A 5‐year survey of dermatomycoses in southwest Poland,years 2003–2007

The study was performed to analyse the spectrum of dermatomycoses in southwest Poland during the period 2003–2007. A total of 10 486 patients were investigated for fungal skin infections by means of native specimen and cultivating procedures. Skin scrapings, plucked hairs and nail clippings were examined and identified by direct microscopy and culture. From 2468 patients, 2753 fungi were identified including dermatophytes, yeast and moulds. Among the dermatophytes, the most common pathogen isolated was Trichophyton rubrum (59.4%), followed in descending order by: Trichophyton mentagrophytes var. interdigitale (16.6%), Trichophyton mentagrophytes var. mentagrophytes (9.0%), Trichophyton tonsurans (6.8%), Microsporum canis (5.1%) and Epidermophyton floccosum (2.7%). Among the yeast‐like fungi, a marked predominance of Candida species was observed (86.3%). Scopulariopsis brevicaulis was the most commonly isolated mould (25.2%). The most frequently affected body sites were the toenails (53.9%), followed by the fingernails (19.0%). In children under 15 years of age, glabrous skin was the most commonly affected body site with M. canis as the most frequent causative agent.     

Study of onychomycosis in Isfahan,Iran

A mycological study was undertaken in 488 patients suspected of onychomycosis in Isfahan, a large province of Iran, to gain more insight into the prevalence and aetiology of this infection. Direct microscopy of the nail clips was positive in 194 (39.8%) and fingernail onychomycosis was recognised in 141 (72.7%) and toenail onychomycosis in 53 (27.3%) cases. As agents of onychomycosis, yeast were detected in 112 (57.7%), dermatophytes in 27 (13.9%) and non‐dermatophyte fungi in 55 (28.4%) patients. Of the samples cultured, Candida albicans was the most prevalent (84%) yeast. Among dermatophytes, Trichophyton mentagrophytes var. interdigitale was found to be the commonest aetiological agent (8.6%) followed by Epidermophyton floccosum and T. rubrum. Among the non‐dermatophyte moulds, Aspergillus flavus was the most prevalent species (13%). Moreover, nine samples with positive direct microscopy yielded no growth. Females were affected more frequently with fingernail candidal infections than males, and children under 7 years of age were predominantly involved with candidal paronychia. The majority of fungal nail infections were characterised clinically by distal and proximal subungual onychomycosis. The growing trend towards the frequency of fingernail onychomycosis in housewives was noticeable in the last decade in Iran.     

Onychomycosis in Tehran: mycological study of 504 patients

Onychomycosis is a common nail disorder resulting from the invasion of the nail plate by a dermatophyte, yeast or mould species and gives rise to some diverse clinical presentations. The purpose of the present study was to isolate and identify the causative fungi of onychomycosis in the population of Tehran, Iran. Nail samples from 504 patients with prediagnosis of onychomycosis during 2005 were examined both by direct microscopical observation of fungal elements in KOH preparations and in culture for the identification of the causative agent. All samples were inoculated on (i) Sabouraud dextrose agar (SDA, Merck), (ii) SDA with 5% chloramphenicol and cycloheximide in duplicate for dermatophyte and (iii) SDA with 5% chloramphenicol in triplicate for mould isolation. The criteria for the diagnosis of onychomycosis caused by non‐dermatophytic moulds were based on microscopical observation of fungal elements, growth of the same mould in all triplicate culture and no growth of a dermatophyte or yeast in all the cultures. Of 504 cases examined, 216 (42.8%) were mycologically proven cases of onychomycosis (144 fingernails, 72 toenails). Among the positive results, dermatophytes were diagnosed in 46 (21.3%), yeasts in 129 (59.7%) and non‐dermatophytic moulds in 41 (19%). Trichophyton mentagrophytes was the most common causative agent (n = 22), followed by Trichophyton rubrum (n = 13), Candida albicans (n = 42), Candida spp. (n = 56) and Aspergillus spp. (n = 21). Nearly half of the clinically suspected fungal nail infections are onychomycosis and yeast is responsible for most of the infections in Iran.     

