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PubMed1999

The impact of onychomycosis on quality of life: development of an international onychomycosis-specific questionnaire to measure patient quality of life.

BACKGROUND: Onychomycosis is a widespread refractory disease deleteriously affecting quality of life via social stigma and disrupting daily activities. Many physicians perceive onychomycosis as a cosmetic rather than a medical problem. OBJECTIVE: Our purpose was to develop a questionnaire-based instrument to quantify the impact of onychomycosis on patients' quality of life. METHODS: The questionnaire was developed and validated in a multinational cross-sectional study. Completed questionnaires from 532 patients were analyzed: 284 toenail, 248 fingernail (onychomycosis or paronychia). RESULTS: The degree of quality of life impairment from onychomycosis varied by country studied, possibly reflecting cross-national health perception differences. Longer duration of disease, greater involvement of individual nails, and greater number of nails involved were associated with more serious adverse effects. Many physicians underestimated the associated degree of pain. CONCLUSION: The study confirms that onychomycosis physically and psychologically affects patients' lives. The questionnaire may be a valuable tool in evaluating the effect of therapeutic agents on quality of life of patients with onychomycosis.

Cross-Sectional Studies↗
PubMed2006

Safety and efficacy of oral terbinafine in the treatment of onychomycosis: analysis of the elderly subgroup in Improving Results in ONychomycosis-Concomitant Lamisil and Debridement (IRON-CLAD), an open-label, randomized trial.

OBJECTIVES: The primary objective of this subanalysis was to examine the safety, tolerability, and efficacy of terbinafine in the treatment of toenail onychomycosis in the patients aged > or = 65 years in the Improving Results in Onychomycosis Concomitant Lamisil And Debridement (IRON-CLAD) trial. (Lamisil and IRON-CLAD are trademarks of Novartis Pharmaceuticals Corporation, East Hanover, New Jersey.) The secondary objective was to determine if toenail debridement would provide additional efficacy benefits in this subgroup. METHODS: The IRON-CLAD trial was an open-label, randomized, multicenter study of adults who underwent 4 weeks of screening and received terbinafine 250 mg/d for 12 weeks with or without aggressive toenail debridement (at baseline and weeks 6, 12, and 24). Clinic visits occurred at weeks 6, 12, 24, and 48. Safety and tolerability were assessed by adverse event (AE) rates based on changes in laboratory values, patient-volunteered information, answers to investigator questions, and physical examinations. Efficacy was evaluated by mycologic cure (negative microscopy of potassium hydroxide samples and negative culture), clinical cure (> or = 87.5% nail clearing), and complete cure (mycologic cure and complete toenail clearing) at week 48. The present subanalysis of IRON-CLAD results assessed participants aged > or = 65 years (older subgroup). RESULTS: A total of 504 patients were randomized, of whom 75 were aged > or = 65 years. In the older subgroup, the mean (SD) age was 68.9 (3.04), 86.7% (65/75) were white, and 66.7% (50/75) were male. Incidence of AEs reported during the treatment period or within 30 days after treatment discontinuation (treatment-emergent AEs [TEAEs]) was 28.0% in the older subgroup and 23.0% in the overall study population. Most TEAEs were mild (73.7%) to moderate (23.7%) in severity, and most (86.8%) were not suspected by the investigators to be related to study treatment. The most frequently occurring TEAEs in the older subgroup were nausea (4.0%), sinusitis (4.0%) arthralgia (2.7%), and hypercholesterolemia (2.7%). The proportion of participants who withdrew from the trial due to TEAEs was 4.0% (3/75) in the older group and 2.8% (14/504) in the overall population. Only 3 of 11 discontinuations in the older subgroup were due to a TEAE suspected by the investigator to be related to study treatment. Sixty-four percent of the older subgroup took antihypertensive medications, 25% took antidiabetics, and 47% took antilipemic medications. There were no clinical signs of drug interactions in the older subgroup. Clinical efficacy outcomes in the older subgroup were generally good and appeared to be comparable with those in the younger subgroup. At week 48, mycologic cure had occurred in 64.0% (95% CI, 53.1%-74.9%) of the older subgroup, clinical cure in 41.3% (95% CI, 30.2%-52.5%), and complete cure in 28.0% (95% CI, 17.8%-38.2%). Debridement did not appear to affect mycologic outcomes or clinical effectiveness, but rates of clinical and complete cure appeared to be higher among older patients who underwent adjuvant debridement. CONCLUSIONS: The results of this subanalysis suggest that terbinafine was well tolerated and efficacious in these patients aged > or = 65 years with moderate to severe toenail onychomycosis, many of whom were taking antihypertensives, antidiabetics, or lipid-lowering agents concomitantly. There were no reported clinical signs of drug interactions.

