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Onychomycosis is the most common nail disorder in adults. Predisposing factors are immunosuppression, poor peripheral circulation, diabetes mellitus, increasing age, nail trauma, and tinea pedis. Autoimmune patients, who carry many of these predisposing factors, have never been studied. Autoimmune patients, with underlying autoimmune skin diseases; pemphigus, systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), scleroderma, dermatomyositis and cutaneous vasculitis, as well as having abnormal-appearing nail(s) with suspicion of fungal nail infection were included. Clinical information was obtained. The causative organisms were identified by potassium hydroxide preparation and cultured. Duration of onychomycosis in autoimmune patients was twice longer than in non-autoimmune patients. Of those with mycological proven onychomycosis, the autoimmune patients had significantly more affected nails (p < 0.05; chi2, two-sided) compared to the non-autoimmune patients but there was no difference in the affected fingernails or toenails and clinical type of onychomycosis. Candida spp was the most frequently found in autoimmune subjects compared to dermatophytes, Trichophyton rubrum. However, dermatophytes especially Trichophyton rubrum was the most common causative organism in non-autoimmune samples, followed by Candida spp. The causative organisms were more frequently discovered in autoimmune patients, whether by potassium hydroxide (KOH) or culture, than in non-autoimmune patients (p < 0.05; chi2, two-sided).
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PMID:Clinical characteristics and mycology of onychomycosis in autoimmune patients. 1469 80

Two thousand patients who visited the outpatient department at the Institute of Dermatology, Bangkok, were assessed for the presence of foot diseases by questionnaire and physical examination. Abnormalities were detected in 741 individuals (37.1%). Nonfungal conditions were more prevalent (31.4%), mainly consisting of eczema (254 cases, 12.7%) and psoriasis (176 cases, 8.8%). Fungal disease was observed in 119 cases (6.0%). There were 76 cases (3.8%) with tinea pedis and 33 cases (1.7%) with onychomycosis. The identified organisms causing tinea pedis were 57.9% nondermatophyte moulds, 36.8% dermatophytes, and 2.6%Candida spp. The corresponding organisms causing onychomycosis were 51.6% nondermatophyte moulds, 36.3% dermatophytes, and 6.0%Candida spp. Among nondermatophytes, Scytalidium dimidiatum was the leading pathogen while Trichophyton rubrum and T. mentagrophytes were the predominant dermatophytes identified. Diabetes mellitus, peripheral vascular disease and activities related to foot trauma were noted to be predisposing factors for onychomycosis. Footwear, particularly sandals and cut shoes, was the only factor relevant to individuals with tinea pedis (P < or = 0.05). In contrast with other published data on fungal foot infections, this study disclosed a higher prevalence of nondermatophyte organisms, predominantly S. dimidiatum, as the major cause of tinea pedis and onychomycosis. An increase in awareness is necessary to identify such cases, prevent misdiagnosis and initiate appropriate treatment.
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PMID:Prevalence of foot diseases in outpatients attending the Institute of Dermatology, Bangkok, Thailand. 1472 31

Superficial fungal infections of the foot (tinea pedis and onychomycosis) are common among elderly patients. Although most authorities believe that patients with diabetes mellitus have an increased predisposition to dermatophytic infections, some controversies still remain. Because these infections disrupt the skin integrity and provide an avenue for bacterial superinfection, elderly diabetic patients with dermatophytic infection should be promptly treated with an antifungal agent. For most dermatophytic infections of the foot, topical agents are usually effective and less expensive than oral agents. Laboratory diagnosis of fungal infection prior to institution of therapy is recommended. Proper technique for obtaining the specimen is important to ensure a higher chance of isolating the infecting fungus. Commonly used anti-dermatophytic agents that are also active against the yeasts include the imidazoles, the allylamines-benzylamines and the hydroxypyridones, which are also effective against most of the moulds. Oral therapy for tinea pedis, although not well studied, should be limited to patients with more extensive infections, such as vesicobullous and moccasin type, resistant infections or chronic infections. In addition, oral agents should also be considered in diabetic and immunosuppressed patients. On the other hand, treatment of onychomycosis of the foot usually requires systemic therapy. Griseofulvin is the least effective agent when compared with the newer agents. Terbinafine, itraconazole and fluconazole have been shown to have acceptable cure rates. More recently, topical treatment of the nail with 8% ciclopirox nail lacquer, bifonazole with urea and amorolfine have been reported to be successful. Over the past decade, fungal foot infections of the skin and nail are more effectively treated with the introduction of numerous topical and oral agents.
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PMID:Common fungal infections of the feet in patients with diabetes mellitus. 1496 Jan 27

