White Onychomycosis. / Onicomicosis Blanca

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ONICOMICOSIS BLANCA
WHITE ONYCHOMYCOSIS
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***** DERMAGIC-EXPRESS No 16 *********
****** 16 NOVIEMBRE 1.998 *******
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EDITORIAL ESPAÑOL:
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Hola amigos de la red, DERMAGIC, de nuevo con ustedes, el tema de hoy la onicomicosis, haciendo énfasis en la onicomicosis blanca de la cual hay poca literatura. Encontré unas 19 referencias sobre tan interesante patología y las complemente con otros 13 articulos muy buenos sobre el tema.

Esta edición esta dedicada a TODOS los micólogos de nuestro mundo Dermatológico que nos rodea, especialmente a la lista FUNGI, del Dr. Paulo Taborda (Brasil),, saludos.

Dr. Roberto Pribyl, Rolando Hernández,, tuve inconvenientes, justo el día antes del Congreso, y lamentablemente no pude ir, gracias por los comentarios. Espero que se repitan esos eventos y pueda participar. El tiempo ?? la verdad es que no se de donde lo saco,, tengo 14 años de vuelo en informática,,,será eso ??

Dr. Raúl Fachin, me encanto que todo salió bien, DERMAGIC, siempre divulgará información Dermatológica de interés para todos. Felicitaciones a la Residente Arminda Acuña por su premio,,,

Hasta una próxima edición,,, saludos

Próximas ediciones: * EL SOLARASE,,,, * LEISHMANIASIS, PENTAMIDINA E ITRACONAZOLE

Dr. José Lapenta

EDITORIAL ENGLISH:
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Hello friends of the net, DERMAGIC, again with you, today's topic the onychomycosis, making emphasis in the white onychomycosis of which there is little literature. I found some 19 references on so interesting pathology and it supplements them with other 13 very good articles on the topic.

This edition is dedicated to ALL the mycologist of our Dermatologic world that surrounds us, especially to the list FUNGI, of the Dr. Paulo Taborda (Brazil), greetings.

Dr. Marcus Meinardi your e-mail starting from this date is in DERMAGIC, greetings Amsterdam from Venezuela.

I Remind the colleagues Dermatologist from USA and Europe that DERMAGIC is being Liberated through the LIST ACADERM-L, of the Dr. Art C. Huntley.

Until a next edition, greetings

Next editions: * THE SOLARASE,,, * LEISHMANIASIS, PENTAMIDINE AND ITRACONAZOLE

Dr. José Lapenta

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DERMAGIC/EXPRESS(16)
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ONICOMICOSIS BLANCA / WHITE ONICOMICOSIS
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1.) Superficial white onychomycosis.
2.) Childhood white superficial onychomycosis caused by Trichophyton rubrum: report of seven cases and review of the literature.
3.) Proximal white subungual onychomycosis in AIDS.
4.) Proximal white subungual onychomycosis in a kidney transplant patient [letter]
5.) Onychomycosis associated with Onychocola canadensis: ten case reports and a review of the literature.
6.) Proximal subungual onychomycosis due to Microsporum canis.
7.) Unusual clinical features of fingernail infection by Fusarium oxysporum.
8.) Nondermatophyte causes of onychomycosis and superficial mycoses.
9.) The spectrum of nail disease in patients with human immunodeficiency virus infection.
10.) White superficial onychomycosis caused by Trichophyton rubrum.
11.) Proximal white subungual onychomycosis: a sign of immunodeficiency.
12.) Clinical pearl: proximal white subungual onychomycosis in AIDS.
13.) Onychomycosis in graft versus host disease.
14.) Proximal white subungual onychomycosis in a patient with acquired immune deficiency syndrome.
15.) The spectrum of nail disease in patients with human immunodeficiency virus infection.
16.) Onychomycosis and AIDS. Clinical and laboratory findings in 62 patients.
17.) White nails in AIDS/ARC due to Trichophyton rubrum infection.
18.) Fungal infection as a cause of skin disease in the eastern province of Saudi Arabia: prevailing fungi and pattern of infection.
19.) Fungal infections of the nails in Western Australia.
20.) A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: a multicentre study.
21.) Onychomycosis in children: prevalence and treatment strategies.
22.) Pharmacoeconomic analysis of oral therapies for onychomycosis: a US model.
23.) Update on the management of onychomycosis: highlights of the Third Annual International Summit on Cutaneous Antifungal Therapy [see comments]
24.) Prevalence of dermatophyte onychomycosis in Spain: a cross-sectional study.
25.) Economic evaluation of antifungal agents in the treatment of toenail onychomycosis in Germany.
26.) Onychomycosis. Going for cure.
27.) Itraconazole therapy is effective for pedal onychomycosis caused by some nondermatophyte molds and in mixed infection with dermatophytes and molds: a multicenter study with 36 patients.
28.) A questionnaire study on the management of onychomycosis: a Canadian perspective.
29.) Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the fingernail.
30.) Antifungal pulse therapy for onychomycosis. A pharmacokinetic and pharmacodynamic investigation of monthly cycles of 1-week pulse therapy with itraconazole.
31.) Measuring health-related quality of life in onychomycosis.
32.) Prevalence and epidemiology of unsuspected onychomycosis in patients visitingdermatologists' offices in Ontario, Canada--a multicenter survey of 2001 patients.
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1.) Superficial white onychomycosis.
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Author
Bodman MA; Brlan MR
Address
Cleveland Foot and Ankle Clinic, Ohio College of Podiatric Medicine 44106, USA.
Source
J Am Podiatr Med Assoc, 85(4):205-8 1995 Apr

