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Dermatomycoses are dermatological infections very commonly encountered in private dermatological practice since they affect up to one third of the population. However, the symptoms are very often shared by other skin infections and disorders and may be highly atypical. It is thus impossible to make a diagnosis with any certainty on clinical grounds alone. For this reason, mycological diagnosis is essential to either confirm or rule out dermatomycosis, and is unavoidable when antifungal therapy is required for the treatment of ringworm of the scalp or beard, or for onychomycosis. It is also vital where therapy guided by the clinical appearance of lesions has failed or in the event of recurring skin lesions. Confirmation of mycosis enables antifungals to be initiated and a negative test warrants investigation for other underlying causes for the lesions seen. However, regardless of the mycological diagnostic technique employed, the quality of the results depends chiefly on the quality of sampling of the infected site, but also on the expertise of the microbiologist. Standard mycological testing remains the most informative, the least expensive and the sole examination capable of isolating the causative fungus irrespective of the type of mycosis, such as dermatophytosis, scytalidiosis, mould-induced ungual infection, candidiasis, or infections due to Malassezia sp. This is the only examination able to identify epidemiological variations. All other more recent techniques are either based upon simple demonstration of the fungal elements involved, without identification of the fungal species in question, or else they are reliant upon a fungal database that is generally highly incomplete., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Topical antifungal treatments for onychomycosis are applied to clean, unpolished nails for 48 weeks or longer. Patients often wish to mask their infection with nail polish yet there is no evidence to suggest antifungal efficacy in the presence of nail polish., Objective: To determine if tavaborole retains the ability to penetrate the nail plate and inhibit fungal growth in the presence of nail polish., Method: Tavaborole was applied to human fingernails painted with 2 or 4 coats of nail polish, and unpainted nails in an ex vivo model. Nails were mounted on TurChub ® chambers seeded with Trichophyton rubrum and allowed to incubate for 7 days. Antifungal activity was assessed by measuring zones of inhibition., Results and Conclusion: Tavaborole exhibited antifungal activity in all experimental groups. The zones of inhibition of T. rubrum for all experimental groups (2 or 4 coats of polish, unpolished) were greater than infected controls (polished and unpolished), p s  < .001. Tavaborole penetrates polished nails and kills T. rubrum in this ex vivo model.

Dermatophytes are considered as the main pathogens responsible for onychomycosis, but recently successive isolations of yeast-like fungi from the infected nails has led to consider these also as primary agents of nail infections. Trichosporon species which are non-candidal, basidiomycetous, yeast-like, anamorphic fungi are commonly isolated from soil but they are also emerging as important etiological agents of onychomycosis. Three species of Trichosporon viz., T. asahii, T. asteroides and T. faecale were isolated from the infected nails of three female members of a family from district Doda of Jammu and Kashmir State. Among the isolated species of Trichosporon, T. asahii was recovered from the nail samples of all the three members, thus confirming its recognition as a main pathogenic species of onychomycosis. So far, there is no report of T. asteroides and T. faecale causing onychomycosis and hence they constitute new additions to the list of onychomycotic fungi. Some of the predisposing factors like low socio-economic condition, poor hygiene, frequent exposure of finger nails to water and dirt, climatic conditions and nail trauma were observed to be the main causes of nail infection in these patients. However, a link between the pathogenic genus and the genetic makeup of the patients is also probable., (© 2018 Blackwell Verlag GmbH.)

Aspergillus spp. are emerging causative agents of non-dermatophyte mould onychomycosis (NDMO). New Aspergillus spp. have recently been described to cause nail infections. The following criteria are required to diagnose onychomycosis due to Aspergillus spp.: (1) positive direct microscopy and (2) repeated culture or molecular detection of Aspergillus spp., provided no dermatophyte was isolated. A review of 42 epidemiological studies showed that onychomycosis due to Aspergillus spp. varies between < 1 and 35% of all cases of onychomycosis in the general population and higher among diabetic populations accounting for up to 71% and the elderly; it is very uncommon among children and adolescence. Aspergillus spp. constitutes 7.7-100% of the proportion of NDMO. The toenails are involved 25 times more frequently than fingernails. A. flavus, A. terreus and A. niger are the most common aetiologic species; other rare and emerging species described include A. tubingensis, A. sydowii, A. alliaceus, A. candidus, A. versicolor, A. unguis, A. persii, A. sclerotiorum, A. uvarum, A. melleus, A. tamarii and A. nomius. The clinical presentation of onychomycosis due to Aspergillus spp. is non-specific but commonly distal-lateral pattern of onychomycosis. A negative culture with a positive KOH may point to a NDM including Aspergillus spp., as the causative agent of onychomycosis. Treatment consists of systemic therapy with terbinafine or itraconazole.

Onychomycosis is a frequent disorder, which accounts for approximately 50% of nail changes. Many patients are treated for onychomycosis without a mycological verification being done. The patients may be in risk of being treated for a non-existent fungal infection with lack of effect and potential adverse events. This review highlights the importance of choosing the correct sampling and diagnostic methods, as genus and/or species identification is essential when choosing the optimal treatment strategies.

