1
|
Gupta AK, Wang T, Polla Ravi S, Mann A, Bamimore MA. Global prevalence of onychomycosis in general and special populations: An updated perspective. Mycoses 2024; 67:e13725. [PMID: 38606891 DOI: 10.1111/myc.13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge. OBJECTIVE To provide an updated estimate on the prevalence of toenail onychomycosis. METHODS We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients. RESULTS A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture. CONCLUSION Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | - Tong Wang
- Mediprobe Research Inc., London, Ontario, Canada
| | | | | | | |
Collapse
|
2
|
Gupta AK, Wang T, Cooper EA, Summerbell RC, Piguet V, Tosti A, Piraccini BM. A comprehensive review of nondermatophyte mould onychomycosis: Epidemiology, diagnosis and management. J Eur Acad Dermatol Venereol 2024; 38:480-495. [PMID: 38010049 DOI: 10.1111/jdv.19644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 11/29/2023]
Abstract
Nondermatophyte moulds (NDMs) are widely distributed and can be detected in association with mycotic nails; however, sometimes it can be challenging to establish the role of NDMs in the pathogenesis of onychomycosis (i.e. causative vs. contaminant). In studies where the ongoing invasive presence of NDMs is confirmed through repeat cultures, the global prevalence of NDMs in onychomycosis patients is estimated at 6.9% with the 3 most common genus being: Aspergillus, Scopulariopsis and Fusarium. NDM onychomycosis can, in many cases, appear clinically indistinguishable from dermatophyte onychomycosis. Clinical features suggestive of NDMs include proximal subungual onychomycosis with paronychia associated with Aspergillus spp., Fusarium spp. and Scopulariopsis brevicaulis, as well as superficial white onychomycosis in a deep and diffused pattern associated with Aspergillus and Fusarium. Longitudinal streaks seen in patients with distal and lateral onychomycosis may serve as an additional indicator. For diagnosis, light microscopic examination should demonstrate fungal filaments consistent with an NDM with at least two independent isolations in the absence of a dermatophyte; the advent of molecular testing combined with histological assessment may serve as an alternative with improved sensitivity and turnover time. In most instances, antifungal susceptibility testing has limited value. Information on effective treatments for NDM onychomycosis is relatively scarce, unlike the situation in the study of dermatophyte onychomycosis. Terbinafine and itraconazole therapy (continuous and pulsed) appear effective to varying extents for treating onychomycosis caused by Aspergillus, Fusarium or Scopulariopsis. There is scant literature on oral treatments for Neoscytalidium.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | - Tong Wang
- Mediprobe Research Inc., London, Ontario, Canada
| | | | - Richard C Summerbell
- Sporometrics, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
| | - Antonella Tosti
- Fredric Brandt Endowed Professor of Dermatology, University of Miami, Miami, Florida, USA
| | - Bianca Maria Piraccini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| |
Collapse
|
3
|
Yazdanpanah S, Jabrodini A, Motamedi M, Zomorodian K, Kharazi M, Shabanzadeh S, Ghasemi F, Shariat S, Rezaei Arab M. Species distribution and antifungal susceptibility profiles of yeasts isolated from onychomycosis: a cross-sectional study with insights into emerging species. Antonie Van Leeuwenhoek 2023; 117:6. [PMID: 38153531 DOI: 10.1007/s10482-023-01914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/01/2023] [Indexed: 12/29/2023]
Abstract
Candida onychomycosis is a common fungal infection affecting the nails, primarily caused by Candida (C.) species. Regarding the increasing trend of Candida onychomycosis and the antifungal resistant phenomenon in recent years, this study aims to evaluate the epidemiological characteristics of Candida onychomycosis, the distribution of emerging species, and the antifungal susceptibility profiles of isolates. Onychomycosis caused by yeast species was confirmed through direct examination and culture of nail scraping among all individuals suspected to have onychomycosis and referred to a medical mycology laboratory between June 2019 and March 2022. Species of yeast isolates were identified using the multiplex PCR and PCR-RFLP methods. The antifungal susceptibility of isolates to common antifungal agents and imidazole drugs was evaluated according to the M-27-A3 CLSI protocol. Among 101 yeast strains isolated from onychomycosis, Candida parapsilosis complex (50.49%) was the most common species, followed by C. albicans (20.79%) and C. tropicalis (10.89%). Rare species of yeasts such as C. guilliermondii and Saccharomyces cerevisiae were also identified by molecular methods. Results obtained from antifungal susceptibility testing showed significant differences in MIC values of isoconazole, fenticonazole, and sertaconazole among different species. Overall, a fluconazole-resistant rate of 3% was found among Candida species. Moreover, there was a statistically significant difference in MICs of fenticonazole and clotrimazole between the two most prevalent causative species, C. parapsilosis complex and C. albicans. Correct identification of the causative agents of onychomycosis and performing susceptibility testing could be helpful in choosing the most appropriate antifungal therapy.
Collapse
Affiliation(s)
- Somayeh Yazdanpanah
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Jabrodini
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marjan Motamedi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahboobeh Kharazi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shafigheh Shabanzadeh
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farnia Ghasemi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sahar Shariat
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Rezaei Arab
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
4
|
Gupta AK, Cooper EA, Wang T, Polla Ravi S, Lincoln SA, Piguet V, McCarthy LR, Bakotic WL. Detection of Squalene Epoxidase Mutations in United States Patients with Onychomycosis: Implications for Management. J Invest Dermatol 2023; 143:2476-2483.e7. [PMID: 37236595 DOI: 10.1016/j.jid.2023.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Resistance to oral terbinafine, the most commonly used antifungal to treat dermatophytosis and onychomycosis worldwide, is being increasingly reported. In this study, we aimed to investigate the species distribution and prevalence of squalene epoxidase mutations among toenail dermatophyte isolates. Samples from 15,683 patients suspected of onychomycosis visiting the offices of dermatologists and podiatrists in the United States were analyzed. Clinical information was reviewed, and dermatophyte species with or without squalene epoxidase mutations were detected using multiplex real-time PCRs. The frequency of dermatophytes was 37.6%; of isolates belonging to the Trichophyton genus, 88.3% were the T. rubrum complex, and 11.2% were the T. mentagrophytes complex. Individuals aged >70 years exhibited higher infection rates for the T. mentagrophytes complex. The overall mutation rate among Trichophyton spp. was 3.7%, with a higher mutation rate detected in the T. mentagrophytes complex (4.3 vs. 3.6%). Commonly detected mutations were T1189C/Phe397Leu (34.5%), T1306C/Phe415Ser (16.0%), and C1191A/Phe397Leu (11.0%). Squalene epoxidase gene mutations associated with decreased terbinafine susceptibility have been identified in United States patients with toenail onychomycosis. Physicians should be aware of the risk factors for resistance development and engage in antifungal stewardship practices such as directed diagnosis and treatment of dermatophytosis and onychomycosis.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Mediprobe Research, London, Ontario, Canada.
