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The medical term onychomycosis should be understood as chronic infection of the nails caused by a fungus. The most common causative agents are the dermatophytes and Candida species. The less common are certain types of moulds (nondermatophyte moulds or NDMs). In approximately 60-80 % of the cases, onychomycosis is due to dermatophytes. Among dermatophytes, the most often isolated causative pathogen is Trichophyton (T.) rubrum. Other common species are T. interdigitale (formerly T. mentagrophytes), Epidermophyton floccosum, and T. tonsurans. The most significant yeasts causing onychomycosis are Candida albicans and Candida parapsilosis. Predisposing factors for onychomycosis include mainly diseases such as diabetes mellitus, peripheral vascular arterial disease, chronic venous insufficiency, polyneuropathies of diverse etiologies, and immunosuppression, e.g., myeloproliferative diseases (such as lymphoma and paraproteinemia), HIV/AIDS, etc. Other factors facilitating the fungal infection are frequent trauma in professional sportsmen, often accompanied by excessive perspiration. The diagnostic methods that are often applied in different dermatologic departments and ambulatory units are also different. This precludes the creation of a unified diagnostic algorithm that could be used everywhere as a possible standard. In most of the cases, the method of choice depends on the specialist's individual experience. The therapeutic approach depends mostly on the fungal organism identified by the dermatologist or mycologist. This review hereby includes the conventional as well as the newest and most reliable and modern methods used for the identification of the pathogens causing onychomycosis. Moreover, detailed information is suggested, about the choice of therapeutic scheme in case whether dermatophytes, moulds, or yeasts have been identified as causative agents. A thorough discussion of the schemes and duration of the antifungal therapy in certain groups of patients have been included.
1 23
Wiener Medizinische Wochenschrift
ISSN 0043-5341
Wien Med Wochenschr
DOI 10.1007/s10354-012-0139-3
Onychomycosis: modern diagnostic and
treatment approaches
Georgi Tchernev, Plamen Kolev Penev,
Pietro Nenoff, Liliya Georgieva Zisova,
José Carlos Cardoso, Teodora Taneva,
Gabriele Ginter-Hanselmayer, et al.
1 23
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Onychomycosis: modern diagnostic and treatment approaches 1
1 3
Onychomykose: Moderne Diagnostik und
Zusammenfassung  Der medizinische Terminus Ony-
chomykose steht für eine chronische Infektion des
Nagelapparates durch einen Pilz. Zu den häugsten
verursachenden Erregern zählen Dermatophyten sowie
Candida-Arten. Zahlenmäßig weniger bedeutsam sind
bestimmte Schimmelpilze (nicht- Dermatophyten-
Schimmelpilze oder engl. non-dermatophyte moulds).
In etwa 60–80 % der Fälle wird die Onychmoykose jedo-
ch durch Dermatophyten verursacht. Der am häugsten
isolierte Dermatophyt ist Trichophyton (T.) rubrum, wei-
tere relevante Spezies für eine Onychomykose sind T. in-
terdigitale (früher T. mentagrophytes), Epidermophyton
occosum und T. tonsurans. Die wichtigsten, eine Ony-
chomykose verursachenden Hefepilze sind Candida al-
bicans und Candida parapsilosis. Zu den disponierenden
Faktoren, die eine Onychomykose begünstigen, zäh-
len vor allem Stowechselerkrankungen, wie Diabetes
mellitus, aber auch Gefäßerkrankungen, wie periphere
arterielle Verschlusskrankheit, chronisch-venöse Insuf-
Wien Med Wochenschr
DOI 10.1007/s10354-012-0139-3
Onychomycosis: modern diagnostic
and treatment approaches
Georgi Tchernev, Plamen Kolev Penev, Pietro Nenoff, Liliya Georgieva Zisova, José Carlos Cardoso,
Teodora Taneva, Gabriele Ginter-Hanselmayer, Julian Ananiev, Maya Gulubova, Reni Hristova,
Desislava Nocheva, Claudio Guarneri, Nobuo Kanazawa
Assoc. Prof.G.Tchernev()· T.Taneva
Polyclinic for Dermatology and Venerology, University Hospital
Lozenetz, Academic Educational Hospital of the Saint Kliment
Ohridski University, Medical Faculty, Koziak Street 1, 1407 Soa,
P. K . Penev,MD
Department of Dermatology and Venerology, Trakia University,
Medical faculty, Armeiska Street 11, 6000 Stara Zagora, Bulgaria
Prof. Dr. med.P.Neno
Haut- und Laborarzt/Allergologie, Andrologie, Labor für
medizinische Mikrobiologie, Straße des Friedens 8, 04579 Mölbis,
e-mail: neno
Assoc. Prof. L. G. Zisova,MD, PhwD· R.Hristova,MD
Department of Dermatology and Venerology, Medical University
Plovdiv, Vasil Aprilov 15A Street, Plovdiv, Bulgaria
Received: 29 April 2012 / Accepted: 2 August 2012
© Springer-Verlag Wien 2012
J. C. Cardoso
Dermatology and Venerology Department, University Hospital
of Coimbra, Praceta Mota Pinto, 3000-075 Coimbra, Portugal
Assoc. Prof.G.Ginter-Hanselmayer,MD
Department of Dermatology and Venerology, Medical University
of Graz, Auenbruggerplatz 8, 8036 Graz, Austria
e-mail:; gabriele.ginter@
J.Ananiev· Assoc. Prof. M.Gulubova,MD, PhD
Department of General and Clinical Pathology, Medical Faculty,
Trakia University, Armeiska Street 11, 6000 Stara Zagora, Bulgaria
Assoc. Prof. M.Gulubova,MD, PhD
Claudio Guarneri, MD
Department of Social Territorial Medicine, Section of Dermatology,
University of Messina, c/o A.O.U. G. Martino"—via Consolare
Valeria, Gazzi, 98125 Messina, Italy
Nobuo Kanazawa, MD, PhD
Department of Dermatology, Wakayama Medical University
Author's personal copy
2 Onychomycosis: modern diagnostic and treatment approaches
1 3
zienz, Polyneuropathien unterschiedlicher Ätiologie
und immunsupprimierende Krankheiten, z. B. myelo-
proliferative Neoplasien (wie z. B. Lymphome und Para-
proteinämien), HIV/AIDS, etc. Weitere Faktoren, die der
Entstehung einer mykotischen Nagelinfektion Vorschub
leisten, sind lokale Traumen bei Pro- oder Leistungss-
portlern, oft vergesellschaftet mit starker Hyperhidrose.
In dermatologischen Kliniken und Praxen kommen
verschiedene diagnostischen Methoden zur Anwend-
ung Ein einheitlicher diagnostischer Algorithmus wäre
wünschenswert, nach wie vor ist jedoch die persönliche
Erfahrung des Untersuchers entscheidend für die einge-
setzten Methoden. Entscheidend ist, dass der gewählte
therapeutische Ansatz im Wesentlichen vom nachgewi-
esenen Erreger abhängt. In dieser Übersicht wird die
konventionelle Diagnostik von Onychomykosen darg-
estellt. Außerdem wird auf moderne und neu entwick-
elte labordiagnostische Methoden, die zum direkten
Nachweis und zur Identizierung der nachgewiesenen
Erreger der Onychomykose Einzug in die Dermatolo-
gie und Mikrobiologie gefunden haben, eingegangen.
Darüber hinaus wird auf die Auswahl der erfolgver-
sprechendsten lokalen und systemischen erapiefor-
men erläutert, abhängig davon, ob Dermatophyten,
Hefepilze oder Schimmelpilze nachweisbar waren. Die
verschiedenen Schemata der Onychomykosetherapie
für bestimmte Patientenkollektive werden ausführlich
Onychomykose, Trichophyton
rubrum, MALDI-TOF Massenspektroskopie, Uniplex-
PCR-ELISA-Test, Antimykotische erapie, Terbinan,
Fluconazol, Itraconazol, Laserbehandlung
Summary  e medical term onychomycosis should be
understood as chronic infection of the nails caused by
a fungus. e most common causative agents are the
dermatophytes and Candida species. e less common
are certain types of moulds (nondermatophyte moulds
or NDMs). In approximately 60–80 % of the cases, ony-
chomycosis is due to dermatophytes. Among dermato-
phytes, the most often isolated causative pathogen is Tri-
chophyton (T.) rubrum. Other common species are T. in-
terdigitale (formerly T. mentagrophytes), Epidermophyton
occosum, and T. tonsurans. e most signicant yeasts
causing onychomycosis are Candida albicans and Can-
dida parapsilosis. Predisposing factors for onychomy-
cosis include mainly diseases such as diabetes mellitus,
peripheral vascular arterial disease, chronic venous in-
suciency, polyneuropathies of diverse etiologies, and
immunosuppression, e.g., myeloproliferative diseases
(such as lymphoma and paraproteinemia), HIV/AIDS,
etc. Other factors facilitating the fungal infection are fre-
quent trauma in professional sportsmen, often accom-
panied by excessive perspiration. e diagnostic meth-
ods that are often applied in dierent dermatologic de-
partments and ambulatory units are also dierent. is
precludes the creation of a unied diagnostic algorithm
that could be used everywhere as a possible standard.
