Antonella Tosti

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

BACKGROUNDnOnychomycosis 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.nnnOBJECTIVEnOur purpose was to develop a questionnaire-based instrument to quantify the impact of onychomycosis on patients quality of life.nnnMETHODSnThe 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).nnnRESULTSnThe 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.nnnCONCLUSIONnThe 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.

Onychomycosis: Practical Approaches to Minimize Relapse and Recurrence

Introduction: Toenail onychomycosis is a common disease in which treatment options are limited and treatment failures and disease recurrence are frequently encountered. It usually requires many months of treatment, and recurrence may occur in more than half of the patients within 1 year or more after the infection has been eradicated. Data on long-term treatment, follow-up and recurrence are limited. Objective: Our objective is to interpret these data and recommend practical approaches that should minimize recurrence based on our clinical experience. Results: Several factors have been suggested to play a role in the high incidence of recurrence, but only the extent of nail involvement and co-existing diabetes mellitus have been shown to have a significant impact. Conclusion: The use of topical antifungals to prevent recurrences after complete cure was achieved has been suggested by various workers and used successfully in our practice. However, it has never been validated through clinical studies. Topical prophylaxis once weekly or twice monthly would seem appropriate in those patients most at risk. Prompt treatment of tinea pedis is essential, as is ensuring family members are free from disease. Patient education and pharmacologic intervention are equally important, and there are a number of simple strategies patients can employ. Managing onychomycosis is a significant long-term commitment for any patient, and minimizing recurrence is critical to meet their expectations.

Severe Onychodystrophy due to Allergic Contact Dermatitis from Acrylic Nails

Acrylic nails, including sculptured nails and the new ultraviolet-curable gel polish lacquers, have been associated with allergic contact dermatitis (ACD). We report 2 cases of ACD to acrylic nails with severe onychodystrophy and psoriasiform changes including onycholysis and subungual hyperkeratosis. In both cases, the patients did not realize the association between the use of acrylate-based manicures and nail changes. One patient had been previously misdiagnosed and treated unsuccessfully for nail psoriasis. The informed clinician should elicit a history of acrylic manicure in patients with these nail changes, especially in cases of suspected nail psoriasis refractory to treatment. Patch testing is a useful tool in confirming diagnosis.

Onychomycosis and Onychomatricoma

Nail dermoscopy is helpful in the differential diagnosis of nail disorders including onychomycosis and pigmented and nonpigmented nail tumors. We report two cases of onychomatricoma with concurrent onychomycosis of the same digit. In both cases, dermoscopy of the nail plate exhibited features of onychomatricoma, whereas dermoscopy of the distal free edge revealed features of onychomycosis. It is not uncommon for patients with onychomatricoma to develop coexisting onychomycosis, as channels created by the tumor render the nail plate susceptible to invasion by fungi.

Onychomatricoma with Concomitant Subungual Glomus Tumor

Onychomatricoma and glomus tumor are two rare subungual neoplasms with distinct clinical and histopathological features. We report a case of onychomatricoma associated with a glomus tumor in the subungual region of the same finger in a 45-year-old woman. Histopathological examination revealed characteristic findings of both onychomatricoma and glomus tumor. To the best of our knowledge, these two subungual tumors have never before been described occurring concomitantly.

Central Centrifugal Cicatricial Alopecia Presenting with Irregular Patchy Alopecia on the Lateral and Posterior Scalp

Background: Central centrifugal cicatricial alopecia (CCCA) is the most common cause of scarring alopecia among women of African descent which affects the central scalp and spreads centrifugally but spares the lateral and posterior scalp. Objectives: The objective of this study is to report on a new clinical variety of CCCA presenting with patchy alopecia involving the lateral and posterior scalp in addition to the central scalp. Materials and Methods: We reviewed the medical records and the clinical, dermatoscopic and pathologic data of 14 African-American women with CCCA presenting with patchy alopecia. Results: Two patients had individual well-delineated patches of hair loss, and 12 patients had multiple irregular patches of hair loss. In all cases, the alopecia affected the lateral and posterior scalp in addition to the central scalp. Four patients had a history of traumatic hairstyles, and 10 patients were also affected by marginal traction alopecia. On dermatoscopy, the patches showed peripilar white-gray halos and broken hairs. The pathologic diagnosis of CCCA was based on the following features: follicular dropout, absent or only focally preserved sebaceous glands, premature desquamation of the inner root sheath and perifollicular fibrosis with mild inflammatory infiltrate. Conclusion: CCCA can present with patches of hair loss involving the parietal and posterior scalp in addition to the central scalp. Without dermatoscopy and pathology, this variety can be easily misdiagnosed as traction alopecia.