| | | | - Tong Wang
- Mediprobe Research, London, Ontario, Canada
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
| | | | | |
Collapse
|
5
|
Marin-Maldonado F, Pacheco-Torres AL, Gustafson E. Comparative analysis of onychomycosis in Puerto Rico using molecular and conventional approaches. J Mycol Med 2023; 33:101412. [PMID: 37451067 DOI: 10.1016/j.mycmed.2023.101412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Onychomycosis is the most prevalent nail ailment in adults, accounting for 50% of all nail infections. Dermatophyte fungi are the primary cause, but non-dermatophyte molds (NDM) and yeasts can also cause onychomycosis. It remains important to precisely determine the fungal cause of onychomycosis since the response to current treatments may vary between fungal classes. Real-time polymerase chain reaction (qPCR) has become a widespread tool for detecting fungal organisms for diagnosis due to its sensitivity and ability to detect down to the species level. This retrospective study aims to evaluate the qPCR Onycho+ test for dermatophyte detection using remnants of toenails from a cohort of patients from Puerto Rico. Two hundred forty-two toenail samples submitted for histological examination via Periodic acid Schiff (PAS) staining for suspected onychomycosis were analyzed by the Onycho+ test and Sanger sequencing of the internal transcribed spacer (ITS-2). Compared to the gold standard Sanger sequencing method, the Onycho+ test reported an agreement of 91.39%, a sensitivity of 100% and a specificity of 84.5% in detecting dermatophytes, superior to the histology method which had a 69.53% agreement, 85.1% sensitivity and 57.1% specificity. The distribution of fungal organisms detected in this cohort shows a dermatophyte majority but a higher-than-expected proportion of NDMs. Nails negative for the Onycho+ test and positive for histology were mostly NDMs. This study demonstrates that the clinical performance of the Onycho+ test is superior to histology in detecting dermatophytes and that a combination of Onycho+ and histology can result in a higher clinical accuracy.
Collapse
Affiliation(s)
| | | | - Erik Gustafson
- Research Department, CorePlus Servicios Clínicos y Patológicos LLC.
| |
Collapse
|
6
|
Shetty P, Rangegowda SM, Vinay KN, Ravikumar BC, Nagesha PC. Comparative study of safety and efficacy of combination therapy of fractional CO 2 laser and topical amorolfine cream versus oral itraconazole in the treatment of onychomycosis. Lasers Med Sci 2023; 38:147. [PMID: 37354212 DOI: 10.1007/s10103-023-03804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/08/2023] [Indexed: 06/26/2023]
Abstract
Onychomycosis is a fungal infection of the nail unit caused by various species of dermatophytes, non-dermatophytic moulds or yeasts. They pose a therapeutic challenge to the treating dermatologist as the infection is often resistant to treatment and requires prolonged therapy. To evaluate the efficacy and safety profile of fractional CO2 laser and 0.25% Amorolfine hydrochloride cream in the treatment of onychomycosis. In this randomized controlled study on 50 patients with fingernail onychomycosis, one group (25 patients, 30 nails) were treated with fractional CO2 laser and 0.25% Amorolfine hydrochloride cream, and the second group (25 patients, 31 nails) with oral itraconazole pulse therapy. Four treatment sessions were carried out in the first group at an interval of two weeks each. Whereas, the second group received 2 doses of itraconazole pulse therapy with one month interval each. Both the groups were followed up for a period of 4 months. Results were assessed by Onychomycosis severity index(OSI), Physician global assessment scale, patient's subjective score and fungal microscopy. Complete resolution was seen in 14 out of 25(56%) patients and 6 out of 25(24%) patients in group 1 and group 2 respectively. There was statistically significant difference in the response between the two groups during 1st and 2nd follow up (p value - 0.004 and 0.023 respectively). Fractional CO2 laser with amorolfine cream is proved to be a better modality in onychomycosis therapy compared to oral itraconazole pulse therapy, especially in distal lateral subungual and superficial white onychomycosis.
Collapse
Affiliation(s)
- Prajna Shetty
- Department of DVL, Father Muller Medical College, Mangalore, India
| | | | | | | | | |
Collapse
|
7
|
Costa PDS, Basso ME, Negri M, Svidzinski TIE. In Vitro and Ex Vivo Biofilm-Forming Ability of Rhinocladiella similis and Trichophyton rubrum Isolated from a Mixed Onychomycosis Case. J Fungi (Basel) 2023; 9:696. [PMID: 37504685 PMCID: PMC10381150 DOI: 10.3390/jof9070696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/29/2023] Open
Abstract
Infections caused by biofilm-forming agents have important implications for world health. Mixed infections, caused by more than one etiological agent, are also an emerging problem, especially regarding the standardization of effective diagnosis and treatment methods. Cases of mixed onychomycosis (OM) have been reported; however, studies on the microbial interactions between the different fungi in biofilms formed on nails are still scarce. We describe a case of mixed OM caused by the dermatophyte Trichophyton rubrum and the black yeast-like fungus Rhinocladiella similis. Identical growths of both fungi were observed in more than 50 cultures from different nail samples. Additionally, both species were able to form organized single and mixed biofilms, reinforcing the participation of both fungi in the etiology of this OM case. R. similis seemed to grow faster during the process, suggesting that T. rubrum benefits from biofilm development when in combination. Moreover, the biofilm of the Rhinocladiella isolate exhibited exacerbated production of the extracellular matrix, which was not observed with that of a Rhinocladiella reference strain, suggesting that the isolate had natural abilities that were possibly perfected during development in the nail of the patient.