In most of the cases, the method of choice depends on
the specialist’s individual experience. e therapeutic
approach depends mostly on the fungal organism iden-
tied by the dermatologist or mycologist. is review
hereby includes the conventional as well as the newest
and most reliable and modern methods used for the
identication of the pathogens causing onychomycosis.
Moreover, detailed information is suggested, about the
choice of therapeutic scheme in case whether dermato-
phytes, moulds, or yeasts have been identied as causa-
tive agents. A thorough discussion of the schemes and
duration of the antifungal therapy in certain groups of
patients have been included.
Keywords:Onychomycosis, Trichophytonrubrum, MALDI-
TOF MS, Uniplex-PCR-ELISA-Test, Antifungal therapy,
Terbinane, Itraconazole, Laser treatment
Onychomycosis is а fungal infection of the nail plate,
caused by dermatophytes, yeasts, and moulds [1, 2].
Onychomycosis is the most common disease of the nails
worldwide and constitutes about a half of all nail abnor-
malities [2, 3].
Recent studies, concerning onychomycosis prevalence
among population in the USA and Canada, conrmed the
following results: 6.5% [2] and 14% [1], respectively. e
AHIL survey on the other hand, the largest survey under-
taken in 20 European countries on patients with onycho-
mycosis, estimated its prevalence in 29.6% [4].
Depending on its origin, onychomycosis can be divi-
ded into primary and secondary. In primary onycho-
mycosis, fungal invasion aects an intact nail, whereas
secondary onychomycosis occurs in an already abnor-
mal nail aected by various diseases or traumas [5]. It
should be noted, however, that when strictly dened,
primary onychomycosis is a rare occurrence.
Nowadays, an increasing prevalence of onychomy-
cosis has been noted [1]. e most common reasons for
the increasing number of patients with onychomyco-
sis are the increased lifespan of the general population,
the wide use of antibiotics and corticosteroids, the pre-
valence of synthetic clothes over cotton ones, commu-
nity swimming pools, gyms, saunas and spa procedures
becoming a part of everyday life, as well as wearing tight
shoes and sneakers.
ere are numerous factors that can cause or act like
catalysts for the clinical manifestation of onychomycosis.
Among them are diabetes mellitus, smoking, peripheral
vascular arterial disease, varicose syndrome, as well as
some systemic diseases such as paraproteinemias, lympho-
mas, congenital or acquired immune deciencies [6, 7].
A seriously disturbing fact is the gradually increasing
frequency of onychomycosis in children [8]. Some aut-
hors estimate onychomycosis prevalence in children at
0–2.6% [8].
Author's personal copy
Onychomycosis: modern diagnostic and treatment approaches 3
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Another problem also exists, derived from the fact that
often nail psoriasis is misdiagnosed as onychomycosis.
Many psoriatic patients have nail changes which morpho-
logically resemble onychomycosis, and in such patients
further dierential diagnostic procedures are essential to
exclude the presence of coexisting fungal infection [9].
Previously conducted studies report a prevalence rate
of onychomycosis in patients with psoriasis vulgaris vary-
ing in wide ranges from 4.6 [10] to 47.6% [10], 56% [11],
and 43–62% [9]. In such cases, secondary fungal invasion
is most probable. Dystrophic nail changes in psoriasis
vulgaris are a predisposing condition to fungal infections.
Dermatophytes are the most common causative
pathogens of onychomycosis of toenails, while yeasts,
more specically the Candida spp., are more often isola-
ted from ngernails. A correlation between psoriatic nail
change—Nail Psoriasis Area Severity Index—and posi-
tive mycology is observed.
e huge number of psoriatic patients diagnosed with
onychomycosis requires mycological tests to be perfor-
med in all patients with psoriasis [9].
An interesting fact is that in most patients onychomy-
cosis is triggered by a long persisting interdigital mycosis
and vice versa—in at least one-third of the patients with
onychomycosis, a coexisting tinea pedis is observed [12].
Microtraumata, especially in people practicing sports
are considered to be a predisposing condition of great
importance. An interesting fact is that football players
turn out to be the most aected.
Genetic predisposition in patients with onychomyco-
sis should not be neglected [13]. It had been described by
several authors that the autosomal-dominant inheritance
is of utmost importance in the clinical manifestation of dis-
tal subungual onychomycosis, caused by T. rubrum [14].
e reasons why children and adults with Down syn-
drome are more often aected by onychomycosis and
tinea pedis have not been determined yet [15].
In the cases of leading clinical manifestation, the
accurate identication of the causative fungal pathogen
is highly advised. e accurate identication of fungal
causative pathogens is obligatory in patients with sig-
nicant comorbidities and polymedication as well as in
immunosuppressed patients. In such cases, high risk of
frequent fungal infections exists. Systemic candidosis
and sepsis are possible complications due to a blood or
lymphatic spread of fungal infection.
In addition, fungal infections predispose to relapsing
erysipelas, which can be followed by lymphedema [16].
It is assumed that topical antifungal treatment should
be prescribed only after positive microscopic examina-
tion for fungal elements and systemic treatment—after
fungal culture, followed by identication. Despite esta-
blished rules, not every dermatologist and only a low
percentage of general practitioners in Europe initiate
antifungal therapy after testing for fungal infection. An
interesting fact is that according to some European stu-
dies, barely around 50 % of the dermatologists conduct
diagnostic procedures before initiating systemic antifun-
gal therapy. Without systemic therapy there is a conside-
rable risk for the fungal infection to spread to other areas
of the body, most commonly via autoinoculation [1719].
Treatment should be considered in every patient with
onychomycosis; but decision to treat should be made on
individual grounds taking into account several factors
including the degree of nail involvement and the patient’s
general status, comorbidities, and concomitant medicati-
ons. Fungal infection may advance to complete destruction
of the nail plate [20], and involvement of the surrounding
skin is a common event. However, spreading of the infec-
tion to aect other sites of the body is a rare event. Never-
theless, it is important to note that without treatment,
patients can suer from low self-esteem, shame and fear,
and often avoid participating in community activities [20].
Ambulatory and clinical diagnosis
According to some European studies, low percentage of
dermatologists and general practitioners conduct dia-
gnostic procedures before initiating topical or systemic
antifungal therapy [21, 22]. e samples for fungal micro-
scopy should be taken after at least 4–6 days without topi-
cal antifungal therapy; otherwise false negative results can
be obtained. Immediately before the sample is taken, the
nail plate should be cleaned with 70% alcohol, thus dimi-
nishing the possibility of contaminating the samples with
moulds or bacteria. Disinfection procedure is not requi-
red if selective agars which contain cycloheximide (active
against moulds) or chloramphenicol (active against bac-
teria) are used. e sample from the aected area is obtai-
ned through sharp scissors, nail buer, or scalpel, and at
least 15–20 nail scrapings are needed. A special electrical
grinding machine can be used if the obtained material is
not sucient. Some authors consider the best method for
obtaining material for the conrmation of fungal invasion
to be the one in which the diagnostician takes the most
proximal part of the diseased nail as sample [23].
Conventional methods for laboratory
diagnosis of onychomycosis
Conventional methods used for the diagnosis of onycho-
mycosis have been potassium hydroxide (KOH) prepara-
tion and fungal culture of nail samples on Sabouraud’s
dextrose agar.
Fungal microscopy
e easiest and quickest method for the identication of
nail fungal infection is a KOH preparation. However, it is
characterized by low diagnostic sensitivity [10].
e nail fragments are placed on a slide adding 1–2
drops of KOH solution (10–30%) [24]. After a cover slip
is placed, the specimen is put into a humid environment
for at least 2 hours or more (best overnight). Immedia-
tely after that typical morphology of fungal hyphae can
Author's personal copy
4 Onychomycosis: modern diagnostic and treatment approaches
1 3
be observed under the microscope [24]. Some clinicians
heat the slides to accelerate the process, or add color
stains to make hyphae easier to identify.
