

CONCLUSIONS

Non-thermal laser is steadily moving into mainstream medical practice, such as dermatology. Although present studies have demonstrated the safety and efficacy of non-thermal laser for body sculpting, cellulite reduction and onychomycosis treatment, studies demonstrating the efficacy of non-thermal laser as a stand-alone procedure are still inadequate.

Toenail Onychomycosis—A Canadian Approach With a New Transungual Treatment

Background:

Onychomycosis is a difficult-to-treat infection whose current treatment paradigm relies primarily on oral antifungals. The emergence of new topical drugs broadens the therapeutic options and prompts a re-evaluation of the current Canadian treatment strategy.

Objective:

To define a patient-centred Canadian treatment strategy for onychomycosis.

Methods:

An expert panel of doctors who treat onychomycosis was convened. A systematic review of the literature on treatments for onychomycosis was conducted. Based on the results, a survey was designed to determine a consensus treatment system.

Results:

First-line therapy should be selected based on nail plate involvement, with terbinafine for severe onychomycosis (>60% involvement), terbinafine or efinaconazole for moderate onychomycosis (20%-60% involvement), and efinaconazole for mild onychomycosis (<20% involvement). Comorbidities, patient preference and adherence, or nail thickness may result in the use of alternative oral or topical antifungals.

Conclusion:

These guidelines allow healthcare providers and patients to make informed choices about preventing and treating onychomycosis.

A hand surgeon's guide to common onychodystrophies

The human fingernail contributes to the precise dexterity of the fingers, enhances sensibility, allows manipulation of fine objects, and shields the fingertip from traumatic injury. Nail abnormalities are a common incidental finding in the course of a hand surgeon's daily practice. These abnormalities may be clues to systemic, dermatologic, traumatic, and infectious processes that would benefit from further evaluation and treatment. The purpose of this review is to discuss common nail dystrophies and their related diagnoses.

Nail Psoriasis, the unknown burden of disease

BACKGROUND

Psoriasis can be found at several different localizations which may be of various impact on patients' quality of life (QoL). One of the easy visible, and difficult to conceal localizations are the nails.

OBJECTIVE

To achieve more insight into the QoL of psoriatic patients with nail psoriasis, and to characterize the patients with nail involvement which are more prone to the impact of the nail alterations caused by psoriasis.

METHOD

A self-administered questionnaire was distributed to all members (n = 5400) of the Dutch Psoriasis Association. The Dermatology Life Quality Index (DLQI) and the Nail Psoriasis Quality of life 10 (NPQ10) score were included as QoL measures. Severity of cutaneous lesions was determined using the self-administered psoriasis area and severity index (SAPASI).

RESULTS

Patients with nail psoriasis scored significantly higher mean scores on the DLQI (4.9 vs. 3.7, P = <0.001) and showed more severe psoriasis (SAPASI, 6.6 vs. 5.3, P = <0.001). Patients with coexistence of nail bed and nail matrix features showed higher DLQI scores compared with patients with involvement of one of the two localizations exclusively (5.3 vs. 4.2 vs. 4.3, P = 0.003). Patients with only nail bed alterations scored significant higher NPQ10 scores when compared with patients with only nail matrix features. Patients with psoriatic arthritis (PsA) and nail psoriasis experiences more impairments compared with nail psoriasis patients without PsA (DLQI 5.5 vs. 4.3, NPQ10 13.3 vs. 7.0). Females scored higher mean scores on all QoL scores.

CONCLUSION

Greater attention should be paid to the possible impact nail abnormalities have on patients with nail psoriasis, which can be identified by nail psoriasis specific questionnaires such as the NPQ10. As improving the severity of disease may have a positive influence on QoL, the outcome of QoL measurements should be taken into account when deciding on treatment strategies.

