Bianca Maria Piraccini

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.

Treatment of dermatophyte nail infections: An open randomized study comparing intermittent terbinafine therapy with continuous terbinafine treatment and intermittent itraconazole therapy

BACKGROUND terbinafine persists in the nail at effective concentrations for several weeks after discontinuation of treatment. OBJECTIVE Our purpose was to verify whether intermittent terbinafine therapy is effective in dermatophytic onychomycosis and to compare the results of intermittent terbinafine with those of intermittent itraconazole and continuous terbinafine treatment. METHODS An open, randomized study of 63 patients was performed with three treatment regimens: terbinafine, 250 mg daily (21 patients); terbinafine, 500 mg daily for 1 week every month (21 patients); or itraconazole, 400 mg daily for 1 week every month (21 patients). Treatment was continued for 4 months in toenail infections (60 patients) and 2 months in fingernail infections (3 patients). RESULTS At the end of the follow-up period (6 months after discontinuation of treatment) 16 of the 17 patients (94.1%) with toenail onychomycosis were mycologically cured in the terbinafine 250 mg group, 16 of 20 (80%) in the terbinafine 500 mg group, and 15 of 20 (75%) in the itraconazole group. CONCLUSION The percentage of patients who were mycologically cured was higher in the continuous terbinafine group than in the intermittent terbinafine and itraconazole groups, but statistical analysis did not reveal any significant difference between these cure rates.

Relapses of Onychomycosis after Successful Treatment with Systemic Antifungals: A Three-Year Follow-Up

Background: Data about relapses of onychomycosis after treatment with the new systemic antifungals vary among the different studies, with figures ranging from 3 to 20% for terbinafine and from 21 to 27% for itraconazole, depending on the follow-up duration. Objective: To determine the prevalence of relapses of onychomycosis cured by terbinafine compared with that of onychomycosis cured by itraconazole. Methods: We followed up 47 patients whose toenail onychomycosis had been mycologically cured in an open randomized study comparing intermittent itraconazole treatment with continuous terbinafine treatment and intermittent terbinafine therapy. Patients were examined every 3 months for up to 3 years after the end of therapy. At each visit clinical and mycologic (direct microscopy and cultures) evaluations were performed. Results: Eight of the 36 patients (22.2%) who completed the study had a relapse of onychomycosis during the follow-up period, including 2 patients of the terbinafine 250 mg group, 2 patients of the terbinafine 500 mg group and 4 patients in the itraconazole 400 mg group. As the original infection, the relapse was caused in all cases by Trichophyton rubrum. Conclusions: This study shows that 22.2% of patients with onychomycosis successfully treated with systemic antifungals experienced a relapse. The relapse rate increased from 8.3% at month 12 to 19.4% at month 24 and to 22.2% at month 36. Relapses were more common in patients treated with pulse itraconazole (4/11) than in patients treated with continuous (2/12) or intermittent (2/13) terbinafine. Statistical analysis did not reveal any significant difference between relapse rates in the three groups.

Drug-induced hair loss and hair growth : incidence, management and avoidance

SummaryA large number of drugs may interfere with the hair cycle and produce hair loss. Drugs may affect anagen follicles through 2 main different modalities: (i) by inducing an abrupt cessation of mitotic activity in rapidly dividing hair matrix cells (anagen effluvium) or (ii) by precipitating the follicles into premature rest (telogen effluvium). In anagen effluvium, hair loss usually occurs within days to weeks of drug administration, whereas in telogen effluvium, hair loss becomes evident 2 to 4 months after starting treatment.Anagen effluvium is a prominent adverse effect of antineoplastic agents, which cause acute damage of rapidly dividing hair matrix cells. Telogen effluvium may be a consequence of a large number of drugs including anticoagulants, retinol (vitamin A) and its derivatives, interferons and antihyperlipidaemic drugs. Drug-induced hair loss is usually reversible after interruption of treatment. The prevalence and severity of alopecia depend on the drug as well as on individual predisposition. Some drugs produce hair loss in most patients receiving appropriate dosages while other drugs are only occasionally responsible for hair abnormalities.Both hirsutism and hypertrichosis may be associated with drug administration. Drugs most commonly responsible for the development of hirsutism include testosterone, danazol, corticotrophin (ACTH), metyrapone, anabolic steroids and glucocorticoids. Hypertrichosis is a common adverse effect of cyclosporin, minoxidil and diazoxide.

Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Summary Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients. Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole. 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow‐up period showed a complete cure of the nail abnormalities in only one patient.

Calcipotriol ointment in nail psoriasis: A controlled double-blind comparison with betamethasone dipropionate and salicylic acid