Fungal cultures
Another frequently used method for the diagnosis of ony-
chomycosis is fungal cultures. e specimen is put into
a Petri dish, containing agar—usually Sabouraud’s dex-
trose agar (a selective medium that is formulated to allow
the growth of fungi and inhibit the growth of bacteria).
e usage of the Kimmig agar is similar. It is a non-
selective agar, which allows the growth of yeasts, derma-
tophytes, and moulds. Its disadvantage is the need of an
experienced clinician, who will be able to distinguish the
microscopic and macroscopic morphology of the causa-
tive pathogen.
A typical fungal culture requires 2–5 weeks at a cons-
tant temperature around 37 °C to grow. After that a
macroscopic and microscopic identication of the cau-
sative pathogen should be done (Figs. 1 and 2). Some
additional substances are recommended to be used in
order for the bacterial growth in fungal cultures to be
inhibited. Sabouraud’s dextrose agar allows considerably
faster fungal growth in comparison with Kimmig agar.
Both the agars contain antibiotics (Chloramphenicol
50 mg/L, Penicillin, Streptomycin 40,000 IE/L), which
inhibit bacterial growth. In routine diagnostic procedu-
res for the accurate identication of the fungal causative
pathogen, Sabouraud’s 2 or 4%-dextrose agar are predo-
minantly used; Kimmig agar can be used as an alternative.
For selective identication of the causative pathogens
of onychomycosis, especially regarding dermatophytes
and yeasts, Sabouraud’s dextrose agar+ Actidion (cyclohe-
ximide 400mg/L) is recommended. Cycloheximide inhi-
bits the growth of moulds, bacteria, and certain yeasts.
A possible alternative is Mycosel agar (Becton Dickin-
son, Heidelberg, Germany), which contains cyclohexi-
mide [25]. Another alternative is the modied agar for
dermatophytes (SIFIN, Berlin)—2% Sabouraud’s dextrose
agar with additional cycloheximide and chloramphenicol.
e identication of yeasts and dermatophytes is prece-
ded by macroscopic, microscopic, and molecular biolo-
gical observation of the infected people. Dermatophytes
grow for about 2–4 weeks at a temperature of 26–32°C.
Yeasts, especially that of the genus Candida, grow
within 2–4 days at 26–32°C, or up to 37°C. For Candida
albicans and nonalbicans species, culture on the so-cal-
led CHROM agar or biochemical tests (e.g., API 20°C, ID
32 °C, bioMérieux SA, France) is used. Rarely, onycho-
mycosis can be caused by yeasts from the genus Malas-
sezia—especially in immunosuppressed patients or those
with AIDS. e cultivation of Malassezia spp. is performed
onto lipid-enriched Dixon’s agar medium, and the Tween
test is used to identify the dierent Malassezia species.
e growth of moulds begins during the rst days
after the cultivation on Sabouraud agar. ey can be
both causative pathogens or laboratory contaminants.
ey cannot be cultivated on media containing Actidion
(cycloheximide). If a medium with Actidion (cyclohexi-
mide) is routinely used, mould identication as a causa-
tive pathogen can sometimes be impossible. In order for
the moulds to be identied as causative pathogens rather
than laboratory contaminants, they should be isolated in
several consecutive microbiological cultures. e exact
type of causative pathogen is determined by microbiolo-
gical culture [25].
Fluorescence microscopy
is method gains higher sensitivity, when compared
with the direct microscopic examination using KOH pre-
paration. However, UV light (UVA 365nm, special lter)
and a uorescence microscope are needed. A special
uorescent substance is added to the KOH (Blankophor,
Fig. 1Infection due to T. rubrum, 32-year-old swimmer
Fig. 2 Diagnostics of T. rubrum by culture
Author's personal copy
Onychomycosis: modern diagnostic and treatment approaches 5
1 3
Calcouor, or acridinium orange). It binds to fungal
chitin, and marks hyphae and arthrospores appear as
brightening structures.
Histological examination of nail material is rarely used,
but it is a highly informative method. One of the follo-
wing stainings is used—periodic acid-schi (PAS), or
Groccot–Gomori silver staining. It should be conside-
red that although there is a fungal invasion of the tis-
sues, histopathology is not always positive. According
to some retrospective researches undertaken in famous
European University Hospitals, the diagnostic sensiti-
vity of the fungal culture and microscopy is not always
very high. In some cases, they are positive in just about
50–70 % of patients with onychomycosis [25]. e dia-
gnostic sensitivity can be considerably increased by con-
ducting biopsy. However, biopsy is not always advisable
or possible to conduct, e.g., in diabetics. An additional
problem regarding histological diagnosis is that it does
not provide identication of the exact species, although
dermatophytes or yeasts can be suspected [25, 26]. Com-
pared with direct microscopy, histological diagnosis is
much more reliable [27].
e histological diagnosis of fungal elements in tissues
is a highly sensitive method in comparison with the direct
microscopy with KOH preparation and fungal culture.
However, patients often reject this diagnostic procedure [24].
Molecular biological methods as diagnostic tool
Dermatophytes are considered to be one of the most
signicant causative pathogens of onychomycosis
worldwide. Dermatоphytes belong to three genera of
fungi—Trichophyton, Epidermophyton, and Microspo-
rum. T. rubrum is the most common causative agent of
dermatophytosis, followed by T. interdigitale, T. tonsu-
rans, E. occosum, M. gypseum, and rarely M. canis [28].
For their diagnosis, conventional methods can be used—
direct microscopy with KOH preparation, uorescence
staining, or cultivation on Sabouraud’s dextrose agar.
Certain dermatophytes such as Trichophyton spe-
cies of Arthroderma benhamie (genus Trichophyton)—a
zoophilic dermatophyte can be identied only through
molecular biological methods [29, 30]. e conven-
tional classic (macromorphology and miscroscopic
examination) and biochemical methods cannot provide
identication of Trichophyton species of Arthroderma
Benhamiae [26]. e direct microscopy with KOH prepa-
ration, cultivation on Sabouraud’s dextrose agar followed
by specifying of microconidia and macroconidia mor-
phology, presence of chlamydospores, urease activity
are classical methods, showing low specicity and long
duration—around 6 weeks [31]. In addition, for the cor-
rect identication of the results a mycologist with a good
knowledge of the morphological features of dermatophy-
tes is needed.
A precise diagnosis and exact identication of the
causative agent could be performed through some new
molecular biological methods—such as polymerase
chain reaction (PCR) and matrix-assisted laser desorption
ionization (MALDI-TOF MS—time of ight mass spectro-
metry). e last one is used to identify dermatophytes in
fungal material that has been isolated from culture [24].
Polymerase chain reaction (PCR)
PCR is a process of in vitro amplication of a DNA mole-
cule, as a result of which within a few hours millions of
copies of a particular molecule can be generated [24].
Hence, it is a very sensitive and specic method. ere
are dierent primers available to detect dierent species,
including T. rubrum, T. interdigitale, M. gypseum, M.
canis, T. tonsurans, T. violaceum, and E. occosum.
In 1999, the rst special gene probe was used for the
detection of T. rubrum in nail material (Fig. 3) [27].
Polymerase chain reaction-enzyme-linked
immunosorbent assay (PCR-ELISA) for direct
detection of dermatophyte DNA
is new established method comprises an ampli-
cation and hybridization technique, which is used to
detect sequences within the PCR products of ampli-
ed DNA of dermatophytes. e topoisomerase II gene
of the dermatophytes is used as target for the primers
(one of them is labeled by digoxigenin). DNA isolation
is carried out using the Qiagen QIAamp DNA Mini Kit.
e rst step of the amplication process follows those
of the PCR—denaturation, annealing of the primers to
the single-stranded DNA template and elongation. e
ready copies of DNA sequences are used in the second
step—ELISA—in which specic probes (primers) labeled
with biotin, are used to bind to amplied DNA. If derma-
Fig. 3Onychomycosis, 57-year-old man with diabetes
Author's personal copy
6 Onychomycosis: modern diagnostic and treatment approaches
1 3
tophyte DNA is available in the sample, the biotin-labe-
led probe will be xed to streptavidin that is xed to the
bottom of the microtiter plate. After an antibody–antigen
reaction the enzymatic change of the substrate produces
a color change in the microtube that is considered posi-
tive. In this way, the presence of dermatophyte DNA in
the examined sample can be conrmed and the identi-
cation can be performed.