The genus Tritirachium is a mitosporic fungus which inhabits in soil and decaying plant material and also a notable insect pathogen. Human infections with Tritirachium species though rare were previously reported to cause corneal ulcers, otomycosis, onychomycosis, and dermatomycosis of the scalp and hence may be considered as a potential pathogen. Here we report a case of distal lateral subungual onychomycosis involving right great toenail in a 22-year-old female, wherein direct potassium hydroxide preparations, fungal cultures, and molecular sequencing of the isolate established Tritirachium oryzae as the etiological agent. Antifungal susceptibility performed by the microbroth technique of CLSI revealed increased MICs to amphotericin B and low MICs to azoles and echinocandins. The case was managed with surgical nail avulsion followed by topical application of 2% ketoconazole cream resulting regrowth of normal nail. To the best of our knowledge, this is the first report of non-dermatophytic mold T. oryzae causing onychomycosis in India.

Aim: The present investigation's intention was to develop an optimized nail lacquer (NL) for the management of onychomycosis., Materials & Methods: The NL was optimized statistically adopting 3 2 full factorial design having different polymer ratios and solvent ratios. The formulations were assessed for drug permeation drying time and peak adhesive strength of the film. Characterization was done using techniques including attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR), scanning electron microscopy (SEM), differential scanning calorimetry (DSC), x-ray diffraction (XRD), etc., Results & Conclusion: The formulation that had 1:1 polymer ratio and 80:20 solvent ratio was chosen as the optimized formulation. In vitro permeation studies showed better penetration (∼3.25-fold) as well as retention (∼11-fold) of the optimized NL formulation in the animal hoof as compared with the commercial formulation. The findings of in vitro and ex vivo studies elucidated the potential of the optimized formulation. [Formula: see text].

Onychomycosis is a fungal nail infection caused primarily by dermatophytes. Several other nail disorders, including psoriasis, can simulate onychomycosis. Accurate diagnosis is therefore vital for the ongoing treatment and management of onychomycosis and to avoid misdiagnosis and treatment delay, which can be both lengthy and costly. Often, a combination of histologic and laboratory techniques is used to obtain an accurate diagnosis. The potential diagnostic challenges associated with the differential diagnosis of onychomycosis caused by dermatophytes and the most common techniques used to confirm the diagnosis are discussed., (© 2017 The International Society of Dermatology.)

Although there have been reports of the successful diagnosis of skin disorders using deep learning, unrealistically large clinical image datasets are required for artificial intelligence (AI) training. We created datasets of standardized nail images using a region-based convolutional neural network (R-CNN) trained to distinguish the nail from the background. We used R-CNN to generate training datasets of 49,567 images, which we then used to fine-tune the ResNet-152 and VGG-19 models. The validation datasets comprised 100 and 194 images from Inje University (B1 and B2 datasets, respectively), 125 images from Hallym University (C dataset), and 939 images from Seoul National University (D dataset). The AI (ensemble model; ResNet-152 + VGG-19 + feedforward neural networks) results showed test sensitivity/specificity/ area under the curve values of (96.0 / 94.7 / 0.98), (82.7 / 96.7 / 0.95), (92.3 / 79.3 / 0.93), (87.7 / 69.3 / 0.82) for the B1, B2, C, and D datasets. With a combination of the B1 and C datasets, the AI Youden index was significantly (p = 0.01) higher than that of 42 dermatologists doing the same assessment manually. For B1+C and B2+ D dataset combinations, almost none of the dermatologists performed as well as the AI. By training with a dataset comprising 49,567 images, we achieved a diagnostic accuracy for onychomycosis using deep learning that was superior to that of most of the dermatologists who participated in this study.

Recently dermoscopic patterns, that can be useful in the diagnosis of distal and lateral subungual onychomycosis, were identified. In this study, we aimed to determine the frequency of the defined patterns so far and additionally to identify other patterns that were observed and to investigate the place of these patterns in the diagnosis of Distal Lateral Subungual Onychomycosis (DLSO) in the dermoscopic examination of the patients with pre-diagnosis of DLSO. Patients admitted dermatology outpatient clinic of Haydarpasa Numune Training and Research Hospital with the complaint of nail disturbance suspicious for DLSO (97 patients) between the August 2015 and February 2016. Clinical and dermoscopic photographs of the cases with a pre-diagnosis of DLSO were taken and their nails were cut for pathological examination and culture. In hematoxylin and eosin, and periodic acid schiff examination, hyphe and/or spore were observed in 134 (65.4%) and fungal growth was detected in 99 (48.3%) of the nail samples. As a result of logistic regression model analysis, the p values of the 'ruin appearance', 'homogeneous leukonychia', 'punctate leukonychia', and 'black discoloration' patterns preserved their statistical significance (p = 0.015, p = 0.009, p = 0.026, p = 0.040, respectively). We believe that in nail disorders clinically resembling DLSO patients, the presence of dermoscopic patterns of ruin appearance, homogenous leuconychia, punctate leuconychia, and black discoloration strongly supports the clinical diagnosis of DLSO.