Tinea pedis is a chronic fungal infection of the feet, very often observed in patients who are immuno-suppressed or have diabetes mellitus. The practicing allergist may be called upon to treat this disease for various reasons. Sometimes tinea infection may be mistaken for atopic dermatitis or allergic eczema. In other patients, tinea pedis may complicate allergy and asthma and may contribute to refractory atopic disease. Patients with recurrent cellulitis may be referred to the allergist/immunologist for an immune evaluation and discovered to have tinea pedis as a predisposing factor. From a molecular standpoint, superficial fungal infections may induce a type2 T helper cell response (Th2) that can aggravate atopy. Th2 cytokines may induce eosinophil recruitment and immunoglobulin E (IgE) class switching by B cells, thereby leading to exacerbation of atopic conditions. Three groups of fungal pathogens, referred to as dermatophytes, have been shown to cause tinea pedis: Trychophyton sp, Epidermophyton sp, and Microsporum sp. The disease manifests as a pruritic, erythematous, scaly eruption on the foot and depending on its location, three variants have been described: interdigital type, moccasin type, and vesiculobullous type. Tinea pedis may be associated with recurrent cellulitis, as the fungal pathogens provide a portal for bacterial invasion of subcutaneous tissues. In some cases of refractory asthma, treatment of the associated tinea pedis infection may induce remission in airway disease. Very often, protracted topical and/or oral antifungal agents are required to treat this often frustrating and morbid disease. An evaluation for underlying immuno-suppression or diabetes may be indicated in patients with refractory disease.
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PMID:Dermatology for the practicing allergist: Tinea pedis and its complications. 1505 29

The aims of this study were the detection of distribution of dermatophyte species isolated from the clinical samples of patients with dermatophytosis and the evaluation of risk factors for the development of dermatophytosis. A total of 441 skin, nail and scalp/hair specimens obtained from 301 patients (151 were male; age range 2 months-80 years, median 42 years) and 884 foot and hand skin and nail specimens obtained from 221 control subjects (110 were male; age range 5-75 years, median 36 years) were included to the study between the period of January to December 2005. All the samples have been evaluated by direct microscopic (DM) examination and by culture. A total of 121 (40.2%) patients yielded positivity for dermatophytes, of them 63 were positive by both DM and culture methods, seven were only culture positive, and 51 were only DM positive. Nine (9.8%) of 92 culture positive samples from 70 patients were found negative in DM, while 85 (50.6%) of 168 DM positive samples from 114 patients were negative in culture. 23.5% (12/51) of DM positive but culture negative patients were given antifungal therapy previously. The most prominent species isolated from the cultures were Trichophyton rubrum with a rate of 68.4% (63/92), followed by T. mentagrophytes (18.4%); T. violaceum (3.3%); T. verrucosum, T. tonsurans and Epidermophyton floccosum (2.2% for each); T. schoenleini, Microsporum canis and Trichophyton sp. (1.1% for each). Of the patient samples whose cultures were positive, 45% were from the foot skin. The presence rate of dermatophytes in controls was found as 3.2% (7/221); T. rubrum was isolated from the foot skin of five and T. mentagrophytes was isolated in toenail of two control subjects. About 42% of the samples belonged to the patients who admitted to hospital between December to February period. The evaluation of the risk factors revealed that presence of trauma, pet contact, ritual cleansing and diabetes mellitus had no effect on the development of dermatophytoses, however the presence of fungal infection in the family, male gender, some professions (being farmer, worker and retired), and the use of immunosupressive drugs have been found to increase the risk of dermatophytosis. The number of cases with dermatophytoses started to increase beginning from the age of 20 and peaked in the ages between 40-59 years old. As a result T. rubrum was determined as the most frequently isolated dermatophyte and tinea pedis was the most frequently observed clinical form in our hospital, emphasizing the importance of early diagnosis and effective treatment in superficial fungal infections which have high morbidity.
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PMID:[Investigation of the agents and risk factors of dermatophytosis: a hospital-based study]. 1844 66

We report a case of 71-year-old man who developed a hypersensitivity syndrome associated with terbinafine. He was placed on terbinafine (250 mg/d) for the treatment of tinea pedis due to diabetes mellitus. Following the treatment with terbinafine, he developed drug-induced hypersensitivity syndrome (DIHS). Systemic corticosteroid led to transient improvement of his clinical manifestations. Three months after disease onset, he presented with panperitonitis due to ileal perforation, and underwent an emergency operation. The affected ileum was resected and ileostomy was performed in the terminal ileum. Cytomegalovirus (CMV)-specific IgG antibodies were significantly increased, high-titer CMV antigenemia was detected, and pathological examination of the resected ileum confirmed CMV infection. Based on these observations, we strongly recommend that physicians monitor reactivation of the family of herpesvirus other than herpesvirus 6, to manage DIHS properly.
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PMID:Isolated ileal perforation due to cytomegalovirus reactivation during management of terbinafine hypersensitivity. 2061 93