Collapse
Affiliation(s)
- Polyana de Souza Costa
- Medical Mycology Laboratory, Department of Clinical Analysis and Biomedicine, State University of Maringá, Maringá 87020-900, Brazil
| | - Maria Eduarda Basso
- Medical Mycology Laboratory, Department of Clinical Analysis and Biomedicine, State University of Maringá, Maringá 87020-900, Brazil
| | - Melyssa Negri
- Medical Mycology Laboratory, Department of Clinical Analysis and Biomedicine, State University of Maringá, Maringá 87020-900, Brazil
| | | |
Collapse
|
8
|
Gupta AK, Cooper EA, Wang T, Lincoln SA, Bakotic WL. Single-Point Nail Sampling to Diagnose Onychomycosis Caused by Non-Dermatophyte Molds: Utility of Polymerase Chain Reaction (PCR) and Histopathology. J Fungi (Basel) 2023; 9:671. [PMID: 37367607 DOI: 10.3390/jof9060671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
The three most commonly used methods for diagnosing non-dermatophyte mold (NDM) onychomycosis are culture, polymerase chain reaction (PCR), and histopathology. Toenail samples from 512 patients (1 sample/patient) with suspected onychomycosis were examined using all three diagnostic tests. A statistically significant association was found between PCR and histopathology results, as well as between fungal culture and histopathology results. All PCR-positive and culture-positive dermatophyte samples were confirmed by histopathology. However, 15/116 (12.9%) of culture-positive NDM samples had negative histopathology results, while all PCR-positive NDM samples were confirmed by histopathology. The overall rate of dermatophyte detection was higher using PCR compared to culture (38.9% vs. 11.7%); the lower rate of NDM detection by PCR (11.7% vs. 38.9%) could be attributed to the restriction of the assay design to seven pre-selected targets. When repeat sampling in the clinic is not possible, a combination of NDM detection by PCR and positive histopathology of hyphae may be a proxy for NDM infection, particularly where the NDM occurs without a concomitant dermatophyte. There was a high degree of correlation between negative PCR and negative histopathology. A negative PCR result with negative histopathology findings may be a reliable proxy for the diagnosis of non-fungal dystrophy.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
- Mediprobe Research Inc., London, ON N5X 2P1, Canada
| | | | - Tong Wang
- Mediprobe Research Inc., London, ON N5X 2P1, Canada
| | - Sara A Lincoln
- Bako Diagnostics, 6240 Shiloh Rd, Alpharetta, GA 30005, USA
| | | |
Collapse
|
9
|
Salvador A, Veiga FF, Svidzinski TIE, Negri M. Case of Mixed Infection of Toenail Caused by Candida parapsilosis and Exophiala dermatitidis and In Vitro Effectiveness of Propolis Extract on Mixed Biofilm. J Fungi (Basel) 2023; 9:jof9050581. [PMID: 37233292 DOI: 10.3390/jof9050581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
Onychomycosis is a chronic fungal nail infection caused by several filamentous and yeast-like fungi, such as the genus Candida spp., of great clinical importance. Black yeasts, such as Exophiala dermatitidis, a closely related Candida spp. species, also act as opportunistic pathogens. Fungi infectious diseases are affected by organisms organized in biofilm in onychomycosis, making treatment even more difficult. This study aimed to evaluate the in vitro susceptibility profile to propolis extract and the ability to form a simple and mixed biofilm of two yeasts isolated from the same onychomycosis infection. The yeasts isolated from a patient with onychomycosis were identified as Candida parapsilosis sensu stricto and Exophiala dermatitidis. Both yeasts were able to form simple and mixed (in combination) biofilms. Notably, C. parapsilosis prevailed when presented in combination. The susceptibility profile of propolis extract showed action against E. dermatitidis and C. parapsilosis in planktonic form, but when the yeasts were in mixed biofilm, we only observed action against E. dermatitidis, until total eradication.
Collapse
Affiliation(s)
- Alana Salvador
- Departamento de Análises Clínicas e Biomedicina, Universidade Estadual de Maringá (UEM), Avenida Colombo, 5790, Maringá CEP 87020-900, PR, Brazil
| | - Flávia Franco Veiga
- Departamento de Análises Clínicas e Biomedicina, Universidade Estadual de Maringá (UEM), Avenida Colombo, 5790, Maringá CEP 87020-900, PR, Brazil
| | - Terezinha Inez Estivalet Svidzinski
- Departamento de Análises Clínicas e Biomedicina, Universidade Estadual de Maringá (UEM), Avenida Colombo, 5790, Maringá CEP 87020-900, PR, Brazil
| | - Melyssa Negri
- Departamento de Análises Clínicas e Biomedicina, Universidade Estadual de Maringá (UEM), Avenida Colombo, 5790, Maringá CEP 87020-900, PR, Brazil
| |
Collapse
|
10
|
Costa-Orlandi CB, Bila NM, Bonatti JLC, Vaso CO, Santos MB, Polaquini CR, Santoni Biasioli MM, Herculano RD, Regasini LO, Fusco-Almeida AM, Mendes-Giannini MJS. Membranolytic Activity Profile of Nonyl 3,4-Dihydroxybenzoate: A New Anti-Biofilm Compound for the Treatment of Dermatophytosis. Pharmaceutics 2023; 15:pharmaceutics15051402. [PMID: 37242644 DOI: 10.3390/pharmaceutics15051402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 05/28/2023] Open
Abstract
The ability of dermatophytes to live in communities and resist antifungal drugs may explain treatment recurrence, especially in onychomycosis. Therefore, new molecules with reduced toxicity that target dermatophyte biofilms should be investigated. This study evaluated nonyl 3,4-dihydroxybenzoate (nonyl) susceptibility and mechanism of action on planktonic cells and biofilms of T. rubrum and T. mentagrophytes. Metabolic activities, ergosterol, and reactive oxygen species (ROS) were quantified, and the expression of genes encoding ergosterol was determined by real-time PCR. The effects on the biofilm structure were visualized using confocal electron microscopy, scanning electron microscopy (SEM), and transmission electron microscopy (TEM). T. rubrum and T. mentagrophytes biofilms were susceptible to nonyl and resistant to fluconazole, griseofulvin (all strains), and terbinafine (two strains). The SEM results revealed that nonyl groups seriously damaged the biofilms, whereas synthetic drugs caused little or no damage and, in some cases, stimulated the development of resistance structures. Confocal microscopy showed a drastic reduction in biofilm thickness, and transmission electron microscopy results indicated that the compound promoted the derangement and formation of pores in the plasma membrane. Biochemical and molecular assays indicated that fungal membrane ergosterol is a nonyl target. These findings show that nonyl 3,4-dihydroxybenzoate is a promising antifungal compound.