Uniplex-PCR-ELISA-Test includes T. rubrum, T. inter-
digitale, E. occosum, T. tonsurans, M. canis, T. violaceum,
and Trichophyton species of Arthoderma benhamiae
separately. According to some researches, the diagnostic
value of the selective culture media for Dematophytes is
evaluated to be around 82.1 %, and that of PCR-ELISA-
Test 85.8%, respectively [24].
is molecular–biological method allows a conside-
rably quick identication of the causative agent directly
from nail material within 24hours [32]. A multiplex-PCR
for T. rubrum-DNS identication as well as for other cli-
nically relevant dermatophytes (Pan-Dermatophyten-
primer) allows identication within 5hours [33].
e morphological dierentiation between anthro-
pophilic and zoophilic T. interdigitale strains by clas-
sical microscopical and biochemical methods is often
problematic. In particular, it is impossible to dierent-
iate between the zoophilic strains of T. interdigitale, T.
mentagrophytes, and the Trichophyton anamorph of A.
benhamiae. In these cases, molecular identication met-
hods may be applied to answer epidemiological, taxono-
mical, and therapeutical questions [34].
Matrix-assisted laser desorption ionization
MALDI-TOF MS is a routine technique for the identica-
tion of certain bacteria and it is nowadays gaining increa-
sing popularity [27]. At present, the use of the method is
restricted to the identication of a causative agent that
has been cultivated in a microbiological culture [35, 36].
MALDI-TOF MS allows identication of the causative
agents by the molecular weight of their specic protein
e principle of the method—the proteins are added
to crystals of UV-absorbing proteins (matrix). Laser ash
ionizes the matrix molecules and as a result, positive ions
are formed, which are captured by a detector. Small ions
reach the detector before large ions. e dierences in
the time required for the ions to reach the detector show
dierences in analyzed spectrum, thus the causative
agent is identied. e spectrum for every microorga-
nism is individual, so it can be used for identication of
fungal species and subspecies from nail and skin sam-
ples. is method can be used not only for onychomyco-
sis diagnosis, but also in dermatomycosis diagnosis.
is method is specic, sensitive, quick to process,
and has a relatively low cost, being able to detect not
only fungi but also dierent types of bacterial species in
a sample [3739].
According to other sources in the literature, MALDI-
TOF MS, used with special software (SARAMIS), is capa-
ble of identifying the dierent phenotypic variations of
Aspergillus species, even in their specic growth phases
[40]. is technique can be applied and completed wit-
hin a few hours directly from Aspergillus mycelium, and
within a few days if spores are present [41].
MALDI-TOF MS can be used as an additional test
for conrming the results of fungal cultures, especially
when accurate identication of the causative agent is
dicult—Trichophyton species of Arthoderma banha-
miae, for example, an often ignored and misclassied
zoophilic dermatophyte, which causes tinea corporis
and tinea capitis. is method allows successful mor-
phological dierentiation between Arthroderma ben-
hamiae and M. canis (causative agent of tinea capitis).
Such dierentiation turns out to be impossible in above
75% of the cases in which classical diagnostic methods
have been used.
With MALDI-TOF MS dierent species of Candida can
also be dierentiated (such as C. albicans, C. parapsilo-
sis, C. magnoliae, C. dubliniensis, C. lusitaniae, C. krusei,
C. glabrata, C. tropicalis, and C. guilliermondii).
According to other sources in the literature, MALDI-
TOF MS can be used for direct identication of fungal
species in nail material [41]. However, this direct assess-
ment of fungi in clinical samples has to be proved in furt-
her studies.
Restriction fragment length polymorphism (RFLP)
e accurate identication of moulds such as Fusarium,
Acremonium, and Aspergillus, is performed in speciali-
zed laboratories. Firstly, PCR is used for the extraction of
ribosomal RNA followed by RFLP [40].
Therapeutic schemes, choice of treatment
e therapeutic scheme is chosen depending on the
microbiological culture, the results of PCR, and/or MAL-
DI-TOF MS for accurate identication of the causative
agent (see Table1).
Topical antifungal therapy
Topical antifungal therapy is used only in supercial ony-
chomycosis, which aects up to one-third of the nail plate.
e most commonly used medications are Ciclopirox
(Polinail nail lacquer, Batrafen nail lacquer), Naftine
(Exoderil solution), and others.
An antifungal nail lacquer can be used in onychomy-
cosis which aect up to 40 % of the nail surface or not
more than three out of ten nails. According to the inter-
national consensus conference of onychomycosis the
fungal aection should not exceed 50 % of the nail sur-
face. However, some nail lacquers are approved for topi-
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Onychomycosis: modern diagnostic and treatment approaches 7
1 3
cal treatment of an onychomycosis up to 80% of the nail
surface [42].
Systemic antifungal therapy
Itraconazole exhibits ecacy against fungal infections
caused by dermatophytes, yeasts, and moulds.
A so-called pulse therapy with itraconazole 200mg
twice daily for 1 week is recommended. After a thera-
py-free period of 3 weeks, a second pulse therapy with
itraconazole pulse 200mg twice daily should follow [43].
e total number of pulses in onychomycosis is usually 3,
with a maximum 4.
During systemic therapy, an additional topical the-
rapy with Ciclopirox (Polinail nail lacquer, Batrafen nail
lacquer) or Bifonazole cream is recommended [43].
If dermatophytosis of the nails is conrmed then oral
terbinane therapy is recommended. Various therapeu-
tic schemes have been proposed.
In practice, terbinane is usually prescribed as fol-
lows—one oral tablet of 250mg once a day with die-
rent continuity of the therapy course: at least for about 6
weeks in onychomycosis of the ngernails, which is most
often of the distal subungual type. According to the clini-
cal response, therapy can be continued after 6 weeks. In
onychomycosis of toenails, the therapeutic course conti-
nues up to 12 weeks. In cases of slow nail growth, therapy
should be even more prolonged [43].
One important therapeutic scheme is the following:
from the 1st to the 14th day—terbinane 250mg once a
day, followed by 250mg terbinane once a week; treat-
ment duration is until recovery and can achieve up to 1
Another intermittent therapeutic scheme is repor-
ted by Gupta et al. [44]. Terbinane 250mg once daily is
administered for 4 weeks, followed by a 4-weeks break.
According to treatment success, a second and third pulse
may follow [43].
Fluconazole as well as itraconazole are eective against
infections caused by dermatophytes, and in particular
by yeasts (with the exception of Candida glabrata and
Candida krusei), and in case of itraconazole also moulds.
Fluconazole can be successfully administrated as
pulse therapy at a dosage of 150 up to 300 (450)mg once
a week for up to 9 months or until cure is achieved [45].
Onychomycosis due to moulds
Terbinane is the drug of choice with highest evidence
for treatment of onychomycosis due to Scopulariopsis
brevicaulis and Aspergillus spp. Topical drugs may be
eective [46], in particular ciclopirox-containing nail
lacquer in infections due to Scopulariopsis brevicaulis
and Acremonium spp., best in combination with chemi-
cal keratolysis of the nails using 40% urea preparations.
Modification of treatment in certain groups
of patients
Individual modication of therapy is possible, someti-
mes even compulsory—in polymedicated patients with
signicant comorbidities, including liver, kidney, or he-
art failure, as well as immunosuppressed patients (Figs.
4 and 5). Antifungal therapy should be administrated ca-
refully in patients with chronic or active liver diseases.
Before antifungal therapy is initiated, an evaluation of
the possible presence or absence of liver disease should
be done [43]. In patients with kidney diseases, thera-
py should also be carefully administrated. In patients
with immune deciency, the full blood count should be
constantly observed especially when treatment conti-
nues more than 6 weeks. In patients with heart failure,
itraconazol should be used with great caution, since it
Table 1. Some of the most commonly used topical and systemic therapeutic options for onychomycosis
Modality Drug Dose Duration/therapeutic scheme
Systemic Terbinafine 250 mg per day 6 weeks—fingernails
12 weeks—toenails
250 mg Once a day for 2 weeks
Then once per week, up to 1 year
250 mg per day 4-weeks course followed by 4-weeks break
Repeat second or third course according to clinical response
Itraconazol 200 mg twice a day for 1 week Two courses with 3-weeks intervals—fingernails
Three to four courses with 3-weeks intervals—toenails
Fluconazol 150–300 (450) mg once a week Up to 9 months or until cure is achieved
Topical Ciclopirox Once a day Until cure is achieved
Amorolfine Once a week Until cure is achieved
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8 Onychomycosis: modern diagnostic and treatment approaches
1 3
can have a negative inotropic eect with potential for
decompensation of the underlying cardiac disease.
Furthermore, in polymedicated patients, careful
choice of the systemic drug should be done according
to the potential for interactions [47]. In general, in these
patients azol antifungals should be avoided, in particular
Surgical treatment of onychomycosis
It is considered that onychomycosys is one of the fungal
infections among population with the highest percen-
tage of unsuccessful treatment. Although rarely used
independently, surgical treatment is an alternative to
systemic therapy [48]. Topical antifungal medications
are used at the same time and/or immediately after that,
aiming at elimination of the infected nail structures [48].