Dermatophyte species in superficial mycoses in the Kraków district,Poland in the years 1972–2007

Considerable changes in the dermatophyte spectrum have been observed in the past century. Hence, many authors point out the necessity of performing periodical overviews of the mycological flora producing mycoses in humans in a given area. Analysis of dermatophyte species was performed, which were isolated from the lesions in patients suspected of superficial mycosis and referred to the Department of Mycology. The materials were isolated from patients suspected of superficial mycosis from Kraków region from January 1, 1972 through December 31, 2007. A total of 4983 dermatophyte strains were isolated from 23 124 specimens, which amounts to 21.5%. The percentage of dermatophytes isolated in the past decade decreased to 13.1% in the year 2007. Trichophyton rubrum outnumbered Trichophyton mentagrophytes during the entire survey period: 62.4 vs. 33.5%. The participation of Microsporum canis amounted to 1.71% and that of Epidermophyton floccosum to 1.32%. The species M. canis appeared by the end of the 1980s. The remaining dermatophyte species comprised 1% of the isolates. A considerable decrease in dermatophyte isolations has been observed since 2000. Trichophyton rubrum outnumbered T. mentagrophytes during the entire period of study. The percentages of T. rubrum and T. mentagrophytes are decreasing while the percentages of other dermatophytes are slowly increasing.     

Performance of mycology and histopathology tests for the diagnosis of toenail onychomycosis due to filamentous fungi: Dermatophyte and non‐dermatophyte moulds

Improvement of laboratory diagnosis of onychomychosis is important so that adequate treatment can be safely implemented. To evaluate and compare the performance of mycological and histopathological examinations in onychomycoses caused by dermatophyte and non‐dermatophyte moulds. Patients with lateral/distal subungual onychomycosis in at least one hallux were enrolled in the protocol and assessed via mycological and histopathological tests. The isolation of filamentous fungi was considered the gold standard. Test performance was evaluated through sensitivity, specificity and positive and negative predictive values. A total of 212 patients were enrolled in the study. Direct microscopy (DM) was positive in 57.5% patients, and cultures in 34.4%. Among these patients, 23.3% were positive for dermatophytes, with Trichophyton rubrum the most frequently isolated, and 86.3% were positive for non‐dermatophytes, with Neoscytalidium dimidiatum predominance. Histopathology was positive in 41.0% samples. Direct microscopy showed better sensitivity for non‐dermatophyte moulds (P=.000) and nail clipping was more specific for dermatophyte (P=.018). Histopathology of the distal nail plate is a valuable complementary tool for the diagnosis of onychomycosis caused by dermatophytes and direct microscopy is especially useful for non‐dermatophyte molds.     

Epidemiology of onychomycosis in Crete,Greece: a 12‐year study

Onychomycosis is a chronic fungal nail infection caused by dermatophytes, yeasts or non‐dermatophyte moulds (NDMs). It occurs worldwide and accounts for about 50% of all nail disorders. The incidence of the disease and the prevalence of pathogens involved vary in different geographical areas and change with time. This study was undertaken to determine the epidemiology of onychomycosis in Crete, Greece during a 12‐year period. Mycologic nail investigation (direct microscopy and cultures) was performed in samples taken from 3317 patients with clinical suspicion of onychomycosis. Demographic characteristics, comorbidities and concurrent superficial fungal infections at other body sites were also recorded. Onychomycosis was mycologically confirmed in 547 (16.5%) patients. Fingernail onychomycosis was found in 274 (50.1%) patients, toenail onychomycosis in 271 (49.5%), and both toenail and fingernail onychomycosis in two (0.4%). Yeasts were the major causative agents, followed by dermatophytes and NDMs. Candida albicans was the most commonly isolated yeast species and Trichophyton rubrum the most common dermatophyte. Concomitant fungal skin infections were noted in 53 (19.6%) patients with toenail onychomycosis. Factors predisposing to onychomycosis were trauma, diabetes, psoriasis, peripheral circulatory insufficiency and immunosuppression. Mycological investigations are necessary to confirm clinical diagnosis and identify the pathogen, in order to select the most appropriate treatment.     