Background: Microsporum gypseum is a geophilic dermatophyte that colonises keratinous substances in the soil. Fur-bearing animals carry this dermatophyte but are rarely infected. Human infection can be acquired from the soil, carrier or infected animals, and rarely other humans. M gypseum is an uncommon cause of cutaneous infection in humans and typically manifests as tinea corporis, tinea barbae, and tinea capitis. Onychomycosis is rarely caused by M gypseum., Case Summary: We present a case of a 32-year-old white man who presented with a red scaly rash and nail dystrophy after adopting a pet rat 10 years prior to presentation. A fungal culture of a nail clipping grew out M gypseum, and the patient was treated with terbinafine daily for 6 weeks for dystrophic onychomycosis and tinea corporis. After the 6 weeks of treatment, the erythema at the proximal nail fold and distal finger had improved but still persisted. An additional 6 weeks of terbinafine daily completely resolved the clinical manifestations of onychomycosis., Conclusion: The increase in incidence of M gypseum onychomycosis over the past 2 decades is thought to be due to phylogenetic evolution of the dermatophyte from soil saprophyte to a human parasite. Increasing domestication of mammals is also thought to contribute to increasing incidence. Treatment consists of an extended course of terbinafine or itraconazole.

Onychomatricoma is a rare benign neoplasm of the nail matrix first described by Baran and Kint in 1992. Fewer than 80 cases of onychomatricoma have been described in the literature, 15 of which were initially misdiagnosed and treated as onychomycosis. We present the case of a 66-year-old male with thickening and linear xanthonychia of the hallux nail plate secondary to an onychomatricoma misdiagnosed as onychomycosis. Following biopsy for histopathologic analysis, the lesion and proximal nail matrix were surgically excised. At 12 months post-excision, the patient remains asymptomatic without evidence of recurrence. The purpose of the present case report is to make foot and ankle surgeons more cognizant of the pathology, highlight the nonspecific clinical and radiologic findings, and emphasize the importance of interdisciplinary communication for an accurate clinicopathologic correlation and diagnosis of the lesion. Although rare, onychomatricoma should be considered in the differential diagnosis for patients presenting with onychomycosis failing to respond to antimycologic treatment. The clinical index of suspicion for onychomatricoma should increase when only a singular dystrophic nail is involved. Following diagnostic confirmation by histopathology, complete surgical excision is the treatment of choice., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Onychomycosis is one of the most common diseases of the toenails. The costs of diagnosis and treatment are substantial, and as the population ages, the overall cost burden will continue to escalate. The purpose of this study was to correlate dermoscopic features with pathologic diagnosis to support the accuracy of point-of-care diagnosis by dermoscopic examination., Methods: Nail unit pathology reports of 52 patients with abnormal great toenails were compared with the dermoscopic features detected by nail unit dermoscopy., Results: The dermoscopic analysis predicted the laboratory diagnosis in 90.4% of the study patients. The specific dermoscopic findings of short spikes (P < .001), long striae (P < .001), aurora borealis (P < .001), irregular termination (P = .003), dermatophytoma (P = .011), transverse onycholysis (P = .018), and dry scale (P = .04) patterns were all significantly associated with pathology test results consistent with oncyhomycosis. Transverse onycholysis (P = .018) was significantly associated with negative pathology results consistent with the diagnosis of nail dystrophy., Conclusions: Point-of-care examination by dermoscopy positively correlates with histopathologic tests and could be used to diagnose onychomycosis while reducing diagnostic costs.

Onychomycosis is a highly prevalent and intractable disease. The first-line treatment agents are oral preparations, but an effective topical medication has long been desired. The objective was to investigate the efficacy and safety of luliconazole 5% nail solution, an imidazole antifungal agent, for the treatment of patients with onychomycosis. A multicenter, double-blind, randomized phase III study was conducted in Japanese patients with distal lateral subungual onychomycosis affecting the great toenails, with 20-50% clinical involvement. Patients were randomized (2:1) to luliconazole or vehicle once daily for 48 weeks. The primary end-point was the complete cure rate (clinical cure [0% clinical involvement of the nail] plus mycological cure [negative results on direct microscopy]). The adverse event incidence was monitored to evaluate safety. The complete cure rate significantly favored luliconazole (14.9%, 29/194 subjects) versus vehicle (5.1%, 5/99) (P = 0.012). Similarly, the negative direct microscopy rate was significantly higher with luliconazole (45.4%, 79/174) than with vehicle (31.2%, 29/93) (P = 0.026). There were no serious adverse drug reactions. We conclude that once daily topical luliconazole 5% nail solution demonstrated clinical efficacy and was confirmed to be well tolerated., (© 2017 Japanese Dermatological Association.)

The topical treatment of nail fungal infections has been a focal point of nail research in the past few decades as it offers a much safer and focused alternative to conventional oral therapy. Although the current focus remains on exploring the ways of enhancing permeation through the formidable nail barrier, the understanding of the nail microstructure and composition is far from complete. This article reviews our current understanding of the nail microstructure, composition and diseases. A few of the parameters affecting the nail permeability and potential causes of the recurrence of fungal nail infection are also discussed., (© 2017 Blackwell Verlag GmbH.)