Adolescent↗
PubMed1999

L.I.ON. Study: efficacy and tolerability of continuous terbinafine (Lamisil) compared to intermittent itraconazole in the treatment of toenail onychomycosis. Lamisil vs. Itraconazole in Onychomycosis.

We undertook a prospective, randomised, double-blind, double-dummy, multicentre, parallel-group study to compare the efficacy and tolerability of continuous terbinafine (Lamisil) with intermittent itraconazole (Sporanox) in the treatment of toenail onychomycosis. A total of 496 patients (age range 18-75 years) with a clinical diagnosis of dermatophyte toenail onychomycosis, confirmed by positive mycological culture and microscopy (KOH), were recruited from 35 centres in six European countries. They were randomly divided into four parallel groups to receive either terbinafine 250 mg/day for 12 or 16 weeks (groups T12 and T16), or itraconazole 400 mg/day for 1 week in every 4 weeks for 12 or 16 weeks (groups I3 and I4). The primary efficacy measurement at week 72 was mycological cure, defined as negative microscopy and negative culture of samples from the target toenail. At week 72, the mycological cure rates were 75.5% (81/107) in the T12 group and 80.8% (80/99) in the T16 group, compared with 38.3% (41/107) in the I3 group and 49.1% (53/108) in the I4 group. All comparisons (T12 vs. I3, T12 vs. I4, T16 vs. I3, T16 vs. I4) showed significantly higher cure rates in the terbinafine groups (all P<0.0001). In addition, all secondary clinical outcome measures were significantly in favour of terbinafine at week 72. Both treatments were well tolerated, with no significant differences in the number or type of adverse events reported. We conclude that continuous terbinafine is significantly more effective than intermittent itraconazole in the treatment of toenail dermatophyte onychomycosis.

Adolescent↗
PubMed2001

Cost effectiveness of continuous terbinafine compared with intermittent itraconazole in the treatment of dermatophyte toenail onychomycosis: an analysis of based on results from the L.I.ON. study. Lamisil versus Itraconazole in Onychomycosis.

OBJECTIVE: To compare the costs and effectiveness of 2 oral antifungal treatment regimens in patients with dermatophyte toenail onychomycosis. DESIGN AND METHODS: A cost-effectiveness analysis using a model based on data from the Lamisil versus Itraconazole in Onychomycosis (L.I.ON.) study, a randomised controlled trial comparing continuous terbinafine with intermittent itraconazole. The trial included 4 treatment arms: terbinafine 250 mg/day for 12 or 16 weeks (T12, T16) and itraconazole 400 mg/day for 1 week in every 4 weeks for 12 or 16 weeks (I3, I4). Cost calculations for 6 countries (Finland, Germany, Iceland, Italy, The Netherlands, UK) included costs for medication, physician visits, laboratory tests, management of adverse events and management of relapse. Effectiveness was based on complete cure rates (mycological cure plus 100% toenail clearing). Costs per complete cure were determined and both average and incremental cost-effectiveness ratios were calculated. PERSPECTIVE: Healthcare system. MAIN OUTCOME MEASURES AND RESULTS: In the L.I.ON. study, terbinafine was seen to be more effective than itraconazole (cure rates, 45.8 vs 23.4%). In most comparisons (5 of the 6 countries), the costs of T12 were statistically significantly lower than those of I3 [range: -37 to -173 euros (EUR); 1998 values; 1.172 US dollars = EUR1], indicating that T12 was the dominant strategy (i.e. less expensive and more effective). One exception (Finland) showed an incremental cost-effectiveness ratio of EUR524 per additional cure. In the other 5 countries, T16 and 14 were essentially equal in cost, but the greater effectiveness of T16 (cure rates, 55.1 vs 25.9%) resulted in a situation of extended dominance. CONCLUSION: From a healthcare system perspective, continuous terbinafine is less costly and more effective than intermittent itraconazole in the treatment of dermatophyte toenail onychomycosis.