Interdigital intertrigo and onychomycosis has the potential cause of severe bacterial infectious complications with pain, mobility problems, abscess, erysipelas, cellulitis, fasciitis and osteomyelitis. In another hand, diabetic neuropathy, which affects 60-70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes. These people are high suspecting to be infected by dermatophytic infections in interdigital spaces or onychomycosis witch are frequently induce damage to the stratum corneum, leading to bacterial proliferation and secondary infection. A patient presented with an asymptomatic warm, painless, erythematous swelling of the second left toe, which had been present for a few weeks. Clinically, the lesion was categorized as erysipelas upon an insidious abscess formation. Further investigation was undertaken to confirm the presence of diabetes. Leg erysipelas is a common affection which, according to various studies, has both local concomitants (interdigital intertrigo, lymphoedema, surgical antecedents) and/or general causes (immune suppression, diabetes, alcoholism, etc). Interdigital intertrigo, tinea pedis, and onychomycosis present as public health problems that could trigger serious deterioration in patient quality of life, due to complications induced by secondary bacterial infections.
Diabetes Res Clin Pract 2011 Jan
PMID:Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences. 2103 87

1-3% of human population is affected by psoriasis. Nail disorders are reported in 10-80% of patients with psoriasis. Nail deformations vary according to their degree of severity but are mainly represented by pitting, Beau's lines, hyperkeratosis, onycholysis, leuconychia or oil drops. Onychomycosis is a fungal infection of the nails, caused by dermatophytes, yeast and moulds. In this study, 228 patients with psoriasis aged between 18 and 72 were examined (48 - from Plovdiv, Bulgaria; 145 - from Pleven, Bulgaria and 35 - from Thessaloniki, Greece); 145 of them were male and 83 of them were female. The examination of the nail material was performed via direct microscopy with 20% KOH and nail samples plated out on Sabouraud agar methodology. The severity of the nail disorders was determined according to the Nail Psoriasis Severity Index (NAPSI). Positive mycological cultures were obtained from 62% of the patients with psoriasis (52%- Plovdiv, Bulgaria; 70%- Pleven, Bulgaria and 43%- Thessaloniki, Greece). In 67% of the cases, the infection was caused by dermatophytes, in 24% by yeast, in 6% by moulds and in 3% by a combination of causes. All patients with psoriasis were identified with high levels of NAPSI, whereas the ones with isolated Candida had even higher levels. Seventeen percentage of the patients have been treated with methotrexate, 6% have been diagnosed with diabetes and 22% have been reported with onychomycosis and tinea pedis within the family. An increased prevalence of onychomycosis among the patients with psoriasis was found. Dystrophic nails in psoriasis patients are more predisposed to fungal infections. The mycological examination of all psoriasis patients with nail deformations is considered obligatory because of the great number of psoriasis patients diagnosed with onychomycosis.
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PMID:Onychomycosis in patients with psoriasis--a multicentre study. 2177 Nov 6

Onychomycosis describes a chronic fungal infection of the nails most frequently caused by dermatophytes, primarily Trichophyton rubrum. In addition, yeasts (e. g. Candida parapsilosis), more rarely molds (Scopulariopsis brevicaulis), play a role as causative agents of onychomycosis. However, in every case it has to be decided if these yeasts and molds are contaminants, or if they are growing secondarily on pathological altered nails. The point prevalence of onychomycosis in Germany is 12.4%, as demonstrated within the "Foot-Check-Study", which was a part of the European Achilles project. Although, onychomycosis is rarely diagnosed in children and teens, now an increase of fungal nail infections has been observed in childhood. More and more, diabetes mellitus becomes important as significant disposing factor both for tinea pedis and onychomycosis. By implication, the onychomycosis represents an independent and important predictor for development of diabetic foot syndrome and foot ulcer. When considering onychomycosis, a number of infectious and non-infectious nail changes must be excluded. While psoriasis of the nails does not represent a specific risk factor for onychomycosis, yeasts and molds are increasing isolated from patients with psoriatic nail involvement. In most cases this represents secondary growth of fungi on psoriatic nails. Recently, stigmatization and impairment of quality of life due to the onychomycosis has been proven.
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PMID:[Fungal nail infections--an update: Part 1--Prevalence, epidemiology, predisposing conditions, and differential diagnosis]. 2203 17

Foot problems are common in elders, stemming from age-related podiatric mechanical problems or disease-induced pathology. Common mechanical problems include hammertoe, arthritis, bunions, and metatarsalgia. Disease-induced conditions include onychomycosis, athlete's foot, plantar warts, gout, and diabetes. Treatment is case-specific and often involves multiple interventions, including lifestyle changes. Prevention and treatment strategies are presented. Patient education on proper foot care is effective.When patients are unable to reach or see their feet, staff assumes responsibility for foot care.
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PMID:Delving into foot mechanics and related problems. 2215 72


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