Objective: The aim of this study was to examine the accuracy of visual diagnosis of tinea pedis (Athlete's foot) and tinea unguium (fungal nail infection), as well as to provide information on skin abnormalities that could help identify these diseases in aged care facilities (long-term care facilities (LTCFs) and nursing homes)., Method: A multicentre, cross-sectional observational study was conducted in a LTCF and two nursing homes. A dermatologist observed the skin abnormalities in the participants' interdigital and plantar areas, to screen for tinea pedis, and in the participants' toenails, to screen for tinea unguium. If abnormalities were noted, samples such as scales or toenails were collected and examined using direct microscopy. The accuracy of the macroscopic observation for each skin abnormality was examined., Results: A total of 173 residents were recruited. The accuracy of clinical diagnosis using macroscopic observation was relatively low. The sensitivities and specificities for clinical diagnosis were 0.37 and 0.95 for tinea pedis in the interdigital areas, 0.47 and 0.94 for tinea pedis in the plantar areas, and 0.80 and 0.61 for tinea unguium in toenails, respectively. Scales in the plantar areas and discoloration of the toenails were more frequently observed in residents with tinea pedis and tinea unguium than in those without them., Conclusion: Several skin abnormalities were observed in the residents recruited in this study, but there was insufficient correlation with tinea pedis and tinea unguium to be used for screening.

Onychomycosis is a common progressive fungal infection of the nail bed, matrix, or plate leading to destruction and deformity of the toenails and fingernails. The prevalence of onychomycosis is increasing in the United States, particularly in the growing population of Latino patients. In this study, we evaluated the efficacy and safety of efinaconazole solution 10% in Latino patients with onychomycosis. Once-daily application of efinaconazole solution 10% may be an effective topical option for treatment of onychomycosis in this patient population.

Background: Diagnosing fungal melanonychia (FM) is often difficult because it mimics melanonychia caused by other factors. Dermoscopy is helpful in the setting of nail pigmentation. However, the diagnostic characteristics of FM on dermoscopy are not fully elucidated., Objective: We sought to determine the dermoscopic characteristics of FM., Methods: We evaluated the dermoscopic patterns of FM diagnosed at 2 university hospitals from January 2010 to February 2016. We included nail matrix melanocytic activation, nail matrix nevi, and nail unit malignant melanomas as control groups for comparison., Results: In all, 18 FM, 24 melanocytic activation of the nail matrix, 27 nail matrix nevi, and 11 malignant melanoma cases were analyzed. Statistical analysis revealed that yellow color, multicolor pattern, nonlongitudinal homogenous pattern, reverse triangular pattern, subungual keratosis, white or yellow streaks, and scales on the nail were more frequent in FM. However, gray color, longitudinal pattern, and pseudo-Hutchinson sign were less frequent in FM than in controls., Limitations: This was a retrospective study from 2 university hospitals, with a small sample size., Conclusion: The results revealed distinctive dermoscopic patterns for FM. Therefore, dermoscopy can be a useful ancillary tool for diagnosing FM., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Aim : The authors report the biological synthesis of zinc oxide nanoparticles (ZnO-NPs) from the petals extract of Rosa indica L. (rose). Its efficacy was evaluated against two dermatophytes: namely: Trichophyton mentagrophytes and Microsporum canis which cause onychomycosis. The activity of antibiotics against the tested dermatophytes was enhanced, when evaluated in combination with ZnO-NPs. Methods and results: The synthesised ZnO-NPs were preliminary detected by using ultraviolet UV visible spectroscopy, which showed specific absorbance. The ZnO-NPs were further characterised by nanoparticle tracking analysis (NTA), Fourier transform infrared spectroscopy (FTIR), transmission electron microscopy (TEM), X-ray diffraction and Zetasizer. Moreover, nanoparticles containing nail paint (nanopaint) was formulated and its antifungal activity was also assessed against T. mentagrophytes and M. canis . ZnO-NPs and formulated nanopaint containing ZnO-NPs, both showed significant antifungal activity. The maximum activity was noted against M. canis and lesser against T. mentagrophytes. Minimum inhibitory concentration of ZnO-NPs was also determined against the dermatophytes causing onychomycosis infection. Conclusion: ZnO-NPs can be utilised as a potential antifungal agent for the treatment of onychomycosis after more experimental trials.

Background: Onychomycosis is a highly prevalent disease worldwide. There is no standard test for its diagnosis, which remains costly, wasteful, and is sometimes delayed. The diagnostic tests for this disease are few and discordant. The objective was to evaluate the diagnostic validity, performance, and accuracy of culture, nail clipping with Periodic Acid-Schiff -PAS- staining (biopsy), and direct potassium hydroxide (KOH) examination for the study of onychomycosis., Methods: A systematic review was conducted via meta-analysis using 5 databases and 21 search strategies. An ex ante protocol was applied with inclusion and exclusion criteria. Quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool, and the sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratios, receiver operating characteristic (ROC) curves, and proportion of correctly diagnosed patients were evaluated with the meta-analysis of studies of evaluations of diagnostic and screening tests (Meta-DiSc) and Epidat using a random effects model., Results: The efficiency or accuracy of the three tests is influenced by the methodological quality of the studies. These values are lower for KOH and culture and higher for biopsy in moderate quality studies., Conclusion: The diagnostic tests evaluated in this meta-analysis independently showed acceptable validity, performance, and efficiency, with nail clipping with PAS staining outperforming the other two tests.