Antifungal Agents↗
PubMed1994

A multinational pharmacoeconomic analysis of oral therapies for onychomycosis. The Onychomycosis Study Group.

Due to increased interest in economic evaluation and the rapid international spread of new healthcare technologies across borders, there is a need to interpret economic evaluations on a worldwide basis. We conducted a multinational cost-effectiveness analysis, from a government payer perspective, comparing four primary oral treatment regimens for onychomycosis of the fingernails and toenails: griseofulvin, itraconazole, ketoconazole and terbinafine. We used a four-step pharmacoeconomic research model which includes all relevant factors affecting costs in 13 countries: Austria, Belgium, Canada, Finland, France, Germany, Greece, Italy, The Netherlands, Portugal, Spain, Switzerland and the U.K. A worldwide meta-analysis of published clinical data served as the statistical input for the pharmacoeconomic model, and demonstrated that terbinafine had the highest success rates (95.0% and 78.3%) of the clinical comparators for fingernails and toenails, respectively. We found that terbinafine was the most effective therapy in relation to cost (therefore giving it the lowest cost-effectiveness ratio) for both infections in all health-care systems analysed.

Antifungal Agents↗
PubMed2000

Epidemiology and prevalence of onychomycosis in HIV-positive individuals.

BACKGROUND: Patients who are human immunodeficiency virus (HIV) positive are predisposed to the development of infections including tinea pedis and onychomycosis. While smaller studies have been reported, there has been no large study evaluating the prevalence of onychomycosis in HIV-positive individuals, or comparing the development of onychomycosis in a typical temperate area with that in a typical tropical area. METHODS: HIV-positive individuals were evaluated at five clinics: four in Ontario, Canada and one in Sao Paulo, Brazil. The subjects were asked questions to determine the epidemiology of onychomycosis in HIV-positive individuals. The feet were examined and nail material was obtained for mycologic examination to determine the causative organism of onychomycosis. RESULTS: A total of 500 subjects were examined (415 men and 85 women; age (mean +/- SE), 39 +/- 0.4 years; 400 Canadian, 100 Brazilian). The racial origins of the Canadian patients were: Caucasian, 83.8%; Asian, 4.3%; African-American, 8.1%; Hispanic, 3.3%; American Indian, 0.3%. The Brazilian origins were: Caucasian, 68.7%; African, 18.1%; mixed race, 13.3%. Abnormal appearing nails and mycologic evidence of onychomycosis were present in 200 (40.0%) and 116 (23.2%), respectively, of 500 subjects. The prevalence of onychomycosis in the Canadian and Brazilian samples was 24.0% (96 of 400) and 20.0% (20 of 100), respectively. The projected prevalence of onychomycosis in HIV-positive individuals in Canada was 19.9% (95% CI: 16.0-23.9%) after taking into account the age and sex distribution of HIV-positive individuals in the population. When nails appeared clinically abnormal, the prevalence of onychomycosis was 50.5% (Canada, 51.3%; Brazil, 45.5%). For comparison, published data indicate that the prevalence of onychomycosis in immunocompetent individuals living in Canada is 6.9%. The clinical presentation of onychomycosis for the whole sample (n=500) was: distal and lateral subungual onychomycosis (DLSO), 20.0%; white superficial onychomycosis (WSO), 3.6%; proximal subungual onychomycosis (PSO), 1.8% (Canadian and Brazilian samples: DLSO 21.2% vs. 15.0%, WSO 3.3% vs. 5.0%, and PSO 1.5% vs. 3.0%). The distribution of the causative fungal organisms was: dermatophytes: Candida species: nondermatophyte molds, 73:2:2 (Canadian and Brazilian samples: dermatophytes 95.5% vs. 90.9%, Candida species 3.0% vs. 0%, and nondermatophyte molds 1.5% vs. 9.0%). The use of protease inhibitors, reverse transcriptase inhibitors, or oral antifungal agents did not make a significant difference in the prevalence of onychomycosis for both the Canadian and Brazilian groups. Patients with onychomycosis were aware of their abnormal appearing nails (chi2(1)=69.7, P<0.001), embarrassed by the appearance of their nails (chi2(1)=29.7, P<0.001), and took measures to hide their nails from other individuals. A higher proportion of individuals with onychomycosis experienced discomfort compared with those without the disease (chi2(1)=9.0, P=0.003). Also, individuals who experienced pain in the nail unit were more likely to have onychomycosis (risk odds ratio (ROR), 2.2; 95% CI: 1.0-4.7, P=0.05). CONCLUSIONS: The prevalence of onychomycosis in HIV-positive individuals in the sample of 500 patients was 23.2%. In the Canadian (n=400) and Brazilian (n=100) samples, the corresponding figures were 24% and 20%, respectively, with the predominant causative organisms being dermatophytes. The projected prevalence of onychomycosis in HIV-positive Canadians is 19.9%. Predisposing factors include a CD4 count of approximately 370, a positive family history of onychomycosis, a history of tinea pedis, and walking barefoot around pools. Onychomycosis can be symptomatic, a source of embarrassment, and a potential cause of morbidity.