A cutting edge overview: psoriatic disease

Psoriasis is a lifelong skin disease, affecting about 2% of the global population. Generalized involvement of the body (erythroderma), extensive pustular lesions, and an associated arthritis known as psoriatic arthritis (PsA) are severe complications of psoriasis. Genetic, immunologic, and environmental factors contribute to its pathogenesis. A complete understanding of the pathogenesis of psoriasis and psoriatic arthritis is lacking. Cytokines, chemokines, adhesion molecules, growth factors like NGF, neuropeptides, and T cell receptors all act in an integrated way to evolve into unique inflammatory and proliferative processes typical of psoriasis and PsA. Management of psoriasis requires exemplary skin care along with careful monitoring of arrays of comorbidities which includes arthritis and coronary artery disease. In many ways, psoriasis can be considered a model autoimmune disease. This statement itself is ironic considering that it was not recognized as immune mediated until relatively recently. Fortunately, the immunobiology has made enormous strides and there are now excellent therapeutic options for patients. In this thematic review, we have attempted to provide summaries of not only basic science and clinical research, but also an overview of future research directions.

Identification of psoriatic patients at risk of high quality of life impairment

Psoriasis is a systematic chronic disease with large influence on patients' quality of life (QoL). The aim of this study was to assess the QoL of patients with psoriasis using generic, dermatology-specific and psoriasis-specific instruments simultaneously, to investigate the relationships between dimensions or subscales of the questionnaires and to identify categories of patients at risk of a high QoL impairment. The study comprised 100 consecutive patients with psoriasis treated at the Department of Dermatology, Clinical Center "Zvezdara", Belgrade, from January to December 2011. Three QoL questionnaires were administered: the EuroQol-5D (EQ-5D), the Dermatological Life Quality Index (DLQI) and the Psoriasis Disability Index (PDI). The Psoriasis Area and Severity Index was used in evaluating disease severity. According to our results the QoL of psoriatic patients was impaired (the overall DLQI and PDI scores were 10.5 ± 7.2 and 13.4 ± 8.7, respectively, while EQ visual analog scale score was 48.8 ± 25.1). The most predictive factor of QoL impairment was disease severity, followed by sole and nail involvement. Psoriatic arthritis and bleeding were also associated with impaired QoL. Significant correlations between the instruments used in this study were in the expected directions. Mainly strong and moderate significant correlations ranging 0.26-0.84 were seen between DLQI and PDI instruments. A detailed approach to QoL assessment may give to the dermatologist useful information that could be of help in identifying patients belonging to categories at risk of high QoL impairment due to psoriasis, thus guiding them in clinical practice.

Safety and tolerability of luliconazole solution 10-percent in patients with moderate to severe distal subungual onychomycosis

The study objective was to evaluate the safety, tolerability, systemic exposure, and pharmacokinetics (PK) of 10% luliconazole solution (luliconazole) when topically applied once daily to all 10 toenails and periungual areas in patients with moderate to severe distal subungual onychomycosis. In this single-center, open-label study, 24 patients applied 20 mg/ml of luliconazole (twice the clinical dose) for 29 days with a 7-day follow-up. Complete PK profiles were determined on days 1, 8, 15, and 29. Safety/tolerability assessments included application site reactions, adverse events, vital signs, clinical laboratory findings, and electrocardiograms. Mean luliconazole plasma concentrations remained around the lower limit of quantitation (0.05 ng/ml) and were comparable on days 8, 15, and 29 (range, 0.063 to 0.090 ng/ml), suggesting steady state occurred by day 8. Every patient had undetectable plasma luliconazole levels for at least 11% of the time points, and 12 of the 24 patients had undetectable levels for at least 70% of the time points. The maximum plasma concentration of luliconazole (C(max)) observed in any patient was 0.314 ng/ml and the maximum area under the concentration-time curve from 0 to 24 h (AUC0-24) was 4.34 ng · h/ml. Five patients (21%) had measureable luliconazole levels in the plasma 7 days after the last dose. The median concentration of luliconazole in the nail at this time point was 34.65 mg/g (from 42 of 48 collected toenail samples). There was one mild incidence of skin erythema on day 5 that resolved on day 8, there were no reports of drug-induced systemic side effects, and there was no evidence of QT prolongation. Luliconazole, when applied once daily to all 10 fungus-infected toenails for 29 days, is generally safe and well tolerated and results in significant accumulation of drug in the nail. Systemic exposure is very low, with no evidence of drug accumulation.