Onychomycosis is caused by dermatophytes, yeasts or non-dermatophyte molds; when caused by dermatophytes, it is called tinea unguium. The main etiological agents are Trichophyton rubrum and Trichophyton interdigitale. The most frequent types are distal and lateral subungual onychomycosis. Diagnosis usually requires mycological laboratory confirmation. Dermoscopy can be helpful and also biopsy is an excellent diagnostic method in uncommon cases or when mycological test is negative. Treatment must be chosen according to clinical type, number of affected nails and severity. The goal for antifungal therapy is the clearing of clinical signs or mycological cure.

Background: Topical onychomycosis therapies are usually inadequate, and patient compliance to systemic therapies is poor. Recently, interest in laser therapy for the treatment of onychomycosis has increased. We sought to investigate the efficacy of long-pulsed Nd:YAG laser therapy for onychomycosis., Methods: Thirty patients with mycologically confirmed onychomycosis received long-pulsed 1064-nm Nd:YAG laser therapy, moving the beam in a spiral pattern over the whole nail plate two times, with a 1-minute pause between passes. Laser therapy was performed with a spot diameter of 4 mm at a speed of 25 mm/sec once weekly for 4 weeks using fluencies ranging from 40 to 60 J/cm 2 , depending on the thickness of the nail plate. Patients were evaluated in terms of clinical improvement and mycologic cure., Results: Thirty patients started and 15 completed the study. Mycologic cure was achieved in nine patients (60%), of whom eight (89%) were infected with Trichophyton sp. Complete clinical improvement was achieved in seven patients (47%), all of whom were infected with Trichophyton sp. Mycologic cure was not achieved in one of two patients infected with Epidermophyton or in either patient in whom the agent was Candida or Aspergillus; complete clinical improvement did not occur in any of these patients. No serious adverse events were observed., Conclusions: Based on these results, long-pulsed Nd:YAG laser can be used as an effective treatment for onychomycosis, but further studies are needed to draw firmer conclusions.

Background: Onychomycosis is a widespread public health problem, in which T. rubrum and T. mentagrophytes is the commenest causative organisms. Current medical therapy has many drawbacks and side effects. Methylene blue (m.b) photodynamic therapy (pdt) proved efficacy but with lengthy sessions., Objectives: Optimizing methylene blue photodynamic therapy by combination of methylene blue photosensitizer and gold nanoparticles (aunps) in a composite as gold nanoparticles are efficient delivery systems and efficient enhancers of photosensitizers for antifungal photodynamic therapy., Materials and Methods: Eighty newzealand rabbit (Oryctolagus cuniculus) were used and categorized in eight equal groups as follows; healthy and infection control, composite photodynamic therapy and five comparative groups. Photodynamic therapy was initiated at day three to five post inoculation, for four sessions forty eight hours apart. Each group divided and light exposure at two fluencies; 80J and 100J. All groups were investigated macroscopically and microscopically (histopathology and scanning electron microscope) also flowcytometry assessment for cell death and X-ray analysis for gold nanoparticles accumulation in brain and liver tissues were determined., Results: Recovery from infection approaching 96% in gold nanoparticles+light group, around 40% in methylene blue photodynamic therapy and 34% in composite photodynamic therapy. The observed findings confirmed by apparent decrease of apoptosis, however small amounts of gold nanoparticles detected in brain and liver., Conclusion: Light stimulated gold nanoparticles is a promising tool in treatment of onychomycosis., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Onychomycosis is a common dermatological problem and can be identified by direct microscopic examination and fungal culture. However, the positive rate of fungal culture is low. This study investigated the application of scanning electron microscopy in the diagnosis of onychomycosis in 20 patients with negative fungal culture. In this study, a routine glutaraldehyde fixation method was used to prepare specimens for electron microscope examination. Results showed that under the scanning electron microscope, significant structural damage was observed in the nail plate in all patients. Hyphaes were seen in 70% of cases. A mixture of scattered hyphaes, pseudohyphaes, and spores was observed in 30% of cases. A mixture of spores and bacteria was observed in 10% of cases. A mixture of hyphaes and bacteria was observed in 20% of cases. The typical hyphae pierced a thin layer or single layer of corneocytes. Hyphaes could be smooth, sleek, and straight with visible separation, or dry, bent, and folded with a smooth surface. The diameter of hyphaes was 1-2 µm. The scattered spores were the main form of spore growth, and the growth of budding spores can be seen attached to the surface of layered armor. Most of the bacteria were gathered in clumps on the ventral surface, especially in grooves. In conclusion, scanning electron microscopy can be used to preliminarily identify the pathogen involved and the degree of damage in cases where onychomycosis is clinically diagnosed, but fungal culture is negative., (© Wiley Periodicals, Inc.)