Adolescent↗
PubMed1997

Onychomycosis in children: prevalence and treatment strategies.

BACKGROUND: Onychomycosis is observed less frequently in children than adults. Until recently management of onychomycosis in children included topical formulations, oral griseofulvin, and in some cases deferral of treatment. OBJECTIVE: We attempted to determine the prevalence of onychomycosis in North American children 18 years old or younger attending our dermatology offices (three Canadian, two U.S.) and to report the group's experience using fluconazole, itraconazole, and terbinafine for onychomycosis. METHODS: We undertook a prospective, multicenter survey in which all children, regardless of presenting complaint, were examined for onychomycosis by a dermatologist. In instances of clinical suspicion appropriate nail samples were obtained for light microscopy and culture. RESULTS: A total of 2500 children under age 18 were examined in the five-center survey (1117 males and 1383 females, mean +/- S.E. age: 11.2 +/- 0.1 years). There was one child with fingernail and ten with mycologically confirmed toenail dermatophyte onychomycosis. The overall prevalence of onychomycosis was 0.44%. Considering those children whose primary or referring diagnosis was not onychomycosis or tinea pedis, the prevalence of onychomycosis was 0.16%. Outside the survey we have seen six other children with dermatophyte onychomycosis; these 17 cases form the basis for the remainder of the report. Of the 17 children, eight (47%) had concomitant tinea pedis infection, and in 11 (65%) a sibling, parent, or grandparent had onychomycosis or tinea pedis. Management included topical terbinafine (two patients: one cured, one failed therapy), topical ketoconazole (one patient: clinical improvement), oral fluconazole (two patients: one cured, one had Down's syndrome and was noncompliant), oral itraconazole (four patients: three cured with subsequent recurrence at follow-up in one patient, one lost to follow-up), oral terbinafine (five patients: four cured with subsequent recurrence at follow-up in one patient, one failed therapy). One child received no therapy following discussion with the parents, one was lost to follow-up and one was found to have asymptomatic hepatic dysfunction with hepatitis C at pretherapy bloodwork. CONCLUSION: The prevalence of onychomycosis in our sample of North American children 18 years old or younger was 0.44% (n = 2500). In the subset of children whose primary or referring diagnosis was not onychomycosis, the prevalence of onychomycosis was 0.16%. Children with onychomycosis should be carefully examined for concomitant tinea pedis, and their parents and siblings checked for onychomycosis and tinea pedis. The newer oral antifungal agents fluconazole, itraconazole, and terbinafine may be effective and well-tolerated in the treatment of onychomycosis in this age group. These drugs should be carefully evaluated in a larger cohort of children with onychomycosis.

Adolescent↗
PubMed2000

Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases.