Onychomycosis in children: a survey of 46 cases

This is a retrospective study of the agents, clinical aspects, sources of infection and therapy of onychomycosis in children. In the period 1989-2000, we observed 46 consecutive children, until 16 years of age with onychomycosis (29 boys, 17 girls, mean age 10.8 years). Dermatophytes were isolated in 30 cases (Trichophyton rubrum in 22 cases, Trichophyton mentagrophytes in five, Epidermophyton floccosum in two and Trichophyton violaceum in one) and Candida spp. in 16, associated with Trichophyton rubrum in two. Moulds were isolated in three children (Fusarium oxysporum in one, Scopulariopsis brevicaulis in another and Aspergillus fumigatus associated with Trichophyton rubrum in a third). The commonest features were distal and distolateral subungual hyperkeratosis in dermatophyte infections (93%) and onychodystrophy and paronychia in Candida infections (56% and 50% respectively). Forty patients achieved clinical and mycological recovery. It is appropriate to suspect onychomycosis in children, perform microbiological diagnosis and undertake early treatment. An approach of this kind may help to prevent nail dystrophy and the spread of infection.     

A clinico‐epidemiological study on tinea gladiatorum in Iranian wrestlers and mat contamination by dermatophytes

Dermatophytosis is still being considered as one of the major public health problems in wrestlers. Objectives: To identify the prevalence, clinical pattern, aetiological agents and the predominant transmission route of dermatophytoses in Iranian wrestlers, a study was carried out in 2008. In total, 270 wrestlers from eight wrestling salons were evaluated. Classical mycological techniques were performed on 135 skin scraping samples of 110 wrestlers suspicious for dermatophytoses and 240 touch preparation samples of wrestling mats. Diagnosis of the fungus type was made based on macroscopical and microscopical characteristics of the colonies. 19.2% of the evaluated wrestlers were inflicted with tinea gladiatorum. The head and neck were the most prevalent (36.5%) areas of involvement, followed by arms and forearms (28.8%), trunk (21.2%), as well as groin and knee (13.5%). The mean age of patients was 21 years and the most frequent age group was 10–19 years (51.9%). Trichophyton tonsurans was the most frequently isolated species representing 82.7% of isolates, followed by T. rubrum (5.8%), T. mentagrophytes var. interdigitale and Epidermophyton floccosum (3.8% each), and T. mentagrophytes var. mentagrophytes and T. verrucosum (1.9% each). Of 24 wrestling mats surveyed, 33.3% were heavily contaminated with T. tonsurans. Tinea gladiatorum in Iran is a common phenomenon among wrestlers, transmission pattern of which appears to be through man‐to‐man and mat‐to‐man contact. Furthermore, the clinical features of the disease are not consistent with those of the general population of Iran.     

Application of cosmetic nail varnish does not affect the antifungal efficacy of amorolfine 5% nail lacquer in the treatment of distal subungual toenail onychomycosis: results of a randomised active‐controlled study and in vitro assays

As onychomycosis is unsightly, this study clinically evaluated whether the antifungal efficacy of amorolfine 5% nail lacquer (NL) was affected by a masking, natural‐coloured, cosmetic nail varnish applied 24 h later; in vitro investigations were also performed. Subjects with mild‐to‐moderate distal subungual toenail onychomycosis were randomised to receive amorolfine 5% NL once weekly with or without cosmetic nail varnish applied 24 h later. After 12‐week treatment, antifungal activity of affected toenail clippings was assessed by measurement of zones of inhibition (ZOIs) on Trichophyton mentagrophytes seeded agar plates. Mean diameters were 53.5 mm for the amorolfine 5% NL‐alone group (n = 23) and 53.6 mm for amorolfine 5% NL plus cosmetic nail varnish group (n = 25). Also, mycological cultures of subungual debris at week 12 were negative for all subjects in both groups. Most subjects (88%) reported that cosmetic nail varnish masked their infected toenails. Additionally, cadaver human nails coated in vitro with or without cosmetic nail varnish 10 min or 24 h post amorolfine NL application all gave ZOIs on Trichophyton rubrum agar plates representing potent antifungal activity. In conclusion, cosmetic nail varnish applied post amorolfine had no effect on the subungual antifungal activity of amorolfine 5% NL or its penetration through toenails.     