Background: The aim of this study was to verify efficacy and tolerability of sequential therapy with 40% urea paste followed by 1% bifonazole urea in mild to moderate distal subungual onychomycosis of the toenails., Methods: It was an seven weeks open study. Sequential patients affected by mild to moderate distal subungual onychomycosis of the toenails agreed to apply on the affected nail 40% urea paste in occlusion overnight for the first three weeks, with gentle scraping with a spatula the following day, followed by 1% bifonazole cream once a day for 4 weeks. Efficacy evaluation was based on mycology, clinical photography and investigator and patient assessment. Tolerability assessment included subjective and objective evaluations., Results: The ten patients enrolled (mean age 57.5 years) completed the study. Onychomycosis was caused in nine cases by dermatophytes and by Scopulariopsis brevicaulis in one patient. At the end of the study, mycological examination was negative in all 10 patients. Clinical photographs showed a reduction of the percentage of the nail affected by onychomycosis in 8 cases, cure in 2 and considerable reduction of the nail thickness, already evident after 7 days. All patients reported to be satisfied by the treatment, which was judged easy to perform and well tolerated., Conclusions: Treatment with urea and bifonazole is effective and well tolerated, and easy to do also by elderly patients.

Onychomycosis is a fungal infection of nail unit that is caused by dermatophytes. Oral Terbinafine hydrochloride (TBF-HCl) is being used for the treatment of onychomycosis since 24 years. The side effects caused by the systemic application and limitations of topical administration of this drug regarding the diffusion through nail lead to the development of a new formulation based on, TBF-HCl-loaded liposome. The newly obtained film formulations were prepared and characterized via several parameters, such as physical appearance, drug content, thickness, bioadhesive properties and tensile strength. In vitro and ex vivo permeation studies were performed to select an optimum film formulation for antifungal activity to show the efficiency of formulations regarding the treatment of onychomycosis. The in vitro release percentages of drug were found 71.6 ± 3.28, 54.4 ± 4.26, 56.1 ± 7.48 and 46.0 ± 2.43 for liposome loaded pullulan films (LI-P, LII-P) and liposome loaded Eudragit films (LI-E, LII-E), respectively. The accumulated drug in the nail plates were found 31.16 ± 4.22, 24.81 ± 5.35, 8.17 ± 1.81 and 8.92 ± 3.37 for LI-P, LII-P, LI-E and LII-E, respectively, which within therapeutic range for all film formulations. The accumulated drug in the nail plate was found within therapeutic range for all film formulations. The efficacy of the selected TBF-HCl-loaded liposome film formulation was compared with TBF-HCl-loaded liposome, ethosome, liposome poloxamer gel and ethosome chitosan gel formulations. It was found that TBF-HCl-loaded liposome film formulation had better antifungal activity on fungal nails which make this liposome film formulation promising for ungual therapy of fungal nail infection.

Background: Trichophyton rubrum (T.rubrum) caused onychomycosis is the most common nail fungal disease. The common diagnostic methods are direct microscopic examination and fungal culture. In this study we used scanning electron microscopy (SEM) and transmission electron microscopy (TEM) to study the subungual ultrastructural changes in T. rubrum induced onychomycosis., Methods: Six outpatients with onychomycosis were recruited and T.rubrum infection was confirmed by fungal culture. Six toenail samples were collected and prepared for SEM characterization. The cultured fugal colonies were prepared for SEM and TEM characterization., Results: 1) SEM showed significant structural damages and the formation of a thin layer or a single layer of keratinocytes in all infected nail plates. Hyphae (piercing or penetrating keratinocytes layers), arthrospores and local bacterial aggregation were observed on the ventral surface of the nail plates. 2) SEM of the cultured fungal colony showed relatively straight, highly branched hyphae and microconidias; TEM showed branching hyphae that were composed of double-layer cell walls. Hyphae had nucleus, mitochondria, liposomes, lysosomes, scattered rough endoplasmic reticulum, myeloid bodies and aggregated ribosomes. There were high-density particles outside the hyphae., Conclusion: SEM showed a large number of hyphae penetrated the keratinocytes layer, suggesting that T. rubrum can cause severe damage to the stratum corneum. TEM showed the ultrastructural features of T. rubrum-induced infection before treatment.

Mycological examination is still the cornerstone for the diagnosis of onychomycosis for many dermatologists, but sampling technique interferes on its sensitivity and specificity. Nail abrasion may be used to reach the most proximal part of the lesion and can be easily accomplished with an electric abrasor. We suggest nail plate dermoscopy to identify the best location for localized abrasion to obtain adequate samples for mycological examination.