BACKGROUND: Nail invasion by nondermatophytic molds (NDM) is considered uncommon with prevalence rates ranging from 1.45% to 17. 6%. OBJECTIVE: We report the clinical features and response to treatment of onychomycosis caused by these molds. METHODS: From 1995 through 1998 we performed a mycologic study on 1548 patients affected by nail disorders, and we diagnosed 431 cases of onychomycosis including 59 cases of onychomycosis caused by molds. These include 17 patients with onychomycosis caused by Scopulariopsis brevicaulis, 26 patients with onychomycosis caused by Fusarium sp, 9 patients with onychomycosis caused by Acremonium sp, and 7 patients with onychomycosis caused by Aspergillus sp. RESULTS: Onychomycosis caused by S brevicaulis, Fusarium sp, and Aspergillus sp may often be suspected by clinical examination. In fact 38 of 50 patients with onychomycosis resulting from these molds were affected by proximal subungual onychomycosis associated with inflammation of the proximal nailfold. In our experience mold onychomycosis is not significantly associated with systemic diseases or immunodepression. NDM are difficult to eradicate; by using and combining different treatments (systemic itraconazole, systemic terbinafine, topical terbinafine after nail plate avulsion, and ciclopirox nail lacquer) we were able to cure only 69.2% of patients with S brevicaulis onychomycosis, 71.4% of patients with Acremonium onychomycosis, and 40% of patients with Fusarium onychomycosis. Aspergillus onychomycosis, on the other hand, responded very well to therapy and all our patients were cured after systemic or topical treatment. Eradication of the mold produced a complete cure of the nail abnormalities in all the patients who responded to treatment. CONCLUSION: Clinical examination usually suggests diagnosis of onychomycosis resulting from NDM. Topical treatment can be more successful than systemic therapy to cure onychomycosis caused by S brevicaulis, Fusarium sp, and Acremonium sp.

Administration, Topical↗
PubMed2000

Prevalence and epidemiology of onychomycosis in patients visiting physicians' offices: a multicenter canadian survey of 15,000 patients.

A prospective, multicenter study to determine the epidemiology of onychomycosis was performed in the offices of 3 dermatologists and 1 family physician in Ontario, Canada. In the sample of 15,000 patients, abnormal-appearing nails were observed in 2505 persons (16. 7%). There were 1199 patients (8%) with toenail or fingernail onychomycosis confirmed on mycologic examination, with 1137 patients (7.6%) who had only pedal onychomycosis, 40 patients with toenail and fingernail onychomycosis (0.27%), and 22 patients (0.15%) with only fingernail onychomycosis. The condition was more common in male patients (P <.0001) and older persons (P <.0001). The ratio of onychomycosis in toenails/fingernails was 19:1. When onychomycosis was present in toenails, the ratio of distal/lateral subungual onychomycosis (DLSO) to white superficial onychomycosis to proximal subungual onychomycosis was 360:59:1. The extent of DLSO in toenails was mild (< or =25% nail involvement), moderate (26%-74% disease), and severe (> or =75% nail involvement) in 27.6%, 39.9%, and 32.5% of patients, respectively. After adjusting for the age and sex distribution of the general population, the projected rate of onychomycosis in Canada is 6.5% (95% confidence interval [CI], 6. 1%-6.9%). The organisms causing toenail onychomycosis were 90.5% dermatophyte, 7.8% nondermatophyte molds, and 1.7% Candida spp. The corresponding organisms causing fingernail onychomycosis were 70.8%, 0%, and 29.2%, respectively. In a large sample of 15,000 patients, abnormal-appearing nails were present in 17% of the sample with mycologic evidence of toenail or fingernail onychomycosis in 8%. The projected prevalence of onychomycosis in Canada is 6.5% (95% CI, 6. 1%-6.9%).

Adolescent↗
PubMed2000

Onychomycosis in the elderly.