Abstract

A study on the incidence and causative organisms of pedal superficial white onychomycosis within several patient populations is presented. Early recognition, debridement, and topical antifungal therapy for several weeks with attention to biomechanical factors should resolve the infection and prevent progression to a more destructive form of onychomycosis.

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2.) Childhood white superficial onychomycosis caused by Trichophyton rubrum: report of seven cases and review of the literature.
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Author
Ploysangam T; Lucky AW
Address
Department of Dermatology, University of Cincinnati Medical Center, OH, USA.
Source
J Am Acad Dermatol, 36(1):29-32 1997 Jan

Abstract

BACKGROUND: Although white superficial onychomycosis (WSO) is well recognized in adults and considered to be mainly caused by Trichophyton mentagrophytes, childhood WSO is rare. WSO caused by Trichophyton rubrum in prepubertal children has never been reported. OBJECTIVE: Our purpose was to describe the existence of WSO in children and to emphasize that T. rubrum may be its main cause.

METHODS: Seven children with WSO seen between 1988 and 1993 were examined. Only patients who had a positive potassium hydroxide preparation and a positive fungal culture were included.

RESULTS: Seven healthy prepubertal children, 2 to 9 years of age, were identified with WSO. All cases were proved to be caused by T. rubrum. Six patients had associated tinea pedis, and five had a family history of tinea pedis. Topical antifungal therapy was partially effective in some cases.

CONCLUSION: This report documents the existence of WSO in prepubertal children. All cultures grew T. rubrum. Although onychomycosis is not as common in prepubertal children as in adults, it may be underrecognized

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3.) Proximal white subungual onychomycosis in AIDS.
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Author
Silva-Lizama E; Logemann H
Address
Department of Dermatology and Mycology, Guatemalan Social Security Institute, Central America.
Source
Int J Dermatol, 35(4):290-1 1996 Apr
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4.) Proximal white subungual onychomycosis in a kidney transplant patient
[letter]
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Author
Chang P; Arenas R
Source
Int J Dermatol, 34(8):591 1995 Aug

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5.) Onychomycosis associated with Onychocola canadensis: ten case reports
and a review of the literature.
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Author
Gupta AK; Horgan-Bell CB; Summerbell RC
Address
Department of Medicine, Sunnybrook Health Science Center and the University of Toronto,
Ontario, Canada. [email protected]
Source
J Am Acad Dermatol, 39(3):410-7 1998 Sep

Abstract

BACKGROUND: Onychocola canadensis is a nondermatophyte mold associated with onychomycosis particularly in temperate climates (eg, Canada, New Zealand, and France). The slow growth rate of O canadensis and lack of resemblance to any other known nail-infecting fungus may have delayed its discovery. We are aware of 23 mycologically confirmed cases of O canadensis in the literature.

OBJECTIVE: We describe 10 previously unreported Canadian patients, specimens from whom grew O canadensis. We also review the literature on infections associated with this organism.

METHODS: Cases of O canadensis onychomycosis were diagnosed on the basis of (1) the finding of compatible filaments on direct microscopy of nail and (2) consistent culture from repeated specimens. All patients from whom O canadensis was isolated were followed up, but those in whom outgrowth was not consistent were not accepted as having "authentic" infections.