Although there are limited data available on gender as an outcome variable in the treatment of onychomycosis, differences in disease prevalence and impact in males versus females have been observed. This article provides a gender subgroup analysis based on results from recent studies evaluating the efficacy, safety, and tolerability of efinaconazole topical solution 10% in the treatment of onychomycosis. Data were collected from two 52-week, prospective, multicenter, randomized, double-blind studies of patients 
(age range, 18-70 years) randomized to receive either efinaconazole topical solution 10% or vehicle for treatment of onychomycosis. Results from this analysis indicated that once-daily application of efinaconazole topical solution 10% may provide a useful topical option for treatment of mild to moderate toenail onychomycosis, especially in female patients.

Superficial white onychomycosis is characterized by opaque, friable, whitish superficial spots on the nail plate. We examined an affected halux nail of a 20-year-old male patient with scanning electron microscopy. The mycological examination isolated Trichophyton mentagrophytes. Abundant hyphae with the formation of arthrospores were found on the nail's surface, forming small fungal colonies. These findings showed the great capacity for dissemination of this form of onychomycosis.

Onychomycosis caused by Fusarium spp. is emerging, but some factors associated with its development remain unclear, such as whether this genus is keratinolytic. The main aim of the present study was to evaluate the ability of Fusarium to use the human nail as a single source of nutrients. We also performed an epidemiological study and antifungal susceptibility testing of Fusarium spp. that were isolated from patients with onychomycosis. The epidemiological study showed that Fusarium species accounted for 12.4 % of onychomycosis cases, and it was the most common among nondermatophyte molds. The most frequent species identified were F. oxysporum (36.5 %), F. solani (31.8 %), and F. subglutinans (8.3 %). Fluconazole was not active against Fusarium spp., and the response to terbinafine varied according to species. Fusarium was able to grow in vitro without the addition of nutrients and invade healthy nails. Thus, we found that Fusarium uses keratin as a single source of nutrients, and the model proposed herein may be useful for future studies on the pathogenesis of onychomycosis.

Onychomycosis is the most common nail disorder. The treatment for this type of infection is one of the main difficult ones in clinical practice, due to the fact that the nails are nonvascularized structures, which compromise the penetration of drugs delivered systemically and favor slow nail growth. We present two devices based on light-emitting diode arrays as light sources for the treatment of onychomycosis by photodynamic therapy (PDT). PDT is an emerging technique that uses a photosensitizer (PS) activated by light in the presence of oxygen. The PS absorbs energy from light and transfers it to oxygen, producing reactive oxygen species such as hydroxyl radicals, superoxide, and singlet oxygen which inactivate fungi and bacteria. Our proposal is the use of a portable and secure light source device in patients with onychomycosis. Additional advantages are the low cost involved, the possibility of topical treatment rather than systemic and the simplicity of operation. These advantages are important to ensure the implementation of this technology for the treatment of an impacting health problem.

Onychomycosis is a common fungal infection of the nail unit that results in discoloration, subungual debris, thickening, onycholysis, and often pain and impairment of mobility. Dermatophytomas are characterized by a thick fungal mass within and under the nail plate and are especially resistant to treatment. Here we report a case of a patient with a dermatophytoma who had failed oral terbinafine but was successfully treated with efinaconazole 10% topical solution.

Purpose: Through the characterisation of the human onchomycotic nail plate this study aimed to inform the design of new topical ungual formulations., Methods: The mechanical properties of the human nail were characterised using a Lloyd tensile strength tester. The nail's density was determined via pycnometry and the nail's ultrastructure by electron microscopy. Raman spectroscopy analysed the keratin disulphide bonds within the nail and its permeability properties were assessed by quantifying water and rhodamine uptake., Results: Chronic in vivo nail plate infection increased human nailplate thickness (healthy 0.49 ± 0.15 mm; diseased 1.20 ± 0.67 mm), but reduced its tensile strength (healthy 63.7 ± 13.4 MPa; diseased 41.7 ± 5.0 MPa) and density (healthy 1.34 ± 0.01 g/cm(3); diseased 1.29 ± 0.00 g/cm(3)). Onchomycosis caused cell-cell separation, without disrupting the nail disulfide bonds or desmosomes. The diseased and healthy nails showed equivalent water uptake profiles, but the rhodamine penetration was 4-fold higher in the diseased nails using a PBS vehicle and 3 -fold higher in an ethanol/PBS vehicle., Conclusions: Onchomycotic nails presented a thicker but more porous barrier, and its eroded intracellular matrix rendered the tissue more permeable to topically applied chemicals when an aqueous vehicle was used.

Onychomycosis is a common chronic nail disorder where dermatophytes are the predominant pathogens. However, non-dermatophytic moulds like Aspergillus can also be implicated as the causative agents. Herein, we report a rare case of onychomycosis due to Emericella quadrilineata ( Aspergillus tetrazonus) in an apparently immunocompetent host.