Onychomycosis is found more frequently in the elderly, and in more males than females. Onychomycosis of the toes is usually caused by dermatophytes, most commonly Trichophyton rubrum and T. mentagrophytes. The most common clinical presentations are distal and lateral subungual onychomycosis (which usually affects the great/first toe) and white superficial onychomycosis (which generally involves the third/fourth toes). Only about 50% of all abnormal-appearing nails are due to onychomycosis. In the remainder, trauma to the nail, psoriasis and conditions such as lichen planus should be considered in the differential diagnosis. Therefore, the clinical impression of onychomycosis should be confirmed by mycological examination, whenever possible. The management of onychomycosis may include no therapy, palliative treatment with mechanical or chemical debridement, topical antifungal therapy, oral antifungal agents or a combination of treatment modalities. In the US, the only new oral agents approved for treatment of onychomycosis are terbinafine and itraconazole. Fluconazole is approved for onychomycosis in some other countries. Ciclopirox nail lacquer has recently been approved in the US for the treatment of onychomycosis. In some other countries topical agents such as amorolfine are also used. Griseofulvin and ketoconazole are no longer preferred for the treatment of onychomycosis. The new oral antifungal agents are effective and well tolerated in the elderly. Patient selection should be based on the history (including systems review and medication record), examination and baseline monitoring, if indicated. Laboratory monitoring during therapy for onychomycosis varies among physicians. A combination of removal of the diseased nail plate or local measures and oral antifungal therapy may be optimal in certain instances, e.g. when lateral onychomycosis or dermatophytoma are present. For dermatophyte toe onychomycosis the recommended duration of therapy with terbinafine is 250 mg/day for 12 weeks. For itraconazole (pulse) the regimen is 200 mg twice daily for 1 week on, 3 weeks off, repeated for 3 consecutive pulses and with fluconazole the regimen is 150 to 300 mg once weekly given for a usual range of 6 to 12 months or until the nail plate has grown out. In some instances, if extra therapy is required, one suggestion is that 4 weeks of terbinafine or an extra pulse of itraconazole are given between months 6 and 9 from the start of therapy. Once cure has been achieved, it is important to counsel patients on the strategies of reducing recurrence of disease.

Age Factors↗
PubMed1997

Prevalence and epidemiology of unsuspected onychomycosis in patients visiting dermatologists' offices in Ontario, Canada--a multicenter survey of 2001 patients.

BACKGROUND: Questionnaire studies have been used to determine the prevalence of onychomycosis in the United Kingdom and Europe. One disadvantage of this methodology is that the patient self-diagnoses the onychomycosis. There have been very few large studies involving clinical examination of the nails of subjects, followed by mycological confirmation of the onychomycosis. We therefore determined the prevalence of onychomycosis in patients visiting dermatologists' offices in Ontario, Canada. METHODS: In a prospective, multicenter study, the finger- and toenails of all new patients presenting to dermatologists' offices were examined by a board-certified dermatologist. If there was clinical suspicion of onychomycosis, then nail samples were obtained for mycological examination at a central laboratory. Patients referred specifically for the management of onychomycosis were excluded. RESULTS: Toenails appeared abnormal in 455 (22.7%) of 2001 patients. Mycologically-confirmed pedal onychomycosis was present in 182 (9.1%) of the 2001 patients. The estimated value of the prevalence of onychomycosis in Ontario is 6.86% (95% confidence interval (CI): 5.8-8.0%), when corrected for age and sex of the general population using census data. Onychomycosis increased with age (P < 0.0001). The odds of males having onychomycosis was 84.3% greater than females of the same age (P = 0.0003). The distribution of organisms in the 141 patients with pedal onychomycosis who were culture positive was: dermatophytes 131 (92.9%), Candida species 4 (2.8%) and non-dermatophyte molds 6 (4.3%). CONCLUSIONS: The prevalence of mycologically-confirmed toenail onychomycosis was 9.1%, with the estimated prevalence in Ontario being 6.86%. The majority of patients with abnormal-appearing nails were unaware they might have onychomycosis, that it is infectious and potentially treatable, suggesting that there is potential for increased public awareness and education.

Adolescent↗
PubMed1999

Combined distal and lateral subungual and white superficial onychomycosis in the toenails.