Surgical treatment could be accompanied by topical or
systemic therapy. Surgical nail plate removal could be
combined with topical antifungal therapy. is method
provides very good clinical results. Such treatment has
been applied in cases of Scopulariopsis brevicaulis and
Acremonium species infections [49]. Surgical treatment
is also necessary in fungal infections resistant to sys-
temic or topical treatment [49]. Besides avulsion (the
forcible tearing away of nail plate), the mechanical the-
rapy of onychomycosis includes abrasion (scraping o
the supercial layer) of the nail [49]. Partial avulsion is
recommended in cases of distal lateral subungual ony-
chomycosis and partial subungual onychomycosis as an
adjuvant to local therapy.
Laser treatment of onychomycosis
Because of the high morbidity rate of onychomycosis
and the low results of oral and topical therapy, adminis-
trated separately or at the same time, as well as common
relapses, modern and noninvasive treatment methods
have been investigated. One of them is laser treatment
[50]. It is applied as 0.65 ms pulsed Nd:Yag 1,064nm
laser. Patients are treated 2–3 times with minimum
3-weeks interval between sessions. It is well tolerated.
According to the literature, in seven out of eight cases
(87.5%) fungal cultures are negative after the second or
third procedure. Because of that, treatment with 1,064
Nd:YAG laser is to be carefully explored, concerning its
long-term eect in relation to clinic and microbiology,
as well as specifying the individual number of treatment
courses and optimal regimen [50]. e advantage of
Nd:YAG 1,064 nm laser compared with lasers with lon-
ger exposure to radiation is that there is no need of skin
cooling, which simplies the procedure. Adverse eects
and complications are not signicant. It is recommen-
ded for the nails not to be long for better results.
Laser therapy consists of radiation of 2mm area with
233J/sm energy without cooling spray, gel, or local anest-
hetic. Every nail is treated separately vertically and hori-
zontally, forming a cross over the surface of the nail. e
duration of treatment is 45seconds or less for every nail
plate. For prevention of reinfection, patients are secured
with daily use of antifungal cream. Revision is made 4
–6 months after the treatment. e ecacy of therapy is
estimated after the secondary microbiological examina-
tion is performed [50].
Noveon is a laser with dual wavelength of 870nm and
930nm. Its parameters are close to those of the infrared
diods [51]. ese machines are used for the treatment
of onychomycosis because of their unique photolethal
eect to infective agents [51]. ese lasers have no terato-
genic risks, unlike the photodynamic therapy (PDT) with
UV beam. Also, there is no toxic photoablation deriving
from the Nd:YAG lasers. e results from several clinical
researches show that these lasers are suitable for the tre-
atment of onychomycosis irrespective of the stage of nail
damage [51].
e femtosecond (f-sec) infrared titanium-sapphire
laser does not damage the surrounding tissues [52].
is laser achieves selective delivery of energy into deep
layers of the nail bed. In this kind of lasers, interaction
with environment is nonlinear [52]. Besides, the deep
penetration of this laser contributes to the elimination
of deeply located dermatophytes without damaging the
surrounding tissues. Ecacy of treatment is evaluated
by subculture, while assessment of collateral damages is
done by scanning electron microscopic [52]. Experience
shows that the f-sec laser inhibits fungus growth suc-
cessfully in examined specimens, while lower intensity
damages the nail plate [52].
CO2 laser also improves the condition of patients with
onychomycosis and gives good results [53, 54]. Other
authors have also reported an experimental method of
approaching the laser treatment of onychomycosis [55].
Photodynamic therapy (PDT)
Photodynamic therapy is based on the usage of photo-
sensitizing agents and light with exact wavelength. Sing-
let oxygen is generated, leading to cell death. It has been
examined whether PDT is appropriate for treatment of
supercial nail infections. ere is a research concer-
ning the eciency of PDT in onychomycosis caused by
moulds—Acremonium sclerotigenum [56]. PDT, combi-
ned with methyl-aminolevulinic acid, is administrated
in three sessions, with 15 days interval between each
procedure [56]. Another study reveals the eect of 5-ami-
nolevulinic acid (ALA). e dermatophyte T. rubrum,
causative agent of onychomycosis, metabolizes ALA to
protoporphyrin IX (PP IX) in liquid culture. In optimal
conditions, a typical red uoroscence is seen. It is indu-
ced by PP IX and is estimated qualitatively with Wood’s
lamp or uoroscent microscope. Optimal concentration
of ALA is 1–10mmol/L. ALA causes signicant reduction
of dermatophyte growth and lack of PP IX uorescence,
if higher concentration of ALA is used. A combination
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Onychomycosis: modern diagnostic and treatment approaches 9
1 3
between ALA and light clearly demonstrates the inhibi-
tory eect of PDT with ALA. is method is promising as
far as reduction of T. rubrum colonization in onychomy-
cosis is concerned [57].
One of the possible PDT schemes is: Damaged nail
surface is coated lavishly with 20% urea unguentum and
is covered with a folio for 10hours. e nails are subse-
quently treated with 20% solution of ALA methyl ester in
liquid cream for 5hours, but only after protection from
light with plaster and aluminium folio has been done.
Protoporphyrin uorescence is conrmed with UV-beam
and spectrophotometer before PDT. It’s observed in nail
base and periphery of fungal lesions. e nail (including
proximal and lateral nail borders) is exposed to radia-
tion horizontally and vertically with pulsed laser 630nm
light, 100J/sm2 using excimer laser [58] PDT with 5-ALA,
applied once a week [59]. A bearable pain has been repor-
ted in patients during the procedure but it tends to disap-
pear the next day. Improvement in the condition occurs
after 6–7 treatment courses (total dosage 600–700J/sm2).
Most frequently, dermatophytes are not found in post-
treatment investigations—microscopy with KOH pre-
paration and culture [57]. According to the literature,
there are no relapses of onychomycosis after 3–6 months.
In comparison, improvement is not observed after tre-
atment with ALA or radiation solely [59]. According to
recent researches, PDT with methylaminolevulinate is
also a successful treatment of refractory onychomycosis
caused by nondermatophytic moulds [58].
PDT is suitable for treatment of distal and lateral
subungual onychomycosis caused by T. rubrum [60].
e advantages of PDT are the lack of side eects, con-
cerning kidney and liver function, as well as the lack of
risk to patients with systemic diseases and the absence
of interaction with other drugs [57, 59]. Old age is not a
contraindication for treatment. On the other hand, oral
therapy with antifungal agents may not be eective and it
may be even contraindicated in case of intolerance. PDT
is a very good alternative in these cases [58, 60].
Currently, the most frequently used diagnostic methods
for fungal infection conrmation are the conventional
ones—direct microscopy with KOH preparation and cul-
ture on Saboraud agar.
Culture identies the exact causative agent and in this
way makes it easier to choose the most suitable medica-
tion [25].
Culture has a diagnostic sensitivity of 50–70%. As a
result, 30–50 % of fungal agents cannot be identied by
conventional methods [25].
Fluorescence method and histology/PAS are less used.
A number of data reveals that PAS staining is a considera-
bly sensitive method in comparison with other methods
for diagnosis, but not all patients will accept this invasive
manipulation [24, 25].
Fungal tests are very important in the dierential dia-
gnosis of nail diseases, since other condition such as
lichen planus, psoriasis, and nail dystrophy of dierent
causes may have features that can be confused with ony-
chomycosis. Having in mind that onychomycosis fre-
quently occurs in cases of primary or genetically damaged
nails, this problem is not very easy to be solved [9, 24, 25].
Modern additional methods, which are molecular–
biological—PCR, Uniplex-PCR-ELISA-Test, and MALDI-
TOF MS—will probably play a very important role in the
diagnosis of onychomycosis [24, 40].
PCR is an easy and rapid method. Extraction of DNA
takes up to 30minutes, whereas elongation takes 5hours.
PCR results are ready within a day. is method is charac-
terized by high sensitivity and diagnostic specicity that
exceed the classic diagnostic methods. e specicity of
PCR analysis derives from the possibility of revealing the
exact causative agents in the presence of other microor-
ganisms, viruses, and cells of macroorganisms [24].