The current Indian epidemic of superficial dermatophytosis due to Trichophyton mentagrophytes—A molecular study

The disease burden of chronic‐relapsing and therapy‐refractory superficial dermatophytosis dramatically increased in India within the past 5‐6 years. In order to evaluate the prevalence of this trend, 201 skin scrapings were collected from patients from all parts of India and were tested for dermatophytes using both fungal culture and a PCR‐ELISA directly performed with native skin scrapings. Fungal culture material was identified by genomic Sanger sequencing of the internal transcribed spacer (ITS) region and the translation elongation factor (TEF)‐1α gene. In total, 149 (74.13%) out of the 201 samples showed a dermatophyte‐positive culture result. Out of this, 138 (92.62%) samples were identified as Trichophyton (T.) mentagrophytes and 11 (7.38%) as Trichophyton rubrum. The PCR‐ELISA revealed similar results: 162 out of 201 (80.56%) samples were dermatophyte‐positive showing 151 (93.21%) T mentagrophytes‐ and 11 (6.79%) T rubrum‐positive samples. In this study, we show for the first time a dramatic Indian‐wide switch from T rubrum to T mentagrophytes. Additionally, sequencing revealed a solely occurring T mentagrophytes “Indian ITS genotype” that might be disseminated Indian‐wide due to the widespread abuse of topical clobetasol and other steroid molecules mixed with antifungal and antibacterial agents.     

Dermatophyte susceptibility varies towards antimicrobial textiles

Dermatophytoses are a widespread problem worldwide. Textiles in contact with infected skin can serve as a carrier for fungus propagation. Hitherto, it is unknown, whether antifungal textiles could contribute in controlling dermatophytes e.g. by disrupting the chain of infection. Testing of antimicrobial fabrics for their antifungal activities therefore is a fundamental prerequisite to assess the putative clinical relevance of textiles for dermatophyte prevention. Fabrics finished with either didecyldimethylammonium chloride (DDAC), poly‐hexamethylenbiguanide, copper and two silver chloride concentrations were tested for their antifungal activity against Trichophyton rubrum, Trichophyton mentagrophytes and Candida albicans. To prove dermatophyte susceptibility towards the textiles, swatches were subjected to DIN EN 14199 (Trichophyton sp.) or DIN EN ISO 20743 (C. albicans) respectively. In addition, samples were embedded, and semi‐thin sections were analysed microscopically. While all samples showed a clear inhibition of C. albicans, activity against Trichophyton sp. varied significantly: For example, DDAC completely inhibited T. rubrum growth, whereas T. mentagrophytes growth remained unaffected even in direct contact to the fibres. The results favour to add T. mentagrophytes as a test organism in textile dermatophyte efficacy tests. Microscopic analysis of swatches allowed detailed evaluation of additional parameters like mycelium thickness, density and hyphae penetration depth into the fabric.     

Prevalence of onychomycosis among patients with nail psoriasis who are not receiving immunosuppressive agents: Results of a pilot study

Nail psoriasis and onychomycosis can often be hard to differentiate clinically and may coexist, complicating each other's course. The aim of this study was to determine the prevalence of onychomycosis among patients with nail psoriasis not being treated with immunosuppressive agents, which constitute an independent risk factor for fungal infections. A cross‐sectional study was performed. All adult patients with nail psoriasis who were not receiving antifungal and/or immunosuppressive treatment were recruited at the 2nd University Dermatology Department of Aristotle University of Thessaloniki from 10/2016 till 02/2017. If onychomycosis was clinically suspected, nail samples were collected and direct microscopy with 15% KOH solution and culture were performed. Target‐NAPSI and DLQI score were also calculated. Of the 23 patients recruited, 20 were men and 3 were women, with a mean age of 53.43 years (48.25, 58.62), a mean target‐NAPSI score of 10.72 (9.62, 11.77) and a mean DLQI score of 10.17 (7.46, 12.89). A total of 34.78% of patients tested positive for onychomycosis. Yeast were isolated in 37.50% of cases, non‐dermatophyte filamentous fungi in 37.50% and T. rubrum in 12.50%. The prevalence of onychomycosis among nail psoriasis patients is higher than that among the general population of Greece (15%‐20%). Yeast and moulds predominate in infection cases of nail psoriasis patients.     