BACKGROUND: The 5 main types of onychomycosis are distal and lateral subungual onychomycosis (DLSO), white superficial onychomycosis (WSO), proximal subungual onychomycosis (PSO), Candida onychomycosis, and total dystrophic onychomycosis (TDO) (primary or secondary type). In the literature there is infrequent discussion about 2 types of onychomycosis present in the toenails of the same individual. OBJECTIVE: We attempted to determine the prevalence and etiologic organisms of DLSO and WSO occurring in the same individual. METHODS: We surveyed 4411 subjects presenting to dermatology offices for causes other than the management of onychomycosis. In each patient the toenails were examined. If they appeared abnormal, nail material was obtained for mycologic evaluation; partitioned sampling was performed when more than one type of onychomycosis was present. RESULTS: In our series, 39 (0.9%) of 4411 patients had the combination DLSO and WSO, compared with 417 (9.4%) and 111 (2.5%) who had DLSO and WSO, respectively. After controlling for age and sex in the general population, the projected prevalence rates of DLSO, WSO, and combined DLSO and WSO in the province of Ontario, Canada were 7.1%, 1.5%, and 0.5%, respectively. The combination of DLSO and WSO in the toenails of an individual occurred more frequently than that predicted by chance alone (P <.0001). Nine (0. 2%) of 4411 subjects had DLSO and WSO on the same nail. In 23 (59%) of 39 subjects both the DLSO and WSO were associated with Trichophyton mentagrophytes. In the remaining 16 subjects other organisms cultured were T rubrum, Acremonium spp, Aspergillus spp, Fusarium oxysporum, and Onychocola canadensis. In 33 (84.6%) of 39 subjects with the combination of DLSO and WSO on the toenails, the same fungal organism was associated with both the DLSO and WSO. CONCLUSION: When both DLSO and WSO are concurrently present in the toenails of an individual, partitioned sampling (ie, sampling for each of the two types of onychomycosis) may provide us with a better understanding of the different organisms associated with the onychomycosis and the relationship between the two types of onychomycosis.

Aged↗
PubMed2004

Risk factors associated with onychomycosis.

OBJECTIVE: To examine possible risk factors related to onychomycosis. BACKGROUND: Onychomycosis is a common disease with multifactorial aetiology, but little is known about the risk factors for this disease. PATIENTS AND METHODS: Questions related to signs, symptoms and possible risk factors associated with onychomycosis were sent to 3992 persons aged 16 years and older selected randomly from the Icelandic National Registry. Patients with suspected onychomycosis, based on photographs, were offered mycological examination. Data from the questionnaire and the results of mycological examination were used to calculate the odds ratio (OR) for several factors that might be associated with onychomycosis. RESULTS: Two thousand four hundred and eighty-six subjects responded to the questionnaire. Prevalence for mycologically determined onychomycosis was 11.1% in the Icelandic population. A history of the following factors more than doubled the risk of onychomycosis: cancer (OR 3.44; 95% CI 1.15-10.35), psoriasis (OR 2.44; 95% CI 1.61-3.72), tinea pedis interdigitalis (OR 3.93; 95% CI 3.11-4.95), the moccasin form of tinea pedis (OR 4.26; 94% CI 3.34-5.45), parents with onychomycosis (OR 2.59; 95% CI 1.89-3.53), children with onychomycosis (OR 3.48; 95% CI 2.05-5.88), spouse with onychomycosis (OR 2.53; 95% CI 1.72-3.72), regular swimming activity (OR 2.57; 95% CI 2.00-3.30) and age 50 years or older (OR 2.74; 95% CI 2.19-3.42). CONCLUSIONS: Several risk factors are associated with onychomycosis. Knowledge of these risk factors is important when treating and educating patients with onychomycosis.

Adolescent↗
PubMed1998

Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey.