From this point of view, the ability of PCR can be de-
ned as unique. By using this method, it is easy to identify
and diagnose dermatophytes that are dicult to detect
Fig. 4Tinea pedis, 57-year-old patient, caused by T. rubrum
Fig. 5Onychomycosis, a 70-year-old man; causative patho-
gen—T. rubrum
Author's personal copy
10 Onychomycosis: modern diagnostic and treatment approaches
1 3
by classic methods. e analysis is made with minimal
amount of specimen and at the same time concomitant
diagnosis of a number of species in one clinical sample
is possible. By PCR, dierent biologic specimens can be
examined, including those directly taken from skin lesi-
ons, nails, and hair (Figs. 4 and 5). ese properties allow
wide usage of the method by dermatologists and mycolo-
gists [24]. In conclusion, PCR is a more reliable method
than direct microscopy and culture. At the moment, this
method is not available in all clinics and laboratories,
although it is used as an additional diagnostic tool to the
classic methods. is method has considerably increased
the percentage of positive results and has reduced the
time needed for achieving an accurate diagnosis. e cul-
ture gives results in 3–4 weeks, whereas PCR method wit-
hin a maximum of 1–2 days. is method is also reliable
as far was necessary investments and materials for main-
tenance are concerned. At present, the wide use of the
method is restricted only by labor intensity and the need
of more sta. In recent years, it is considered that mole-
cular biology methods will completely replace conventio-
nal methods, which are currently considered as standard
methods. e establishment of separate specialized cen-
ters and laboratories aiming to focus their activity in this
eld could be signicant to the exact identication of the
causative agent and administration of proper systemic
therapy. e choice of treatment and duration of antifun-
gal therapy depends on the identication of the causative
agent—dermatophytes, moulds, and yeasts. Besides the
well-known topical and systemic antifungal medicati-
ons, in recent years new treatment methods have gained
popularity—PDT and laser treatment have been success-
fully applied.
e most frequently used diagnostic methods for the
conrmation of fungal infection are still the conventional
ones—direct microscopy with KOH preparation and cul-
ture on Sabouraud’s dextrose agar. Only a restricted num-
ber of laboratories perform modern diagnostic molecular
biology methods such as PCR and MALDI-TOF MS. is
results in problems in creating a universally accepted
diagnostic algorithm. At present, treatment options for
onychomycosis include topical and systemic antifungal
medications, as well as surgical treatment, PDT, and laser
treatment for very particular situations.
erapy with terbinane is preferred in cases of ony-
chomycosis caused by dermatophytes. It has a very good
eect in infections caused by Trichophyton, Microspo-
rum, and Epidermophyton species [61, 62]. erapy with
terbinane has also good eect in infections with moulds
[62, 63]. It is, however, less eective against yeasts, since
it is primarily fungistatic against some species, for exam-
ple, Candida albicans and Candida parapsilosis [62, 63].
Because of the powerful fungicid eect of terbinane
against dermatophytes and moulds, many clinicians pre-
fer systemic therapy with terbinane instead of itracona-
zole or uconazole.
On the other hand, therapy using uconazole or itra-
conazole schemes (pulse treatment) is preferred when
yeasts are identied, but it is considered a second-line
treatment for dermatophyte infections.
Surgical treatment as well as more recently described
options such as PDT or laser treatment should, in princi-
ple, be reserved for cases that have not responded ade-
quately and/or for patients with contraindications for the
more conventional therapeutic options.
Conict ofinterest
e authors declare that there is no actual or potential
conict of interest in relation to this article
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Author's personal copy
... Toenail infections are among the most frequent infections in podiatry and cause clinical complications. Foot infections are normally caused by dermatophyte fungi and most commonly affect the first toe [1][2][3]. Global prevalence of onychomycosis is estimated at 2 to 8%. This range is due to factors inherent to the population studied, such as social habits, climate, age, immunosuppression status (diabetes, transplants, chemotherapy) and altered states of the circulatory and neuropathic systems [1][2][3][4]. ...
... Global prevalence of onychomycosis is estimated at 2 to 8%. This range is due to factors inherent to the population studied, such as social habits, climate, age, immunosuppression status (diabetes, transplants, chemotherapy) and altered states of the circulatory and neuropathic systems [1][2][3][4]. Onychomycosis is responsible for 50% of nail disorders and can limit activities of daily life. It is also associated with a negative psychosocial impact that can cause patients to become socially isolated [5][6][7][8]. ...
... The approach was clinically monitored in three ways. Firstly, a microbiological study was conducted before and after treatment to determine its efficacy, through traditional culture technique in Agar Sabouraud with chloramphenicol (Condalab, Spain) at 30 • C during three to four weeks [2,3]. To avoid environmental contamination of the samples, before taking the sample, the patients' fingers were irrigated with 70 • alcohol, and nail clippings were collected with sterile material after the complete evaporation of the disinfectant. ...
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Onychomycosis is the main cause of toenail disorders and is produced by a fungal infection. It is becoming more prevalent because of new lifestyles and immunosuppression statuses. The therapeutic approach to onychomycosis is under considerable study because of the lengthy treatments that require strong patient commitment, the limited efficacy of treatments, the inclusion of active substances that can be hepatotoxic and cause pharmacological interactions, and/or the questionable efficacy of treatments due to a lack of clinical trials. This study responds to the demand for rapid treatment with minimal pharmacological interactions. Methods: The efficacy of nitric acid 60% treatment in patients with onychomycosis was monitored and studied. The antifungal efficacy of nitric acid was measured by microbiological culture before and after treatment and the clinical evolution of nail dystrophy was quantitatively measured by monitoring with the Onychomycosis Severity Index (OSI). Results: The results show that, with the protocol used, nitric acid 60% painlessly cured 40% (microbiologic cure) of the cases treated, and in all cases, clinical improvement was observed (p = 0.011). Conclusions: The treatment with nitric acid 60% is as efficient as conventional treatments, requires less patient compliance of the treatment and produces no pharmacological interactions, providing alternative treatment in the case of hepatotoxicity.
... Fungal infections are increasing due to factors including their spread among at-risk populations, population longevity, the use of immunosuppressive treatments, diabetes mellitus, obesity, hyperhidrosis and nail injury (Hoy et al., 2012;Leung et al., 2020;Papini et al., 2015;Tchernev et al., 2012;Thomas et al., 2010). However, oral treatment of these infections has disadvantages, including increased resistance due to overuse of antifungal agents, pharmacological interactions with other medicines and adverse side effects such as the risk of hepatic lesion, thus limiting the suitability of this type of treatment (Abd Rashed et al., 2021;Martín-Aragón & Benedí, 2004;Valdes & M. P., 2000;Vlahovic, 2016). ...
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Aims: This work examines the available scientific evidence about the efficiency of essential oils (EO) as an alternative therapy to traditional treatment of fungal infections, including onychomycosis, assessing the effect of the three EO most frequently studied for their antifungal activity (thyme, cinnamon and tea tree EO) against three causative agents of fungal diseases in humans: Trichophyton rubrum, Trichophyton mentagrophytes complex and Candida albicans. Methods and results: The PRISMA statement protocol was followed to conduct a bibliographical search and 54 articles that met all the inclusion criteria were retrieved. Differences were observed in the MIC and MFC values depending on the microorganism strain and the EO used. The lowest MIC were observed with C. zeylanicum EO (0.013-1,120 μL mL-1 ) against the three microorganisms. For MFC, the lowest value was found for T. vulgaris EO (4.2 μL mL-1 ) against T. rubrum. Conclusions: The antifungal effects of EO could be a very promising solution to overcome the therapeutic shortcomings of antimycotic medication. More experiments are needed to examine the properties of these oils to devise effective and non-aggressive therapies for treatment of dermatophytosis. Significance and impact of study: The results indicate that EO remain good candidates for future treatments and could provide a solution for failed medications and/or adverse reactions to current pharmacological treatments.
... As shown in our in vitro study, terbinafine and itraconazole were the best candidates for NDM onychomycosis treatment, but it needs more details about in vivo data analysis. One reason for the good effects of terbinafine is its appropriate penetration into the nail matrix 36 . ...
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Onychomycosis is a fungal disease that caused by different types of fungi. Non-dermatophyte molds are a large saprophytic fungi group that live in nature and could affect traumatic nails. The aim of this study was to identify non-dermatophyte molds causing onychomycosis and evaluation of several antifungal activities against the isolates. The samples consisted of 50 non-dermatophyte molds isolated from patients with onychomycosis confirmed by direct and culture examination fungal. DNA was extracted, amplified, and sequenced. Disk diffusion method was used to evaluate itraconazole, fluconazole, ketoconazole, terbinafine, posaconazole, and econazole activity against the isolates. The species identified as: Aspergillus flavus 22 (44%), A. niger 12 (24%), A. fumigates, 3 (6%), A. sydowii 3 (6%), A. terreus 1 (2%), Penicillium commune 2 (4%), P. glabrum 2 (4%), P. chrysogenum, 1 (2%), Fusarium solani 3 (6%) and F. thapsinum 1 (2%). Most of the samples were sensitive to terbinafine, itraconazole, and econazole and 94% of the isolates were resistant to fluconazole. This study showed that Aspergillus species were the most common cause of non-dermatophyte mold onychomycosis and fluconazole was the most resistant antifungals. Care must be taken to choose the appropriate antifungal drug for a better cure.