Background: Data on the dermoscopic features of fungal melanonychia are limited., Aim: To identify the dermoscopic features of fungal melanonychia., Methods: We reviewed patient files, clinical history and dermoscopic images of all cases with a diagnosis of fungal melanonychia seen at our dermoscopy unit within the past year., Results: In total, 14 cases with 20 involved nails were reviewed. The most common type of melanonychia was melanonychia striata (7/20). Multicoloured pigmentation was observed in 19 of the nails. The main dermoscopic pattern was homogeneous pigmentation; however, black pigmented aggregates, presenting as either coarse granules or pigmented clumps, accompanied this homogeneous pigmentation in 16 lesions. Matt black pigmentation, matt white pigmentation, yellow to brown pigmentation, black reverse triangle (wider at the distal than the proximal end), superficial transverse striation and blurred appearance were the other features., Conclusions: We have identified a number of dermoscopic features appearing in fungal melanonychia, which should help in diagnosis of this disease., (© 2014 British Association of Dermatologists.)

"Nail clipping is a simple technique for diagnosis of several nail unit dermatoses. This article summarizes the practical approach, utility, and histologic findings of a nail clipping in evaluation of onychomycosis, nail unit psoriasis, onychomatricoma, subungual hematoma, melanonychia, and nail cosmetics, and the forensic applications of this easily obtained specimen. It reviews important considerations in optimizing specimen collection, processing methods, and efficacy of special stains in several clinical contexts. Readers will develop a greater understanding and ease of application of this indispensable procedure in assessing nail unit dermatoses.", (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Podiatric physicians routinely use electric drills for the treatment of nail and skin conditions. The grinding process produces human nail and skin dust that is generally vacuumed into bags in the grinding unit. Many of the nails are thought to be mycotic, particularly because they are obtained from patients with symptoms of dermatophyte infections. Currently, there is limited information available on the detection of fungi from nail dust samples. Herein, we attempt to address this situation and outline some of the difficulties that pathology laboratories face in isolating and identifying dermatophytes from nail samples., Methods: Fifty nail dust bags from podiatric medical clinics across all of the states and territories of Australia were collected and analyzed. Samples from the bags were inoculated onto primary isolation media. Fungal colonies that grew were then inoculated onto potato dextrose agar for identification using standard morphological (macroscopic and microscopic) features., Results: One hundred fifty-one colonies of dermatophytes were identified from 43 of the 50 samples. In addition 471 nondermatophyte molds were isolated, along with some yeasts and bacteria., Conclusions: The most common dermatophytes isolated were from the Trichophyton mentagrophytes/interdigitale complexes. Trichophyton rubrum, Trichophyton tonsurans, Trichophyton soudanense, and Epidermophyton floccosum were also isolated. An unidentified group of dermatophytes was also present. The three most common genera of nondermatophyte molds were Aspergillus, Penicillium, and Scopulariopsis, all of which have been implicated in onychomycosis and more general disease. The presence of viable fungal pathogens in the dust could potentially pose a health problem to podiatric physicians.

Candida parapsilosis is an emerging fungal pathogen that was once thought to be solely a colonizing organism. C. parapsilosis is increasingly becoming reported as the most common Candida species that causes onychomycosis. Clinical findings include typically severe dystrophy of the nail fold and plate as well as thickening and fragmentation of the plate, particularly in the distal plate. We present a unique case of C. parapsilosis infection of the nail bed without infection of the nail plate and with twenty-nail melanonychia.

Onychomycosis represents about 50% of ungueal pathology. Dermatophytes (especially Trichophyton rubrum and Trichophyton interdigitale) are the main species involved in tinea pedis. Yeasts of the Candida (Candida albicans, Candida parapsilosis,...) genus are predominant on hands and very often associated with ungueal disease and perionyxis. Fungi other than the classic dermatophytes and yeasts can be rarely isolated from nail diseases. Among them, species belonging to Scopulariopsis, Aspergillus and Fusarium genus are mainly found, but their involvement in the disease must be proved. Other fungi, presenting a special affinity to keratin (pseudodermatophytes), such as Neoscytalidium dimidiatum (ex Scytalidium dimidiatum) from tropical and subtropical areas and Onychocola canadensis from Northern America and Europe, are considered as real pathogens in nail diseases. A multidisciplinary approach, including clinicians and biologists, is required to confirm the mycosis. This comparative review emphasizes the importance of histological examination, as well as molecular approaches, which are very contributive to the diagnosis of onychomycosis. The role of the laboratory is to identify at the species level the fungus isolated from nail scrapings and to show its involvement in the ungueal lesions., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction: Onychomycosis, a common chronic fungal infection affecting fingernails and toenails, globally may affect 10 - 30% of the population. This chronic disease is difficult to eradicate. The goal of developing a highly effective and safe topical treatment has not yet been reached as it depends on the type of onychomycosis and the variety of invaders., Areas Covered: Topical drug delivery to the nail is highly desirable in treating nail disorders. However, efficacy of topical therapies is low due to their limited permeability across the nail plate. Advances have especially been made by the development of new therapeutic options including new drug entities, new formulations and reformulations. This overview updates emerging topical treatments for onychomycosis, research progress and future perspectives., Expert Opinion: Development of novel effective noninvasive topical therapy for treating onychomycosis and other nail diseases such as psoriasis is long overdue. Previously there was a lack of basic knowledge about nail and its barrier properties, but with the recent increased interest in this field both from industry and academia, we hope extensive research will continue in this field to bring about successful and safe treatments for such chronic diseases.