The number of individuals diagnosed with diabetes mellitus is increasing. The diabetic may present with complications involving all systems of the body. While onychomycosis is often observed in diabetics, there have been no large studies on the prevalence of the condition in this patient group. We examined the prevalence of onychomycosis in diabetics attending diabetes and dermatology clinics in London, Ontario, Canada and Boston, MA, U.S.A. Diabetic subjects seen in dermatology offices were for unrelated dermatoses; those referred specifically for the management of onychomycosis were excluded from the sample. A total of 550 diabetic subjects was evaluated (283 males and 267 females), age 56.1 +/- 0.7 years (mean +/- SEM). Patients with type I diabetes constituted 34% of the sample. The racial origin was: 531 Caucasians, 17 Asians, one African-American and one American-Indian. Abnormal-appearing nails and mycological evidence of onychomycosis (mostly due to dermatophytes) were present in 253 (46%) and 144 (26%), respectively, of 550 subjects. The development of onychomycosis was significantly correlated with age (P < 0.0001) and male gender (P < 0.0001). Males were 2.99 times more likely to have onychomycosis compared with females (95% confidence interval, CI 1.94-4 61). After controlling for age and sex, the risk odds ratio for diabetic subjects to have toenail onychomycosis was 2.77 times compared with normal individuals (95% CI 2.15-3.57). After controlling for age and sex, a stepwise logistic regression demonstrated that significant predictors for onychomycosis included a family history of onychomycosis (P = 0.0001), concurrent intake of immunosuppressive therapy (P = 0.035) and peripheral vascular disease (P = 0.023). Toenail onychomycosis was present in 26% of the sample and is projected to affect approximately one-third of subjects with diabetes. Predisposing factors include increasing age, male gender, family history of onychomycosis, concurrent intake of immunosuppressive agents and peripheral vascular disease.

Adolescent↗
PubMed2004

Onychomycosis in central India: a clinicoetiologic correlation.

BACKGROUND: Onychomycosis is mainly caused by dermatophytes, but yeasts and nondermatophyte molds have also been implicated, giving rise to diverse clinical presentations. The etiological agents of the disease may show geographic variation. The aim of the present study was to isolate the causative pathogens and to determine the various clinical patterns of onychomycosis in central India. METHODS: The study population comprised 90 patients with onychomycosis. Nail samples were collected for direct microscopic examination and culture. Clinical patterns were noted and correlated with causative pathogens. RESULTS: The male : female ratio was 3:1 and the mean age was 29.40 +/- 13.61 years. Fingernails were involved in 60%, toenails in 26.67% and both fingernails and toenails in 13.34% of the 90 patients. The clinical types noted were distolateral subungual onychomycosis (64.44%), total dystrophic onychomycosis (17.78%), proximal subungual onychomycosis with paronychia (12.2%), proximal subungual onychomycosis without paronychia (4.44%) and superficial white onychomycosis (1.11%). Dermatophytes were the most common pathogens isolated, being found in 24 patients (26.36%) [Tricophyton rubrum (23.07%), Tricophyton verrucosum (2.22%) and Epidermophyton floccosum (1.11%)], followed by Candida albicans, which was found in 22 patients (24.27%). Thirty-six (39.58%) nondermatophyte molds were isolated from 29 patients. Of these 29 cases, six were associated with Tricophyton rubrum, which was considered the primary pathogen. CONCLUSIONS: Distolateral subungual onychomycosis was the most common clinical presentation; however, total dystrophic onychomycosis and proximal subungual onychomycosis were not uncommon in this part of India. Tricophyton rubrum and Candida albicans were the major pathogens. The clinicoetiologic correlation revealed that a single pathogen could give rise to more than one clinical type.

Adolescent↗
PubMed1997

A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: a multicentre study.

There is some controversy about the prevalence of onychomycosis in patients with psoriasis compared to non-psoriatics. We therefore measured the prevalence of toenail onychomycosis in psoriatics and non-psoriatics attending dermatologists' offices. None of the patients had a referring diagnosis of onychomycosis. The prevalence of pedal onychomycosis in psoriatics (n = 561) was 13%. The odds of patients with psoriasis having onychomycosis was 56% greater than non-psoriatics of the same age and sex (P = 0.02). In the psoriatics, when the toenails were clinically abnormal, the prevalence of onychomycosis was 27%. The odds of developing onychomycosis increased with age (P < 0.0001) and the odds of men developing onychomycosis was 2.5 times that of women (P = 0.0001). The duration of psoriasis did not significantly affect the odds of developing onychomycosis. The fungal organisms recovered from psoriasis subjects with onychomycosis were similar to those in the normal population with onychomycosis (P = 0.58).

Female↗