... Es más común en personas que introducen las manos con frecuencia en el agua (amas de casa, personal sanitario y trabajadores de lavanderias). La afección periungueal puede extenderse y generar infección de la uña, produciendo así la onicomicosis (Tchernev et al., 2012). En la onicomicosis el hongo penetra la matriz y la lámina ungueal produciendo surcos transversales, superficie convexa, áspera y finalmente distrofia total en la figura 2. Otra forma de presentación es la onicomicosis distal, generalmente no hay alteración en la lámina ungueal, pero debido al hiperqueratosis producida, la lámina se separa de su lecho. ...
La candidiasis es una enfermedad micótica debida a levaduras pertenecientes al género Candida. Dentro del gran conjunto de microorganismos que colonizan al ser humano, Candida albicans es el agente etiológico más comúnmente detectado ya que habita como comensal en las superficies mucosas y la piel. C. albicans participa en procesos de fermentación de azúcares y asimilación de nutrientes, pero, en algunas ocasiones se relaciona con procesos patológicos. En los últimos años los avances tecnológicos y médicos; así como el aumento en la incidencia de infecciones por el virus de la inmunodeficiencia humana, el auge creciente de la terapia inmunomoduladora y el uso de antibióticos de amplio espectro durante largos períodos de tiempo se han convertido en los factores de riesgo más importantes para la creciente incidencia de infecciones por microorganismos del género Candida. Debido a esto, resulta imperativo el conocimiento de esta enfermedad y sus formas clínicas más importantes, así como el abordaje diagnóstico y el tratamiento actual; información que recolectamos en este documento para brindar una visión general sobre esta patología.
... Finally, it is worthy to note that matrix-assisted laser desorption/ionization-timeof-flight/mass spectrometry (MALDI-TOF/MS) can now be used for the speedy identification of different dermatophyte species. This method identifies pathogens on the basis of the m/z ratios of highly abundant protein fragments but is presently restricted to the identification of pathogens which have already been cultured [163][164][165][166]. Fourier transform infrared spectroscopy has also been used in the identification of clinically relevant dermatophytes [153]. ...
The growing incidence of scalp ringworm infection globally has generated a lot of public health interest. While the disease remains a common superficial infection among young schoolchildren, it has increasingly been reported in older persons. The disease is caused by some keratin-degrading filamentous fungi, called dermatophytes, especially by zoophilic or anthropophilic species. In this chapter, we describe the pathogenesis of dermatophytes, focusing on the ability of the pathogen to attach and invade the epidermal layers of the skin. The chapter also discusses the epidemiologic spread of the disease in different parts of the world, particularly its growing incidence in older people and infants. When not properly diagnosed or promptly treated, ringworm infection can cause complications leading to other conditions such as folliculitis, alopecia, and dermatophytid reactions. The chapter highlights the complications of the infection, as well as current methods used in the diagnosis, treatment, and community management of the infection. Overall, it provides a recent and comprehensive overview of Tinea capitis and may serve as a useful resource for educators, clinicians, and students, as well as in helping to formulate adequate health policies for managing Tinea capitis infection.
IntroductionOnychomycosis is a chronic fungal infection with increasing incidence and the global prevalence is estimated to be 5.5%. The aim of our study was to perceive objectively severity of onychomycosis by calculating Scoring Clinical Index for Onychomycosis and to correlate this index with accurate laboratory diagnosis in our patients.Materials and methodsThe study population comprised of 417 patients with laboratory confirmed onychomycosis. For each patient, we recorded basic demographic information, site of infection, the most affected nail with onychomycosis, clinical presentation, and type of onychomycosis. The evaluation of the disease severity was based on Scoring Clinical Index for Onychomycosis which was calculated for every patient separately. Mycological identification was done by microscopy and fungal culture.ResultsThe majority of patients had distal and lateral subungual onychomycosis (95.44%) that was localized on big toe (62.59%), with female to male ratio 1.24:1. Male patients had significantly more nails affected with onychomycosis compared with female patients (p = 0.011), while female had significantly more often onychomycosis on fingernails 2–5 (p < 0.05), and they reported significantly more often pain (p < 0.05) and esthetic problems (p < 0.05). Mean Scoring Clinical Index for Onychomycosis was 16.76. Dermatophytes were most frequently isolated (91.85%). In patients with onychomycosis caused by dermatophytes, Scoring Clinical Index for Onychomycosis had significantly higher values (p = 0.032).Conclusion Comprehensive understanding of disease characteristics will allow introduction of individualized treatment plan for each patient, based on proper fungal identification and standardized method of evaluating disease severity, which could help the patient achieve a complete cure.
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(1) Background: Onychomycosis accounts for 50% of nail pathologies and is a therapeutic challenge due to an increase in resistance to antifungal agents. This study aimed to explore the effectiveness of 1064 nm diode laser irradiation for the treatment of Onychomycosis and establish a new set of laser parameters for effective and safe treatment; (2) Methods: An exploratory, single-blinded study was conducted on forty-five patients with toenail Onychomycosis. Digital images and nail clippings were taken for Periodic Acid-Schiff (PAS) staining and fungal microscopy and culture (MC&S). Group 1 received 5% topical Amorolfine lacquer to apply to affected nails. Group 2 received 1064 nm diode laser treatment at 10 mW/s, hallux 790 J/cm2 and lesser digits 390 J/cm2 (standard treatment). Group 3 received 1064 nm diode laser treatment at 10 mW/s, hallux 1 100 J/cm2 and lesser digits 500 J/cm2 (new treatment parameters). After laser treatment, nail temperatures were taken with a surface thermometer; (3) Results: PAS staining was more sensitive in identifying Onychomycosis (91.1%), compared to Fungal Microscopy (44.4%). Comparing treatment requirements over a period of 24 weeks, there was a statistical significance, p ≤ 0.01 (**), for standard laser treatment and, p ≤ 0.001 (***), for new laser parameter treatment, indicating treatment needed over time decreased. No adverse effects were noted with new laser therapy. An 86.7% visual improvement was noted in Group 3 after 24 weeks; (4) Conclusions: Phototherapy, or photo thermolysis, was the best treatment option for Onychomycosis. A new protocol for the standardization of laser irradiation with the possible inclusion into the Scoring Clinical Index for Onychomycosis treatment plan, was proposed.
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Onychomycosis is one of the most frequent reasons for visiting podiatrist clinics. Complementary tests and the accurate identification of the infectious agents are key issues for a successful treatment of onychomycosis. This is particularly important when lifestyle, age and immunodepressed patients increase the prevalence of non-dermatophyte fungal infection. In this paper, we describe issues related to onychomycosis prevalence in a population of patients, mostly with rural lifestyles, visiting a podiatry clinic in a rural area of Spain. A total of 51 cases were studied with an average age of 65.96 ± 21.28 years (the youngest being 16 years and the oldest being 95 years). Fungal agents were isolated using conventional sampling and microbiological culture techniques. The results obtained with these techniques were compared with the results obtained with a direct methodology using molecular biology, by PCR and nucleotide sequencing of the ITS-5.8S rDNA fragment. The classical culture methodology confirmed the infection in 76.5% of the samples (n = 39), while the PCR confirmed the infection in 84.3% (n = 51) of the nails, although the difference between these results did not show statistical significance (p = 0.388). We found a high variability in agents, with more yeasts than dermatophytes as etiological agents of onychomycosis. However, only among individuals older than 65 years, was the difference between yeasts (82%) and dermatophytes (18%) was statistically significant (p = 0.004). Among the agents of non-dermatophyte onychomycosis, we found predominantly fungi (yeasts) of the Candida genus, interestingly with no isolates of Candida albicans, and moulds of the Aspergillus genus.