Collapse
Affiliation(s)
- Caroline B Costa-Orlandi
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Níura M Bila
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
- Department of Para-Clinic, School of Veterinary, Eduardo Modlane University (UEM), Maputo 257, Mozambique
| | - Jean Lucas C Bonatti
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Carolina O Vaso
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Mariana B Santos
- Department of Chemistry and Environmental Sciences, Institute of Biosciences, Humanities and Exact Sciences, São Paulo State University (U.N.E.S.P.), Sao Jose do Rio Preto 15054-000, SP, Brazil
| | - Carlos R Polaquini
- Department of Chemistry and Environmental Sciences, Institute of Biosciences, Humanities and Exact Sciences, São Paulo State University (U.N.E.S.P.), Sao Jose do Rio Preto 15054-000, SP, Brazil
| | - Mariana M Santoni Biasioli
- Department of Biological Sciences, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Rondinelli D Herculano
- Department of Bioprocesses and Biotechnology, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Luis O Regasini
- Department of Chemistry and Environmental Sciences, Institute of Biosciences, Humanities and Exact Sciences, São Paulo State University (U.N.E.S.P.), Sao Jose do Rio Preto 15054-000, SP, Brazil
| | - Ana Marisa Fusco-Almeida
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| | - Maria José S Mendes-Giannini
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (U.N.E.S.P.), Araraquara 14800-903, SP, Brazil
| |
Collapse
|
11
|
Hainsworth S, Lawrie AC, Vanniasinkam T, Grando D. Metagenomics of Toenail Onychomycosis in Three Victorian Regions of Australia. J Fungi (Basel) 2022; 8:1198. [DOI: 10.3390/jof8111198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Onychomycosis is a fungal disease of the nail that is found worldwide and is difficult to diagnose accurately. This study used metagenomics to investigate the microbiology of 18 clinically diagnosed mycotic nails and two normal nails for fungi and bacteria using the ITS2 and 16S loci. Four mycotic nails were from Bass Coast, six from Melbourne Metropolitan and eight from Shepparton, Victoria, Australia. The mycotic nails were photographed and metagenomically analysed. The ITS2 sequences for T. rubrum and T. interdigitale/mentagrophytes averaged over 90% of hits in 14/18 nails. The high abundance of sequences of a single dermatophyte, compared to all other fungi in a single nail, made it the most likely infecting agents (MLIA). Trichophyton rubrum and T. interdigitale/mentagrophytes were found in Bass Coast and Shepparton while only T. interdigitale/mentagrophytes was found in Melbourne. Two nails with T. interdigitale/mentagrophytes mixed with high abundance non-dermatophyte moulds (NDMs) (Aspergillus versicolor, Acremonium sclerotigenum) were also observed. The two control nails contained chiefly Fusarium oxysporum and Malassezia slooffiae. For bacteria, Staphylococcus epidermidis was in every nail and was the most abundant, including the control nails, with an overall mean rate of 66.01%. Rothia koreensis, Corynebacterium tuberculostearicum, and Brevibacterium sediminis also featured.
Collapse
|
12
|
Nikitha S, Kondraganti N, Kandi V. Total Dystrophic Onychomycosis of All the Nails Caused by Non-dermatophyte Fungal Species: A Case Report. Cureus 2022; 14:e29765. [DOI: 10.7759/cureus.29765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
|
13
|
Alfageme-García P, Jiménez-Cano VM, Ramírez-Durán MDV, Gómez-Luque A, Hidalgo-Ruiz S, Basilio-Fernández B. Onychomycosis in Two Populations with Different Socioeconomic Resources in an Urban Nucleus: A Cross-Sectional Study. J Fungi (Basel) 2022; 8:jof8101003. [PMID: 36294568 PMCID: PMC9604941 DOI: 10.3390/jof8101003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/22/2022] Open
Abstract
Onychomycosis is one of the most common foot conditions. Mixed onychomycosis and onychomycosis caused by non-dermatophyte moulds are increasing in incidence, especially in vulnerable populations, hence the importance of this study, which presents the prevalence of onychomycosis in a population of homeless people, comparing the findings with a sample of a well-resourced population. The total sample consisted of 70 participants, divided into two separate groups, a homeless population and a second group in which we included people attending a private clinic. The average age of the sample is [49.19 ± 28.81] with an age range of 18 to 78 years. In the homeless group, the most prevalent infectious agents were non-dermatophyte fungi, with a total of 48%, compared to 28% in the group housed. The most common site of infection in both groups was the nail of the first finger. We, therefore, conclude that there is a difference in the infecting agent in the homeless population and the population with homes.