Quality of life in patients with toenail onychomycosis

Onychomycosis is a common, chronic fungal nail infection that can have a significant negative impact on patients' physical and social functioning and emotional well-being. This study was undertaken to assess health-related quality of life (HRQoL) in patients with toenail onychomycosis. The Onychomycosis QoL questionnaire (ONYCHO), as a disease-specific instrument, and the Short Form 36 Health Survey (SF-36) as a generic instrument, were applied in 140 consecutive patients affected by onychomycosis. Women and patients who were experiencing toenail onychomycosis for more than 2 years were reporting worse disease-specific HRQoL. The patients working in blue-collar occupations and patients with greater involvement of individual nails were more affected by onychomycosis regarding symptoms. The results of this study confirm that although onychomycosis is not a life-threatening disease, it can significantly reduce patients' QoL.

Ultrasonography reveals nail thickening in patients with chronic plaque psoriasis

Nail psoriasis is usually investigated and diagnosed by clinical examination. Ultrasonography is a non-invasive imaging technique for studying soft tissue involvement. The objective of this study was to estimate nail involvement in patients with chronic plaque psoriasis by ultrasonography. Prevalence, clinical type and severity of nail involvement according to nail psoriasis and severity index (NAPSI) were investigated in 138 patients with psoriasis. The thickness of the plate and bed of the fingernails was measured in 54 patients with psoriasis, 46 healthy controls and 37 patients with chronic eczema, using an ultrasonographic system equipped with a frequency transducer of 18 MHz. The prevalence of nail psoriasis was 73 % (102 out of 138). Onycholysis and thickening of the nail plate were the most common clinical type affecting 56 and 50 % of patients, respectively; splinter haemorrhages was the less common involving 10 % of patients. The mean NAPSI score was 18.4 ± 17.5 (SD; range 0-107). The thickness of fingernail plate and bed was significantly higher in patients with psoriasis with nail disease compared to healthy controls and patients with chronic eczema (p < 0.001). There was a linear correlation between NAPSI and plate and bed nail thickness (r = 0.52 and r = 0.38, p = 0.001). Increased nail plate and bed thickness was observed also in patients with psoriasis without clinically apparent nail involvement. In conclusion, thickening of the nail is a common feature of nail psoriasis also in patients without clinically apparent nail involvement.

New therapeutic options for onychomycosis

INTRODUCTION

Onychomycosis is a fungal infection of the nail apparatus that affects 10 - 30% of the global population. Current therapeutic options for onychomycosis have a low to moderate efficacy and result in a 20 - 25% rate of relapse and reinfection. New therapeutic options are needed to broaden the spectrum of treatment options and improve the efficacy of treatment.

AREAS COVERED

This review discusses the emerging pharmacotherapeutics; including topical reformulations of terbinafine, new azole molecules for systemic and topical administration, topical benzoxaboroles and topical polymer barriers. The paper also discusses device-based options, which may be designed to activate a drug or to improve drug delivery, such as photodynamic therapy and iontophoresis; laser device systems have also begun to receive regulatory approval for onychomycosis.

EXPERT OPINION

Device-based therapeutic options for onychomycosis are expanding more rapidly than pharmacotherapy. Systemic azoles are the only class of pharmacotherapy that has shown a comparable efficacy to systemic terbinafine; however terbinafine remains the gold standard. The most notable new topical drugs are tavaborole, efinaconazole and luliconazole, which belong to the benzoxaborole and azole classes of drugs. Photodynamic therapy, iontophoresis and laser therapy have shown positive initial results, but randomized controlled trials are necessary to determine the long-term success of these devices.