An Idiopathic Leukonychia Totalis and Leukonychia Partialis Case Report and Review of the Literature.

Leukonychia totalis and leukonychia partialis are rare nail findings characterized by complete or partial whitening of the nail plate. Leukonychia totalis and leukonychia partialis are usually inherited or associated with systemic disease. Here, we report the case of a 25-year-old man with idiopathic acquired leukonychia totalis and leukonychia partialis and review the literature on this topic.

Clinical and Dermoscopic Features of the Scalp in 31 Patients with Dermatomyositis

Background: Scalp involvement is not directly evaluated in patients with dermatomyositis (DM). Therefore, the exact frequency of scalp dermatomyositis (SDM) and its clinical and trichoscopic characteristics have been poorly described. Objective: The aim of this study was to determine the frequency and clinical and dermoscopic features of SDM in patients diagnosed with DM. Methods: We performed a descriptive prospective, cross-sectional observational study that included all patients diagnosed with DM at a Mexican academic institute over the course of a year. Results: Twenty-four out of 31 patients with DM had scalp involvement at clinical examination, with a prevalence of 77.4%. SDM was clinically characterized by erythema in all cases, scales in 20 (83.3%) patients, nonscarring alopecia in 21 (87.5%) patients, pruritus in 17 (70.8%) patients, and poikiloderma of the scalp in 16 (51.6%) patients. Twenty-eight patients were evaluated by trichoscopy. The most consistent finding was the presence of enlarged capillaries, found in 20 (71.4%) cases, followed by peripilar casts (57.1%) and tufting and interfollicular scales in 14 (50%) cases. Twenty-two patients also had positive nail fold capillaroscopic features similar to those observed by trichoscopy. Limitations: The simple size was limited. Conclusions: Scalp involvement and alopecia are common in patients with DM, and trichoscopy shows features similar to those found at capillaroscopy. Trichoscopy is a very important tool for diagnosis of scalp involvement in patients with DM.

Ciclopirox Hydroxypropyl Chitosan: Efficacy in Mild-to-Moderate Onychomycosis

The severity and percentage of nail involvement are usually considered the main prognostic factors for the treatment of onychomycosis. This study investigated the efficacy of P-3051 (ciclopirox [CPX] 8% nail lacquer in hydroxypropyl chitosan technology) in a population subset of the pivotal study, selected according to the criteria used in recent onychomycosis pivotal studies. The original study was a multicenter, randomized, three-arm, placebo-controlled, parallel groups, evaluator-blinded study comparing P-3051 with reference CPX (standard, insoluble 8% CPX nail lacquer) and placebo (P-3051 vehicle) in a 2: 2: 1 ratio, applied once daily for 48 weeks to 467 patients with onychomycosis, followed by a 12-week follow up. The primary endpoint was complete cure (negative mycology and 100% clear nail) at the end of treatment. Among the secondary endpoints, response rate (negative mycology and ≥90% clear nail) and negative culture were chosen as most representative for a clinical setting. A population subset (modified intention-to-treat population, 302 patients) was selected, excluding those with more severe disease (> 50% nail involvement), in line with recent onychomycosis pivotal trials. P-3051 was superior to placebo in all parameters but culture at week 60 and was superior to reference CPX in cure and response rates at week 60. Compared to the overall patient population, efficacy rates in the P-3051 group were higher in the subset excluding patients with nail involvement > 50%. Results increased by 33% (from 5.7 to 7.6%) at week 48 and by 19.0% (from 12.7 to 15.1%) at week 60 for cure rate, by 33% (from 24.0 to 31.9%) and 20% (from 28.7 to 34.5%) for response rate, and by 3% (from 89.1 to 91.6%) and 4.0% (from 79.0 to 82.4%) for culture conversion to negative. This post hoc analysis confirms that the severity of onychomycosis is a prognostic factor for responsiveness to antifungal treatments and that this can significantly affect reported efficacy data. The different inclusion criteria should be taken into account when reviewing the efficacy of antifungal agents from different studies.

Platelet-Rich Plasma in the Treatment of Hair Disorders

Platelet-rich plasma (PRP) is highly required by patients with hair loss and is becoming increasingly popular for the treatment of hair disorders worldwide. It is therefore important for dermatologists interested in hair disorders to be ready to answer all the questions their patients will ask regarding the mechanism of action as well as the efficacy and safety of this procedure. This issue of Skin Appendage Disorders contains two review articles focused on PRP. One review is more foPublished online: July 5, 2017