Collapse
|
14
|
Jansen P, Creosteanu A, Matyas V, Dilling A, Pina A, Saggini A, Schimming T, Landsberg J, Burgdorf B, Giaquinta S, Müller H, Emberger M, Rose C, Schmitz L, Geraud C, Schadendorf D, Schaller J, Alber M, Klauschen F, Griewank KG. Deep Learning Assisted Diagnosis of Onychomycosis on Whole-Slide Images. J Fungi (Basel) 2022; 8:912. [PMID: 36135637 PMCID: PMC9504700 DOI: 10.3390/jof8090912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Onychomycosis numbers among the most common fungal infections in humans affecting finger- or toenails. Histology remains a frequently applied screening technique to diagnose onychomycosis. Screening slides for fungal elements can be time-consuming for pathologists, and sensitivity in cases with low amounts of fungi remains a concern. Convolutional neural networks (CNNs) have revolutionized image classification in recent years. The goal of our project was to evaluate if a U-NET-based segmentation approach as a subcategory of CNNs can be applied to detect fungal elements on digitized histologic sections of human nail specimens and to compare it with the performance of 11 board-certified dermatopathologists. Methods: In total, 664 corresponding H&E- and PAS-stained histologic whole-slide images (WSIs) of human nail plates from four different laboratories were digitized. Histologic structures were manually annotated. A U-NET image segmentation model was trained for binary segmentation on the dataset generated by annotated slides. Results: The U-NET algorithm detected 90.5% of WSIs with fungi, demonstrating a comparable sensitivity with that of the 11 board-certified dermatopathologists (sensitivity of 89.2%). Conclusions: Our results demonstrate that machine-learning-based algorithms applied to real-world clinical cases can produce comparable sensitivities to human pathologists. Our established U-NET may be used as a supportive diagnostic tool to preselect possible slides with fungal elements. Slides where fungal elements are indicated by our U-NET should be reevaluated by the pathologist to confirm or refute the diagnosis of onychomycosis.
Collapse
|
15
|
Costa PDS, Prado A, Bagon NP, Negri M, Svidzinski TIE. Mixed Fungal Biofilms: From Mycobiota to Devices, a New Challenge on Clinical Practice. Microorganisms 2022; 10:microorganisms10091721. [PMID: 36144323 PMCID: PMC9506030 DOI: 10.3390/microorganisms10091721] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022] Open
Abstract
Most current protocols for the diagnosis of fungal infections are based on culture-dependent methods that allow the evaluation of fungal morphology and the identification of the etiologic agent of mycosis. Most current protocols for the diagnosis of fungal infections are based on culture-dependent methods that enable the examination of the fungi for further identification of the etiological agent of the mycosis. The isolation of fungi from pure cultures is typically recommended, as when more than one species is identified, the second agent is considered a contaminant. Fungi mostly survive in highly organized communities that provoke changes in phenotypic profile, increase resistance to antifungals and environmental stresses, and facilitate evasion from the immune system. Mixed fungal biofilms (MFB) harbor more than one fungal species, wherein exchange can occur that potentialize the effects of these virulence factors. However, little is known about MFB and their role in infectious processes, particularly in terms of how each species may synergistically contribute to the pathogenesis. Here, we review fungi present in MFB that are commensals of the human body, forming the mycobiota, and how their participation in MFB affects the maintenance of homeostasis. In addition, we discuss how MFB are formed on both biotic and abiotic surfaces, thus being a significant reservoir of microorganisms that have already been associated in infectious processes of high morbidity and mortality.
Collapse
|
16
|
Powell J, Porter E, Field S, O'Connell N, Carty K, Dunne CP. Epidemiology of dermatomycoses and onychomycoses in Ireland (2001 to 2020): A single-institution review. Mycoses 2022; 65:770-779. [PMID: 35598177 PMCID: PMC9327510 DOI: 10.1111/myc.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/19/2022] [Indexed: 12/01/2022]
Abstract
Background Fungal skin infections are recognised as one of the most common health disorders globally, and dermatophyte infections of the skin, hair and nails are the most common fungal infections. Dermatophytes can be classified as anthropophilic, zoophilic or geophilic species based on their primary habitat association, and this classification makes epidemiological analysis useful for the prevention and control of these infections. The Irish contribution to the epidemiology of these infections has been scant, with just two papers (both reporting paediatric tinea capitis only) published in the last 20 years, and none in the last seven. Objectives To perform a comprehensive retrospective epidemiological analysis of all dermatological mycology tests performed in University Hospital Limerick over a 20‐year period. Methods All mycology laboratory test results were extracted from the Laboratory Information Management System (LIMS, iLab, DXC Technologies) from 2001 to 2020 inclusive for analysis. Specimen types were categorised according to the site of sampling. The data were analysed using Microsoft Excel. Results About 12,951 specimens of skin, hair and nails were studied. Median patient age was 42 years (IQR 26–57) with a slight female preponderance (57.2%). Two thirds of samples (67%, n = 8633) were nail, 32% were skin scrapings (n = 4118) and 200 hair samples (1.5%) were received. Zoophilic dermatophytes were more commonly present in females (38% F, 23% M, proportion of dermatophytes) and in those under 10 years of age or from 45 to 70 years (36% and 34% zoophiles, respectively, proportion of dermatophytes), although anthropophiles predominated every age and gender category. Anthropophiles had their highest prevalence in the 10–20 years age category (80% anthropophiles, proportion of dermatophytes), and yeast infections were more prevalent in older patients (29% of >60 year olds vs. 17% of <60 year olds, proportion of all fungal positives). Trichophyton rubrum was the most prevalent pathogen detected, accounting for 53% of all dermatophytes detected, 61% of those detected from nail samples and 34% from skin and hair samples. Trichophyton tonsurans was the most prevalent dermatophyte in tinea capitis, accounting for 37% of dermatophytes detected. Both of these organisms are anthropophilic, and this group showed consistently increased prevalence in proportion to all fungal isolates. The proportion of this dermatophyte class (anthropophiles) increased among both nail samples and skin/hair samples during the study period, from 55% of samples in the first 5 years of the study (2001–2005) to 88% (proportion of dermatophytes) in the final 5 years. Conversely, yeast detection decreased. Conclusions This study provides a detailed overview of the epidemiology of the fungal cultures of skin, nail and hair samples in the Mid‐West of Ireland over a 20‐year period. Monitoring this changing landscape is important in identifying likely sources of infections, to identifying potential outbreaks, and may help guide empiric treatment. To the best of our knowledge, this study provides the first detailed analysis from Ireland of fungal detections from skin, hair and nail samples, and is the first epidemiological fungal report of any kind in over 7 years.