In Germany, the anthropophilic dermatophyte Microsporum ferrugineum has been rarely isolated for the last 50 years. Currently, started in 2016, M. ferrugineum strains were occasionally identified although this dermatophyte is difficult to differentiate from Microsporum audouinii or Microsporum canis. Furthermore, a small outbreak of infections was observed in Germany. From July 2016 until April 2019, 19 patients with M. ferrugineum infections were diagnosed all over Germany. This included 15 both culture and molecular confirmed cases, and four cases exclusively diagnosed based on sequencing of fungal DNA. Cultural analysis revealed slowly growing colonies with white thallus and peripheral yellow-brownish submerged hyphae bundles. The reverse side of the furrowed colonies showed cream color to yellow staining. Microscopically, big spherical and oval double-walled intercalary-localized chlamydospores, typical “bamboo” hyphae, and acute-angled branched hyphae were observed. Fungal culture material from all isolates was identified by polymerase chain reaction (PCR), Sanger sequencing of the internal transcribed spacer (ITS) region, and/or the translation elongation factor (TEF)-1α gene. Results were referred to the M. ferrugineum CBS 497.48 strain (Centraalbureau voor Schimmelcultures CBS, Utrecht, The Netherlands, Patients were children and adolescents under 18 years, mainly males. Suggested source of infection was martial sports, e.g., wrestling, judo, and boxing. Surprisingly, a significant part of affected patients were Germans of Russian descent. A migrant 3-year-old boy from Afghanistan suffering from Tinea capitis was also among the patients. Another strain was isolated from a 10-year-old wrestler with suspected Tinea corporis. There was no migration background or contact to foreigners, the boy did not stay abroad. The mycological challenge is the cultural identification of M. ferrugineum due to the morphological similarity not only to M. canis, but also to M. audouinii, and Trichophyton verrucosum. Phylogenetic analysis of ITS region of ribosomal DNA and the TEF-1α gene was performed using MEGAX, the statistical maximum likelihood method, and the Tamura-Nei substitution model. Bootstrapping was performed with 1000 replicates. The alignment of the ITS sequences (partial 18.S, ITS1, 5.8S, ITS2, partial 28.S) with known sequences deposited at the Genbank database available at the National Center for Biotechnology Information (NCBI), Bethesda, Maryland, U.S., clearly identified the M. ferrugineum strains after cultural analysis. The phylogenetic analysis of the dermatophytes—the dendrogram of fungal strains—demonstrated the genetic differences between M. ferrugineum strains and M. audouinii or M. canis. The three species could be clearly distinguished from each other. In particular, sequencing of the TEF-1α gene allowed a better differentiation between M. ferrugineum and M. audouinii or M. canis than sequencing of the ITS 2 region.
Dermatomykosen sind ein weltweit verbreitetes Krankheitsbild mit steigender Prävalenz. Die herkömmliche Diagnostik mittels direkter Mikroskopie und Kultur hat viele Nachteile und es bedarf daher einer Optimierung. In den letzten Jahren sind viele molekulare Methoden auf PCR-Basis publiziert worden und einige sogar kommerziell erhältlich. Diese unterscheiden sich gravierend in Punkten wie Kosten, notwendiger technischer Ausstattung, Hands-on time etc. Die Entscheidung, welche Methode für ein bestimmtes Labor geeignet ist, fällt also oft schwer. Ziel dieser Arbeit war es deshalb eine In-house Methode (nach Bergmans et al.) und zwei kommerziell erhältliche Kits (FTD Dermatophytes von Fast Track Diagnostics und Mentype® MycoDermQS Lateral Flow von Biotype Diagnostic GmbH) sowohl untereinander als auch mit den klassischen Methoden zu vergleichen. Kriterien waren hierbei Sensitivität und Spezifität aber auch Kosten und Praktikabilität.
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Published data on the prevalence of onychomycosis in psoriasis patients compared with healthy controls are controversial, We therefore conducted a prospective study of toenail onychomycosis, among 113 psoriatic and 106 healthy non­psoriatic subjects, selected from the normal population in the Jerusalem area in the period 2003­05. The results revealed a prevalence of 47.6% toenail onychomycosis among psoriatic patients, compared with 28.4% in normal controls (p=0.0054). Both gender and age affected the prevalence of onychomycosis in both psoriatic and healthy controls, with a higher prevalence in male and elderly subjects. The type and duration of psoriasis were also found to have an impact on the prevalence of onychomycosis. However, the body area involved did not affect the prevalence of onychomycosis in psoriatic patients. Approximately the same percentages of dermatophytes and yeasts were found in psoriatic patients as in healthy controls. However, a higher percentage of moulds was found in psoriatic patients.
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The purpose of this study was to evaluate the efficacy and safety of oral fluconazole for the treatment of finger and toe distal onychomycosis. The study was designed as an open, randomised, multicenter clinical trial to assess the efficacy and adverse reactions of fluconazole 200 mg applied orally once weekly in 170 selected patients with onychomycosis for 4 months on fingers and for 6 months on toes. Clinical success of the fluconazole treatment was observed in 91.2% of the patients (64.7% of cases were evaluated as completely healed, and 26.5% - with clinical improvement), and in 8.8% the treatment had no effect. Fungal eradication was achieved in 59.7% of the patients. Adverse reactions were observed in a total of 13 patients (7.6%): 9 of them reported mild gastrointestinal complaints, and the other 4 patients complained, respectively, of headache and dizziness, macular-papular rash, edema, or hypebilirubinemia. It was concluded that 200 mg oral fluconazole once weekly is a promising regimen for treatment of the finger- and toe onychomycosis; it offers an appropriate method of administration and good clinical results associated with mild adverse reactions.
A 76 year old man, suffering from diabetes mellitus type II, presented with a severe and pustular tinea barbae on the right side of his jaw and mandible. A 35 year old man developed not only superficial, centrifugal spreading but also pustular tinea barbae et faciei on the cheek, chin and nose. The anthropophilic dermatophyte Trichophyton rubrum was isolated from both patients. Treatment included topical antimycotic drugs ciclopiroxolamine and ketoconazole together with systemic itraconazole. Healing occurred without problems after several weeks. Usually tinea barbae is caused by zoophilic dermatophytes. Only rarely is an anthropophilic fungus from this infection of the bearded area. As a true rarity one has to consider tinea barbae due to Trichophyton rubrum. Only 33 descriptions Trichophyton rubrum causing tinea barbae were found in the literature.
Terbinafine is an orally and topically active agent belonging to the allylamine class of synthetic antimycotics. In vitro, terbinafine is active against a broad spectrum of pathogenic fungi. We review here the results from 30 published investigations, with the aim of listing all fungal species in which the drug has been tested. Against dermatophytes, terbinafine has the most potent activity of all available antimycotics, with minimum inhibitory concentrations (MIC) in the range of 1 to 10 ng/ml for most isolates. Terbinafine displays excellent in vitro activity against other filamentous fungi, including species of Aspergillus, Fusarium and Penicillium, and is highly active against a range of dematiaceous fungi (MICs < 1 μg/ml in most cases) and dimorphic pathogens (MICs 0.04-2 μg/ml). Activity against the yeast Candida albicans is strongly dependent on the test method used. While older studies showed poor activity of terbinafine against this species, the recently developed NCCLS reference assay gives a mean MIC of 1.2 μg/ml. The filamentous form of Candida albicans is even more susceptible. Terbinafine is highly active against Candida parapsilosis, but shows poor in vitro activity against Candida glabrata and Candida krusei. Cryptococcus species are also susceptible (MICs well below 1 μg/ml for most isolates), as are some other yeasts such as Malassezia species and Trichosporon beigelii. Terbinafine has been reported to have activity against Pneumocystis carinii and certain pathogenic protozoa. Terbinafine has a primary fungicidal action against dermatophytes, moulds, dimorphic fungi and the yeast Candida parapsilosis, but is fungistatic against Candida albicans. There is evidence for synergy between terbinafine and azoles against various fungi, including azole-resistant pathogens. Terbinafine has a characteristic mechanism of action involving inhibition of ergosterol biosynthesis at the level of squalene epoxidation, resulting in deficiency of the essential membrane component ergosterol, and accumulation of squalene. Squalene accumulation plays an essential role in the fungicidal action of the drug. Terbinafine is a potent inhibitor of squalene epoxidase from Candida and Trichophyton but has no significant effect on mammalian cholesterol biosynthesis. The cloning of fungal and mammalian squalene epoxidases has revealed the existence of fungal-specific sequence regions which may explain the selective action of terbinafine.
Las onicomicosis constituyen una de las infecciones micóticas más prevalentes en la población y con una mayor tasa de fracasos terapéuticos. La terapia fotodinámica (TFD) está basada en el uso de sustancias fotosensibilizantes que, activadas con una luz de adecuada longitud de onda y en presencia de oxígeno, generan especies reactivas del oxígeno que ocasionan la muerte celular. En la actualidad se utiliza con éxito en el tratamiento del cáncer cutáneo no-melanocitario y se está experimentando en otras aplicaciones, como las infecciones superficiales.