Onychomycosis is no longer a rare finding in children

Onychomycosis was considered uncommon in children. This survey was carried out to estimate the frequency of fungal nail infections in children and adolescents (0-18 years of age) attending our clinic in the last decade and gain more insight into the aetiology and clinics of this entity in the paediatric age group. This study is based on data obtained from 2320 children and adolescents suspected of superficial fungal infection. Onychomycosis was diagnosed in 99 cases, representing 19.8% of all mycologically confirmed superficial mycoses (500 cases) in our material. Fingernail onychomycosis was recognized in 52 (10.4%) cases; children under 3 years of age were predominantly involved. Candida albicans was the most common isolated pathogen. Toenail onychomycosis concerned 47 (9,4%) patients; the incidence increased steadily with increasing age. Trichophyton rubrum was the most common aetiological agent with respect to toenail infection followed by T. mentagrophytesvar. interdigitale and T. mentagrophytes var. granulosum. The majority of fungal nail infections were characterized clinically by distal and lateral subungual onychomycosis. The growing trend towards the frequency of toenail and fingernail onychomycosis in children and adolescents was found in the last decade in north Poland. The results of our study show that onychomycosis in prepubertal children is not exceptional and should be considered in differential diagnosis of nail plate disorders.     

Sporicidal effect of amorolfine and other antimycotics used in the therapy of fungal nail infections

Although topical antifungal therapies for treating onychomycosis are available, the cure rate is unsatisfactorily low with a simultaneously high risk of recurrence. One reason might be the formation of dormant fungal cells by the pathogen, known as spores, which can survive in the affected nail keratin, thereby evading the effect of antifungal drugs. In this in vitro study, the ability of amorolfine and four other antimycotics (ciclopirox, bifonazole, terbinafine and fluconazole) to kill microconidia of the dermatophyte Trichophyton rubrum, chlamydospores of the dermatophyte Epidermophyton floccosum and blastospores of the yeast Candida albicans was extensively studied as these fungi occur predominantly in onychomycosis. The effectiveness of all five antimycotics depended on the drug concentration and the incubation time: a concentration of 10–1000 times the minimum inhibitory concentration against growing hyphae cells is needed to exert a sporicidal action. Amorolfine and ciclopirox showed the same sporicidal efficacy and kinetics for all three varieties of spores. Both were more effective than fluconazole and bifonazole against microconidia and chlamydospores as well as slightly more potent against chlamydospores and blastospores than terbinafine after 4 days of incubation and at concentrations of ≥10 μg ml^?1. Finally, sporicidal activity on the tested strains was demonstrated for all five different antimycotics used for onychomycosis treatment.     

Multiplex PCR assay for the detection of common dermatophyte nail infections

Onychomycosis is one of the most prevalent dermatophytic diseases. Mycological methods used in the conventional diagnosis may not be optimal. Multiplex (MX) PCR was reported as a reliable alternative. Dermatophyte gene sequence records were used to design a MX PCR for detection and identification of dermatophytes in nail specimens. A MX PCR method based on the amplification of the chitin synthase 1 and internal transcribed spacer genes was developed. The study included 93 strains of dermatophytes and non‐dermatophytic fungi, six dermatophytic reference strains and 201 nail specimens from patients with dermatophytic onyxis. DNA extraction directly from nail samples was carried out by using the QIAamp DNA extraction kit (Quiagen). A set of primers was designed and their specificity was assessed. MX PCR detected the causal agent in specimens from which Trichophyton rubrum and T. interdigitale grew in culture and also identified a dermatophyte species in an additional 32 specimens that were negative in microscopy and culture. None of the investigated non‐dermatophytic strains was positive. Sensitivity of MX PCR was higher as compared to mycological examination (97% vs. 81.1%). MX PCR for direct detection of dermatophytes from nail samples yielded mixed flora in 32.8% of samples. MX PCR proved sensitive and adequate for the diagnosis of dermatophytic onychomycosis. It is much adapted to cases where culture is negative or contaminated by overgrowing moulds, which makes the identification of the causal agent problematic.     