RESULTS: In 10 patients O canadensis was found to be associated with distal lateral subungual onychomycosis (6 patients), white superficial onychomycosis (1 patient), and as an insignificant contaminant in the nails of 3 patients. Less commonly the organism may cause tinea manuum or tinea pedis interdigitalis. O canadensis appears to be more frequent in the elderly, especially females. It is not unusual for a patient with onychomycosis caused by O canadensis to be a gardener or farmer, suggesting that the infectious inoculum may originate from the soil. The optimal therapy for onychomycosis caused by this organism remains unclear.

CONCLUSION: O canadensis may be the etiologic agent of distal and lateral subungual or white superficial onychomycosis; however, it may sometimes be present in an abnormal-appearing nail as an insignificant finding, not acting as a pathogen.

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6.) Proximal subungual onychomycosis due to Microsporum canis.
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Author
Piraccini BM; Morelli R; Stinchi C; Tosti A
Address
Department of Dermatology, University of Bologna, Cesena, Italy.
Source
Br J Dermatol, 134(1):175-7 1996 Jan

Abstract

A case of proximal subungual onychomycosis due to Microsporum canis in a 36-year-old woman is presented. The onychomycosis involved the left thumb and the little fingernails, with thinning of the nail plate and crumbling of the nail plate surface. A milky-white discoloration of the proximal portion of the left thumbnail was also evident. A 2-mm longitudinal nail biopsy showed a large number of fungal elements in the whole length of the nail plate. Fungal hyphae were more numerous in the ventral nail plate and produced detachment of the superficial nail plate. The nail bed was not invaded by fungal elements and was devoid of inflammatory changes.

Proximal subungual onychomycosis is uncommon in immunocompetent individuals but has frequently been described in patients with AIDS. In our patient, in whom the proximal subungual onychomycosis was due to M. canis, there were no clinical or biochemical signs of immunodeficiency. Oral treatment with terbinafine, 250 mg/daily for 2 months, produced clinical and mycological cure.

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7.) Unusual clinical features of fingernail infection by Fusarium oxysporum.
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Author
Gianni C; Cerri A; Crosti C
Address
Universit`a degli Studi di Milano, Clinica Dermatologica IV, Italy.
Source
Mycoses, 40(11-12):455-9 1997 Dec

Abstract

Four cases of invasion of fingernails caused by Fusarium oxysporum are described. The typical picture of onychomycosis by this non-dermatophytic mould is a 'white superficial onychomycosis' which usually affects the great toenail. Only few cases of fingernail infections by this organism have been described in the literature and, to our knowledge, there are no reported cases on the pustulous and eczema-like aspect of paronychia by Fusarium oxysporum. We report different and unusual clinical features of this infection successfully treated with systemic antifungals. Two patients were treated with terbinafine, 250 mg daily for 3 months, and two patients with itraconazole, 200 mg daily for 3 months.

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8.) Nondermatophyte causes of onychomycosis and superficial mycoses.
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Author
Gupta AK; Elewski BE
Address
Department of Medicine, Sunnybrook Health Science Center, Toronto, Canada.
Source
Curr Top Med Mycol, 7(1):87-97 1996 Dec

Abstract

Compared to dermatophytes, nondermatophytes that may cause distal and lateral subungual onychomycoses are Aspergillus species, Acremonium species, Fusarium oxysporum and Scopulariopsis brevicaulis. White superficial onychomycosis may be caused by nondermatophyte species, for example, Acremonium species, Aspergillus terreus, other Aspergillus species and Fusarium oxysporum. Nondermatophyte molds such as Scopulariopsis brevicaulis may uncommonly result in cutaneous infections. Scytalidium dimidiatum (Scytalidium anamorph of Hendersonula toruloidea) and Scytalidium hyalinum may cause interdigital tinea pedis, and less frequently "moccasin foot" or plantar tinea pedis. Nondermatophytes have generally responded poorly to griseofulvin and ketoconazole. There have been reports of some nondermatophyte fungi responding to itraconazole and terbinafine.

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9.) The spectrum of nail disease in patients with human immunodeficiency virus infection.
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AUTHOR(S): Daniel CR 3d; Norton LA; Scher RK.
SOURCE: Journal of the American Academy of Dermatology 1992 Jul;27(1):93-7

There are no known pathognomonic nail signs of human immunodeficiency virus (HIV) infection. However, several presentations should increase the index of suspicion.