Collapse
Affiliation(s)
- James Powell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland.,School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Emma Porter
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - Sinead Field
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - Nuala O'Connell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland.,School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Kieran Carty
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Colum P Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| |
Collapse
|
17
|
Gupta AK, Cooper EA, Summerbell RC, Nakrieko KA. Utility of polymerase chain reaction for assessment of onychomycosis during topical therapy. Int J Dermatol 2022; 61:1385-1389. [PMID: 35535809 DOI: 10.1111/ijd.16241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/17/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Increased detection of fungi including non-dermatophyte molds (NDMs) using polymerase chain reaction (PCR) methods is well-established. However, the use of PCR to evaluate ongoing onychomycosis treatment outcome has not been investigated. METHODS Nail samples from 28 patients receiving topical efinaconazole were evaluated by both KOH/culture and PCR methods across the study period. Detection of microorganisms by PCR was compared to the culture at baseline and end of study at month 24 (M24). Fungal detection by both methods was evaluated with respect to clinical cure observed as 100% visual clearance of the target toenail. RESULTS By culture, all 28 subjects were dermatophyte-positive at pre-treatment; only 4/28 also exhibited an NDM microorganism. According to PCR, 24/28 subjects were dermatophyte-positive pre-treatment, with 25/28 also exhibiting NDMs. At M24, 18/28 (64.3%) participants had negative KOH/culture results, in contrast to 4/28 (14.3%) negative PCR results. PCR showed higher rates of NDM detection than the culture at baseline as well as M24. Calculations to compare the diagnostic utility of KOH/culture versus PCR found that positive tests with both methods reliably indicate the presence of onychomycosis, but negative PCR correlated better with onychomycosis cure than did KOH/culture. DISCUSSION PCR confirmed a high presence of NDMs pre-treatment, and continued presence of NDMs to M24, with unknown significance requiring further investigation. Though both KOH/culture and PCR have diagnostic limitations, PCR showed better overall utility than culture in predicting onychomycosis topical treatment outcome and should be more strongly considered for evaluation of topical therapies.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | - Richard C Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
18
|
Bitew A, Osman F, Yassin S. Non-Dermatophyte Mold Dominated Onychomycosis in Patients Attending a Rank Higher Specialized Dermatology Clinic in Addis Ababa, Ethiopia. Clin Cosmet Investig Dermatol 2022; 15:507-518. [PMID: 35356385 PMCID: PMC8958195 DOI: 10.2147/ccid.s357738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/12/2022] [Indexed: 01/19/2023]
Abstract
Background Onychomycosis is a common refractory fungal infection associated with significant morbidity. The objective of this study was to determine the prevalence of onychomycosis, and the diversity and species composition of fungal etiological agents. Materials and Methods A clinic-based, prospective, non-randomized cross-sectional study was carried out between October 2018 and June 2019 at Rank Higher Specialized Dermatology Clinic, Addis Ababa, Ethiopia. Nail scrapings were collected aseptically from 200 patients clinically identified with nail disorders of fungal origin by dermatologists. Fungal etiological agents were identified microscopically and by culture method following standard procedures. Results Among 200 nail scrapings, 161 (80.5%) samples were found out to be culture positive. Of these, 135 (83.9%) samples yielded single colonies while 26 (16.1%) mixed colonies gave a total of 190 isolates. Among the isolates, 25.8% were dermatophytes while 61.1% were non- dermatophytes molds, and 13.1% were yeasts. Females were more likely to present dystrophic nails than men. Patients in the middle age group were more affected. Trichophyton interdigitale, Aspergillus spp, and Candida albicans were the dominant species. Conclusion The prevalence rate of onychomycosis in the present study was high. The isolation rate of non-dermatophyte molds was higher than dermatophytes and yeasts. Trichophyton interdigitale, Aspergillus spp, and Candida albicans were the dominant etiological agents. Females and patients in the middle age group were more affected. An increase in the prevalence of non-dermatophyte molds in nail infections dictates further investigation demonstrating how this group of fungi causes onychomycosis.
Collapse
Affiliation(s)
- Adane Bitew
- Department of Medical Laboratory Science, College Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Feruza Osman
- Saint Peter's Specialized Tuberculosis Referral Hospital, Addis Ababa, Addis Ababa Administrative Region, Ethiopia
| | - Seid Yassin
- International Care and Treatment for HIV/AIDS Program, Emergency Operation Center, Addis Ababa, Ethiopia
| |
Collapse
|
19
|
Abstract
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.
Collapse
Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada. .,Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Mesbah Talukder
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| |
Collapse
|
20
|
Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Skin Appendage Disord 2021; 7:351-358. [PMID: 34604322 DOI: 10.1159/000516112] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Mediprobe Research Inc., London, Ontario, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
| |
Collapse
|
21
|
Grynszpan R, Barreiros G, do Nascimento Paixão M, Frasnelli Fernandes M, Aguinaga F, Camargo C, Ramos-E-Silva M, Carneiro S. Coexistence of onychomycosis and nail psoriasis and its correlation with systemic treatment. Mycoses 2021; 64:1092-1097. [PMID: 34061419 DOI: 10.1111/myc.13331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Epidemiological studies indicate that onychomycosis may affect up to 79% of psoriatic patients. Onychomycosis in psoriatic patients is more commonly caused by yeasts comparing with non-psoriatic. OBJECTIVES Evaluate the prevalence of fungi in nail psoriasis. Evaluate the association between direct mycological examination (DME) and mycological culture, Nail Psoriasis Severity Index (NAPSI) and systemic treatment for psoriasis. METHODS Of 133 nails from 20 patients with nail psoriasis were evaluated as follows: 9 patients were using topical treatment and 11 were on systemic treatment. The assessment of psoriasis severity using NAPSI was performed in all psoriatic nails. The presence of fungi was confirmed in DME and culture. RESULTS DME showed the presence of fungal elements in 45 nails (33.83%) with a predominance of blastoconidia (95.5%) No septate hyphae were seen. Mycological culture was positive in 36 (27.06%) samples. Among them, Candida grew in 31 (86.1%): Candida parapsilosis in 15 (48.38%), Candida spp in 14 (45.16%). No growth of dermatophytes was observed. Patients with systemic treatment showed a higher frequency of positive test (DME and culture) for fungi when compared to topic treatment (p:.006). There was a positive correlation between NAPSI, mycological culture and systemic treatment (p:.0063); the risk was four times higher (OR:4.0). LIMITATION OF THE STUDY Sample size. CONCLUSION These results are consistent with some previous reports, Candida was the fungus with higher frequency on the psoriatic nails, however, the role of these fungi is controversial (contamination x colonisation x infection). The fact that the immunosuppressive treatment increases the chance of fungal infection leads us to a greater attention to this patient profile, to prevent the intensification of nail psoriasis (Köbner phenomenon).