Clinical and mycological features of onychomycosis in central Tunisia: a 22 years retrospective study (1986–2007)

Onychomycosis is the most frequently encountered nail disease and may be difficult to diagnose and treat. The objective of this study was to determine the prevalence, the clinical and mycological characteristics of onychomycosis in central Tunisia. It is a retrospective study performed over a 22‐year period (1986–2007). It included 7151 patients (4709 women and 2442 men) with suspected fingernails and/or toenails onychomycosis. The patients were referred to the Mycology‐Parasitology Laboratory of Farhat Hached hospital in Sousse for mycological examination. Both direct microscopy and culture of the nail material were performed to diagnose and identify the causative fungal species. Onychomycosis was confirmed in 78.6% of investigated patients (5624/7151). The positivity rate was higher in women as compared with men. In both men and women, fingernails were most frequently involved than toenails. No significant relation was found between gender and toenails onychomycosis, whereas fingernails were frequently involved in women. As far as aetiological agents are considered, dermatophytes, yeast and moulds were responsible for 49.9%, 47.4% and 2.7% of onyxis cases respectively. In fingernail infections, yeast were the most frequent fungi (83.6%), Candida albicans being the leading species (51.6%). In contrast, in toenail infections, dermatophytes were more frequent (74.1%). Trichophyton rubrum was by far the dominant species (88.1%). Yeast were observed more frequently in women whereas dermatophytes were more common in men. Moulds were involved in 4.2% of cases. The most frequent species were Aspergillus sp. and Chrysosporium sp. Onychomycosis is a frequent disease in central Tunisia. T. rubrum is the predominant agent in toenails infection and yeast, mainly C. albicans, in fingernails onychomycosis.     

A 20‐year survey of tinea faciei

Tinea faciei is an uncommon dermatophytosis affecting the glabrous skin of the face. Between 1988 and 2007 at the Dermatology Department of Cagliari University, 107 cases of tinea faciei have been diagnosed, involving 72 females and 35 males, aged 2–72 years. Incidence peaks were observed between 6 and 15 years (48.59%) and between 36 and 45 years (17.76%). Males below and females above 15 years of age were the most affected. In 61 patients (57.1%), typical forms of tinea faciei were observed, whereas in 46 (42.9%), atypical forms were observed, mainly mimicking discoid lupus erythematosus (nine cases), and polymorphous light eruption (eight cases). Typical cases were present in younger patients, aged between 2 and 15 years, while atypical forms were distributed in any of the decades, but mostly between 36 and 72 years. Of the 46 cases of atypical presentation, 33 were females. The isolated dermatophytes were Microsporum canis (63 cases), Trichophyton rubrum (24 cases) and T. mentagrophytes var. mentagrophytes (20 cases). Seven males and two females aged 4–10 years were also affected by tinea capitis and eight patients (three males and five females) of various ages by tinea corporis. Eleven patients (two males and nine females) aged >35 years were affected by onychomycosis. All patients recovered after local and/or systemic antifungal therapy, without relapse or side effects.     

Fusarium onychomycoses in Switzerland—A mycological and histopathological study

Onychomycoses in temperate climates are most commonly due to dermatophytes, particularly Trichophyton rubrum. Non‐dermatophyte nail infections are much less frequent, and their diagnosis requires a careful and repeated search for a potential dermatophyte that may have been overgrown in culture. A series of histological slides of suspected onychomycoses with uncommon fungal morphology prompted us to search for non‐dermatophytic moulds causing dermatophytosis‐like nail infections. Thirty cases were identified by culture as F solani, F oxysporum, F dimerum or F spp, and two more were only diagnosed histopathologically. None of these patients was immunocompromised. Treatment was mostly unsuccessful with terbinafine whereas itraconazole showed a moderately better treatment result; in all cases, a topical ciclopirox nail varnish in a hydroxychitosan base was added.     

Epidemiology of dermatomycoses of humans in central Poland. Part IV. Onychomycosis due to dermatophytes

The total number of dermatophytoses (7393) included 1567 (21.2%) cases of onychomycosis. Etiological factors in descending order were: Trichophyton rubrum (58.8%), Trichophyton mentagrophytes var. granulosum (26.2%), T. mentagrophytes var. quinckeanum, T. mentagrophytes var. interdigitale (5.1%), Trichophyton tonsurans (4.1%), Trichophyton violaceum (1.5%), Trichophyton spec. (1.1%). An increase in the incidence was noted between 1994 and 1996. At present, onychomycosis is third by incidence among all clinical forms of dermatophyte infections of skin and skin appendages in the Lód? region.