This double‐blind randomized study was designed to compare the efficacy and safety of calcipotriol ointment (50 μg/g) with betamethasone dipropionate (64 mg/g) and salicylic acid (0.03 g/g) ointment in the treatment of nail bed psoriasis. Fifty‐eight patients applied the given drug to the affected nails twice a day for 3–5 months, depending on clinical response. Efficacy was assessed monthly on the basis of nail thickness, measured in millimetres. Photographs of the treated nails were taken at baseline, and after 3 and 5 months. Tolerability was assessed at 3 and 5 months. In patients with fingernail psoriasis, after 3 months of treatment subungual hyperkeratosis was reduced from 2.3 ± 0.1 mm (mean ± SEM) to 1.5 ± 0.1 mm (−26.5%) in the calcipotriol group and from 2.3 ± 0.1 mm to 1.6 ± 0.1 mm (−30.4%) in the betamethasone dipropionate and salicylic acid group [not significant (NS) between treatments, analysis of variance ( ANOVA)]. After 5 months, responders showed a 49.2% reduction in hyperkeratosis in the calcipotriol group (from 2.8 ± 0.1 mm to 1.4 ± 0.2 mm) and 51.7% (from 2.1 ± 0.1 mm to 1.0 ± 0.1 mm) in the betamethasone dipropionate and salicylic acid group (P < 0.001 from baseline, NS between treatments, ANOVA). In patients with toenail psoriasis, after 3 months of treatment there was an overall reduction in hyperkeratosis from 2.6 ± 0.1 mm to 2.1 ± 0.1 mm (−20.1%) in the calcipotriol group and from 3.0 ± 0.1 mm to 2.3 ± 0.1 mm (−22.9%) in the betamethasone dipropionate and salicylic acid group (P < 0.001 from baseline, NS between treatments, ANOVA). By the end of the fifth month there was a 40.7% reduction in hyperkeratosis in the calcipotriol group (from 2.1 ± 0.1 mm to 1.2 ± 0.1 mm) and 51.9% in the betamethasone dipropionate and salicylic acid group (from 2.7 ± 0.1 mm to 1.3 ± 0.1 mm; P < 0.0001 from baseline, NS between treatments, ANOVA). The results of the study show that calcipotriol is as effective as a combination of a topical steroid with salicylic acid in the treatment of nail psoriasis and represents a safe alternative in the topical treatment of nail psoriasis.

Uncommon clinical patterns of Fusarium nail infection: report of three cases.

Three cases of proximal subungual onychomycosis due to Fusarium oxysporum, including a patient with a fingernail infection. are described. All patients were immunocompetent and presented with acute paronychia associated with proximal or total lekonychia of the affected nails. Nail avulsion followed by topical treatment produced clinical and mycological cure. The literature on Fusarium onychomycosis is discussed. The combination of proximal subungual onychomycosis with subacute or acute paronychia involving fingernails or toenails is highly suggestive of Fusarium sp.

Evaluation of the Efficacy of Acitretin Therapy for Nail Psoriasis

OBJECTIVE To evaluate the therapeutic efficacy of acitretin in patients with isolated nail psoriasis. DESIGN Open study involving 36 patients with moderate to severe nail psoriasis treated with acitretin. SETTING University-based outpatient dermatology clinic specializing in nail diseases. PATIENTS A total of 27 men and 9 women (mean age, 41 years) with nail psoriasis. INTERVENTION Therapy consisted of acitretin, 0.2 to 0.3 mg/kg/d, for 6 months. MAIN OUTCOME MEASURES Clinical evaluation, and Nail Psoriasis Severity Index (NAPSI) and modified NAPSI scores before therapy, every 2 months during therapy, and 6 months after treatment. RESULTS The mean percentage of reduction of the NAPSI score after treatment was 41%; the mean percentage of reduction of the modified NAPSI score of the target nail was 50%. Clinical evaluation at 6 months showed complete or almost complete clearing of the nail lesions in 9 patients (25%), moderate improvement in 9 (25%), mild improvement in 12 (33%), and no improvement in 6 (11%). CONCLUSION Results from low-dose acitretin therapy show NAPSI score reductions comparable with those studies evaluating biologic drugs for nail psoriasis and suggest that low-dose systemic acitretin should be considered in the treatment of nail psoriasis.

Dealing with Melanonychia

Melanonychia describes a brown or black pigmentation of the nail plate caused by the presence of melanin. In this article, we review possible causes of melanonychia and discuss the main problems of management of patients with this condition. The goal in the management of melanonychia is early diagnosis of melanoma of the nail matrix and bed. Melanoma of the nail bed is also known as subungual melanoma. We discuss clinical, dermoscopic features that may help the clinician in selecting lesions that should have excisional biopsy and evaluate different options for the excision. Addressing melanonychia is still a difficult task, and the correct management of pigmented bands in children is far from established. Dermoscopy is possibly a useful tool but the real benefit of this technique, screening lesions to determine which ones need to be removed, remains to be proven.

Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents

BACKGROUND Recurrences (relapse or reinfection) of onychomycosis are not uncommon, with percentages reported in various studies ranging from 10% to 53%. OBJECTIVE We sought to determine the prevalence of long-term recurrences of toenail onychomycosis caused by dermatophytes cured after systemic antifungal treatment with terbinafine (T) or itraconazole (I) and identify risk factors for recurrences. METHODS This 7-year prospective study, started in 2000 and ended in 2007, included 73 patients periodically followed after successful treatment of toenail onychomycosis using either T, 250 mg daily (59 patients), or I, 400 mg daily, for 1 week per month (14 patients). Patients were evaluated every 6 months, with clinical and mycological evaluations being performed. RESULTS Twelve of 73 patients (16.4%) developed a recurrence of onychomycosis a mean time of 36 months after successful treatment. These included 5 of the 14 patients (35.7%) who had taken I and 7 of the 59 (11.9%) who had taken T (P = .046). LIMITATIONS The number of patients treated with T (59 patients) was more than that for I (14 patients). CONCLUSION The administration of systemic T to treat the first episode of onychomycosis may provide better long-term success than I in those patients with a complete response. Other factors including the presence of predisposing factors, use of nail lacquer as a prophylactic treatment, and the dermatophyte strain isolated were not significantly related to relapse.