Collapse
Affiliation(s)
- Rachel Grynszpan
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gloria Barreiros
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marilene do Nascimento Paixão
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Frasnelli Fernandes
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Felipe Aguinaga
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cláudia Camargo
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia Ramos-E-Silva
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sueli Carneiro
- Sector of Dermatology, Medical Clinics Post-Graduation Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Medical Specialties Department, Post Graduation Course, Sector of Dermatology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
22
|
Gupta AK, Venkataraman M, Anbalagan N, Guenin EP. One size does not fit all: the need for individualized treatment based on factors that may affect the therapeutic outcome of efinaconazole 10% solution for the treatment of toenail onychomycosis. Int J Dermatol 2021; 60:1296-1302. [PMID: 34216026 DOI: 10.1111/ijd.15739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/28/2021] [Accepted: 05/28/2021] [Indexed: 11/27/2022]
Abstract
Successful management of onychomycosis is a challenge because cure rates with most antifungals are relatively low and recurrence rates are high. A drug-based approach by treating the nail alone may not suffice. There are several host-related factors (age, sex, body mass index [BMI], and patient's quality of life), disease-related factors (disease severity, duration, and the number of toenails affected), and comorbidities (tinea pedis and diabetes) that may affect treatment efficacy. Here, we review the post hoc analyses of the phase III trials of efinaconazole 10% solution that have investigated the impact of these factors on topical therapy for toenail onychomycosis. The significant clinical variables that may affect the efficacy of efinaconazole include sex, BMI, disease severity, disease duration, and tinea pedis. As older patients may have slower toenail growth and more severe, longstanding disease compared with younger patients, they may require longer treatment duration, beyond the 48-week standard regimen. Treatment compliance may need to be discussed for an improved health outcome. Therefore, these prognostic factors need to be carefully evaluated, which may aid in formulating individualized therapy to maximize treatment success.
Collapse
Affiliation(s)
- Aditya K Gupta
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc, London, ON, Canada
| | | | | | | |
Collapse
|
23
|
Vlahovic TC, Gupta AK. Efinaconazole topical solution (10%) for the treatment of onychomycosis in adult and pediatric patients. Expert Rev Anti Infect Ther 2021; 20:3-15. [PMID: 34106031 DOI: 10.1080/14787210.2021.1939011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Onychomycosis, a common nail disorder caused by fungal infection, can be managed pharmaceutically with oral or topical treatments. While oral treatments are often used first-line to treat nail infections, these systemic antifungals are not appropriate for all patients, and no oral treatments are approved for use in children in the USA. Given this need, topical antifungals were developed, which can be used as monotherapy or in combination with oral drugs.Areas Covered: Efinaconazole 10% solution is an azole antifungal indicated for topical treatment of toenail onychomycosis in pediatric and adult patients. This qualitative literature review summarizes available chemical, pharmacological, efficacy, safety, and post-marketing surveillance data of efinaconazole 10% topical solution. Efinaconazole 10% has been shown to be safe and efficacious regardless of disease severity/duration at baseline; patient gender, ethnicity, or age (including pediatrics); or comorbidities such as diabetes or tinea pedis. Overall, efinaconazole is a safe and effective clinical option for the treatment and management of onychomycosis.Expert Opinion: Efinaconazole is the first new antifungal approved for onychomycosis in 10 years in the USA. It has comparable efficacy to systemic antifungal agents such as itraconazole, and a favorable adverse events profile with minimal systemic exposure and no drug-drug interactions.
Collapse
Affiliation(s)
- Tracey C Vlahovic
- Temple University School of Podiatric Medicine, Philadelphia, PA, US
| | - Aditya K Gupta
- Mediprobe Research Inc., London, ON, CAN.,Department of Medicine, University of Toronto, Toronto, ON, CAN
| |
Collapse
|
24
|
Nowicka D, Nawrot U. Tinea pedis-An embarrassing problem for health and beauty-A narrative review. Mycoses 2021; 64:1140-1150. [PMID: 34145648 DOI: 10.1111/myc.13340] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/31/2021] [Indexed: 12/19/2022]
Abstract
Fungal infections present with a broad spectrum of diseases in humans (from relatively mild superficial infections of the skin and mucous membranes to the invasive or chronic infections of internal organs, which have a high mortality rate). Globally, up to 1.6 million people die each year as a result of various types of mycoses. Currently, many scientific studies focus on the best possible understanding of the aspects of the epidemiology and pathogenesis of invasive mycoses and effective methods to combat them. However, mycoses of the skin and its appendages remain a relatively less explored area. In some communities, superficial mycoses are a frequent problem as they affect nearly 70% of the population, an example of which is the athlete's foot. It involves the nails (onychomycosis) and skin (tinea pedis). It is mainly caused by keratin-decomposing dermatophyte fungi. Less often, infections are caused by non-dermatophyte moulds (Fusarium, Aspergillus, Scopulariopsis) or yeasts. Several factors have been listed as having substantial influence on the development of dermatophytosis, including those related to climate, season, geographical region, as well as to demography, socioeconomic and cultural customs, professions or contact with animals. In this review, we summarise the current knowledge about aetiology, epidemiology, diagnostics and therapy of tinea pedis with a special focus to the role of podologic management in spreading, prevention and therapy of mycoses. The article presents up-to-date knowledge on the management of the patient from the diagnosis, treatment and skincare, to counselling on how to prevent fungal skin infections in the long term.
