Richard K. Scher

Luliconazole: a review of a new antifungal agent for the topical treatment of onychomycosis

Luliconazole is a novel, broad‐spectrum, imidazole antifungal under development in the USA as a treatment for dermatophytic skin and nail infections. In vitro, luliconazole is one of the most potent antifungal agents against filamentous fungi including dermatophytes. Luliconazole has been formulated in a 10% solution with unique molecular properties, which allow it to penetrate the nail plate and rapidly achieve fungicidal levels in the nail unit. These properties make luliconazole a potent compound in the treatment of onychomycosis. This article reviews the development of luliconazole solution, 10% its molecular properties, preclinical and clinical data and its future perspectives for the treatment of fungal infections.

Longitudinal melanonychia: when to biopsy and is dermoscopy helpful?

Longitudinal melanonychia (LM) is a common presenting problem in general dermatology, and represents a diagnostic challenge to clinicians given its broad differential diagnosis that includes both benign and malignant entities. The decision of when a biopsy is required is incredibly challenging for dermatologists. Dermoscopy is a noninvasive technique that enhances the clinical evaluation of LM, and has demonstrated potential in improving the clinical decision making as to whether or not to biopsy LM. However, it is critical for clinicians to understand the limitations of dermoscopy, and that although it is able to add new criteria for the diagnosis of ungual pigmentation, it does not replace histopathologic diagnosis. Biopsy of the nail unit should be performed in any case where doubt based on the clinical evaluation exists.

Efinaconazole in the treatment of onychomycosis

Efinaconazole 10% topical solution is a new triazole recently approved for the treatment of onychomycosis. It inhibits fungal lanosterol 14α-demethylase in the ergosterol biosynthesis pathway, has potent antifungal activity against dermatophytes, as well as activity against Candida spp. and non-dermatophyte molds, and showed promising results in clinical trials. This review summarizes the mechanism of action, in vitro and in vivo data, clinical trials, safety, and quality-of-life data of efinaconazole as it applies to the treatment of onychomycosis.

Onychophagia: A nail-biting conundrum for physicians

Abstract Onychophagia, defined as habitual nail biting, is a common disorder affecting 20–30% of the population and all age groups. It may lead to significant psychosocial problems, have a negative impact on quality of life, and cause complications involving both the nail unit and the oral cavity. The objective of this paper is to review the prevalence, etiology, history, physical examination, complications and management of nail biting. Since onychophagia is a challenging disorder to treat, a multi-disciplinary approach should be taken involving dermatologists, internists, pediatricians, psychiatrists and dentists.

Onychotillomania: Diagnosis and Management

Onychotillomania, defined as self-induced trauma to the nail unit, either by picking or pulling at the nails, affects 0.9% of the population. It may lead to severe irreversible nail dystrophy, melanonychia, or infections. Although no large clinical trials have assessed the efficacy of treatments, cognitive-behavioral therapy, physical barrier methods, and pharmacological treatments have shown some benefits in case reports. The objective of this article is to review the prevalence, diagnostic criteria, etiology, historical and physical examination findings, pathological features, and current treatment methods. Onychotillomania remains a clinical challenge to dermatologists, pediatricians, internists, and psychiatrists in practice, as there are no evidence-based treatment methods.

A survey-based study of management of longitudinal melanonychia amongst attending and resident dermatologists

while working to increase access to care for the rural Atitl an community. The program thus far has been funded through the Penn Department of Dermatology, supplemented by patient and provider donations. Our aims are to educate both Penn and INDERMA residents in medical care in resourcelimited environments, foster a dialogue between residents with varied training experiences, and encourage interest in global health. INDERMA residents are urged to collaborate with local underserved communities and are introduced to Americanmedical practice. Intermittent yearly clinical support currently bears resemblance tomedicalmissions, but our goal is sustainable care. As such, long-term goals include building frameworks for local care, partnerships with long-term programs, including the year-round PennGuatemala Health Initiative, and establishment of telemedicine to connect local Guatemalan dermatologists to isolated communities. Milestones andmetrics are actively being developed to critically and objectively evaluate the community impact the program may have. We hope to grow this collaboration into a sustainable model of dermatology care that supports educational goals for both Penn and INDERMA residents and develop additional metrics to measure the success of the partnership.

Onychomycosis – a small step for quality of care

Abstract Onychomycosis is a fungal infection of the nail unit, representing the most common nail disorder and accounting for 50% all nail diseases. Unfortunately, many patients are mismanaged, as physicians routinely treat onychomycosis empirically, falsely believing that they can make the diagnosis based on history and clinical inspection alone. We propose and provide evidence for why the diagnosis of onychomycosis should be confirmed by objective methods in each patient before initiating treatment.

Prognostic Factors in Onychomycosis Treatment

Onychomycosis is a common fungal disease of the nail unit with a prevalence of 10% to 12% in the United States. Despite therapeutic innovations in the last few decades, as many as 20-25% of patients do not achieve a complete cure, and 10-53% are reported to relapse after successful treatment. Some of the factors associated with a poor response to onychomycosis have been well studied. They include patient characteristics and morbidities, nail characteristics, and the infecting organism. Therefore, the goal of therapy is to identify these specific prognostic features for each patient and devise an appropriate treatment plan that will allow for the best chance for cure. Scoring systems may be helpful for grading the severity of onychomycosis and predicting the therapeutic outcome.

Part II: Onychomycosis: Treatment and Prevention of Recurrence

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.

Part I: Onychomycosis: Clinical Overview and Diagnosis

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily life, and impair social interactions. In this continuing medical education series we review the epidemiology, risk factors, and clinical presentation of onychomycosis and demonstrate current and emerging diagnostic strategies.