Collapse
Affiliation(s)
- Danuta Nowicka
- Department of Dermatology, Venereology and Allergology, Wrocław Medical University, Wrocław, Poland
| | - Urszula Nawrot
- Department of Pharmaceutical Microbiology and Parasitology, Wroclaw Medical University, Wrocław, Poland
| |
Collapse
|
25
|
Silva-Neves V, Hugo V, Alves P, Amado JC, Pais-Vieira C, Sousa F, Cerqueira F, Pinto E, Pais-Vieira M. Quality of life and therapeutic regimen management in onychomycosis patients and in vitro study of antiseptic solutions. Sci Rep 2021; 11:12789. [PMID: 34140577 DOI: 10.1038/s41598-021-92111-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/04/2021] [Indexed: 12/02/2022] Open
Abstract
Onychomycosis or tinea unguium (EE12.1) and Onychomycosis due to non-dermatophyte moulds (1F2D.5) (OM) is a fungal infection of the nail plates with a high prevalence that often affects vulnerable people with co-existing health problems. Gold standard pharmacological treatments for onychomycosis have been associated with low success rates and increasing antifungal resistance, suggesting that treatment outcome is dependent on multiple variables. Here, the prevalence of OM and quality of life were characterized in two vulnerable populations—Hospital patients and Homeless people. Comparing both groups, the most prevalent fungal species were identified in Hospital patients. Then, the in vitro fungicidal properties of the antiseptics povidone-iodine, polyhexamethylene biguanide-betaine, octenidine dihydrochloride, and a super-oxidized solution against two ATCC strains (Candida albicans and Aspergillus niger) and three clinical fungal isolates from Hospital patients (Candida parapsilosis, Trichophyton interdigitale, and Trichophyton rubrum) were tested. OM prevalence was high in both patient groups studied, who also reported a reduction in quality of life and concerns about the state of their feet. In addition, Hospital patients had a non-negligent therapeutic regimen management style. Antiseptics tested in vitro revealed antifungal properties. As antiseptics are low-cost and easy to apply and have few iatrogenic effects, the demonstration of fungicidal properties of these solutions suggests that they may constitute potential supportive therapeutics for OM.
Collapse
|
26
|
Abstract
BACKGROUND AND OBJECTIVE With the widespread use of antifungals to treat superficial mycoses, reports of antifungal resistance are increasing. Antifungal resistance is becoming a public health challenge and needs to be addressed in parallel with antibacterial and antiviral resistance. METHODS We review the growing resistance of fungal pathogens such as Trichophyton species and the emergence of novel pathogens, including multidrug-resistant strains in superficial mycoses. We also discuss the importance of laboratory diagnosis and antifungal susceptibility testing (AFST) in the management of recalcitrant infections. RESULTS AND CONCLUSION Antifungal resistance can occur naturally or develop over time when fungi are exposed to antifungals. The frequency of terbinafine-resistant Trichophyton isolates is increasing. Opportunistic pathogens such as Aspergillus and Candida species have developed resistance to classic azoles such as itraconazole and fluconazole, and the newer azoles such as posaconazole and voriconazole. Although uncommon, topical antifungals such as efinaconazole and tavaborole have shown to induce resistance in Trichophyton rubrum. The emergence of multidrug-resistant Trichophyton mentagrophytes/interdigitale, Candida auris, and Aspergillus species causing severe infections is highly concerning. Routine AFST should be considered to determine the most effective treatment, especially if there is failure to therapy. Combination treatment of oral and topical antifungals may be a consideration for managing recalcitrant infections.
Collapse
Affiliation(s)
- Aditya K Gupta
- Department of Medicine, Division of Dermatology, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | |
Collapse
|
27
|
Gupta AK, Summerbell RC, Venkataraman M, Quinlan EM. Nondermatophyte mould onychomycosis. J Eur Acad Dermatol Venereol 2021; 35:1628-1641. [PMID: 33763903 DOI: 10.1111/jdv.17240] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/09/2021] [Indexed: 01/21/2023]
Abstract
Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.
Collapse
Affiliation(s)
- A K Gupta
- Mediprobe Research Inc., London, ON, Canada.,Department of Dermatology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - R C Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | | |
Collapse
|
28
|
Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. The increasing problem of treatment-resistant fungal infections: a call for antifungal stewardship programs. Int J Dermatol 2021; 60:e474-e479. [PMID: 33729567 DOI: 10.1111/ijd.15495] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Antimicrobial stewardship (AMS) programs have been widely recognized among the public health community. These programs focus majorly on bacterial infections, efficient antibiotic use, and measures to curb increasing antibacterial resistance. AMS programs are successfully established around the globe; however, very few include antifungal stewardship (AFS). The increasing incidence of superficial and invasive fungal infections, combined with delayed or inaccurate diagnosis, has contributed to the overprescribing and overuse of antifungal agents. Such increased exposure to antifungal agents may be a reason for the emergence of increasing antifungal resistance among fungal pathogens. With mounting reports of treatment failures and resistant infections, the evidence to support the need for AFS programs is increasing. AFS is an emerging branch of AMS programs that requires global attention and recognition.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
| |
Collapse
|
29
|
Gupta AK, Renaud HJ, Quinlan EM, Shear NH, Piguet V. The Growing Problem of Antifungal Resistance in Onychomycosis and Other Superficial Mycoses. Am J Clin Dermatol 2021; 22:149-57. [PMID: 33354740 DOI: 10.1007/s40257-020-00580-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 01/06/2023]
Abstract
Superficial mycoses are becoming increasingly resistant to current antifungal medications. As alternative therapeutic options are limited, the increasing frequency of reports of antifungal resistance is alarming. This epidemic parallels the rise of antibiotic resistance; however, the significance of this problem has yet to gain global attention. Here, we discuss the reports of antifungal resistance from around the world, present our own experience with treatment-resistant infections, and examine alternative treatment strategies. The majority of reports of recalcitrant infections indicate terbinafine resistance as the causative factor. Single-point mutations in the squalene oxidase gene is the most reported mechanism of resistance to terbinafine. Mixed infections of dermatophytes with non-dermatophyte molds and/or yeasts are becoming more prevalent and contributing to the resistant nature of these infections. The key to selecting an effective antifungal therapy for a recalcitrant infection is identification of the infectious organisms(s) and testing susceptibility of the organism(s) to antifungal drugs. Combination and sequential therapy regimens are options, but both require active monitoring for hepatic and renal function, drug interactions, and other adverse effects. Selected topical antifungals with a wide spectrum of activity may also be considerations in some clinical presentations. Innovative treatment regimens and novel therapeutics are needed to overcome the rising epidemic of antifungal resistance.
Collapse
|