(1) Proximal white subungual onychomycosis or superficial white onychomycosis, especially of the fingernails, is present. Trichophyton rubrum appears to cause both most commonly in HIV-infected patients. Periungual dermatophyte involvement and involvement of all 10 fingernails is unusual in non-HIV-infected persons.

(2) Candida is a primary pathogen of the nail bed and nail plate especially if many nails are involved.

(3) A destructive, almost granulomatous-like psoriatic involvement of the nails is present.

(4) Squamous cell carcinoma of the nail bed in a young adult. There are no clinical trails to confirm the efficacy of therapy mentioned in this article. The treatment suggestions are empirical and are the personal views of the authors.

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10.) White superficial onychomycosis caused by Trichophyton rubrum.
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SO - Cutis 1984 Apr;33(4):384, 386
AU - Sweren RJ
MJ - Onychomycosis [etiology]
MN - Adult; Foot Dermatoses [etiology] [microbiology] [pathology]; Nails [pathology]; Onychomycosis [microbiology] [pathology]; Trichophyton [isolation & purification]
MT - Case Report; Female; Human
PT - JOURNAL ARTICLE

AB - A patient with T. rubrum WSO is reported. The presence of this pathogen, a rare cause of this condition, can be confirmed by examination of smears and cultures taken from scrapings of the white spots on the nail plate.

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11.) Proximal white subungual onychomycosis: a sign of immunodeficiency.
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SO - J Am Acad Dermatol 1994 Jan;30(1):129-30
AU - Rongioletti F; Persi A; Tripodi S; Rebora A
AD - Department of Dermatology, University of Genoa, Italy.

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12.) Clinical pearl: proximal white subungual onychomycosis in AIDS.
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SO - J Am Acad Dermatol 1993 Oct;29(4):631-2
AU - Elewski BE
AD - Department of Dermatology, University Hospitals of Cleveland, OH 44106.

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13.) Onychomycosis in graft versus host disease.
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SO - Cutis 1987 Sep;40(3):237-41
AU - Basuk PJ; Scher RK
AD - Department of Medicine, Brown University Program in Medicine, Providence, Rhode Island.
MJ - Graft vs Host Disease [complications]; Onychomycosis [etiology]
MN - Adult; Mouth Diseases [etiology]; Nail Diseases [etiology]
MT - Case Report; Human; Male
PT - JOURNAL ARTICLE; REVIEW (30 references); REVIEW, MULTICASE

AB - Graft versus host disease is associated with a myriad of cutaneous signs and few nail manifestations. A case of documented chronic graft versus host disease with the initial cutaneous presentation of white superficial onychomycosis is presented. The patient developed a lichenoid eruption in an unusual distribution and a reticulated hyperpigmentation of the face. Culture of the nails was positive for Trichophyton rubrum, an uncommon cause of white superficial onychomycosis, this being the third known reported case. Histopathologic examination revealed fungal elements in the superficial nail plate with an absence of fungus in the ventral aspect of the nail plate. A summary of cutaneous skin and nail manifestations in graft versus host disease is presented.

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14.) Proximal white subungual onychomycosis in a patient with acquired
immune deficiency syndrome.
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SO - Int J Dermatol 1986 Nov;25(9):586-7
AU - Noppakun N; Head ES

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15.) The spectrum of nail disease in patients with human immunodeficiency virus infection.
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SO - J Am Acad Dermatol 1992 Jul;27(1):93-7
AU - Daniel CR 3d; Norton LA; Scher RK
AD - Department of Medicine (Dermatology), University of Mississippi Medical Center, Jackson.
MJ - HIV Infections [complications]; Nail Diseases [complications]; Opportunistic Infections [complications]
MN - Candidiasis, Cutaneous [complications]; Dermatomycoses [complications]; Nail Diseases [diagnosis]
MT - Human
PT - JOURNAL ARTICLE

AB - There are no known pathognomonic nail signs of human immunodeficiency virus (HIV) infection. However, several presentations should increase the index of suspicion.

(1) Proximal white subungual onychomycosis or superficial white onychomycosis, especially of the fingernails, is present. Trichophyton rubrum appears to cause both most commonly in HIV-infected patients. Periungual dermatophyte involvement and involvement of all 10 fingernails is unusual in non-HIV-infected persons.

(2) Candida is a primary pathogen of the nail bed and nail plate especially if many nails are involved.

(3) A destructive, almost granulomatous-like psoriatic involvement of the nails is present.

(4) Squamous cell carcinoma of the nail bed in a young adult. There are no clinical trails to confirm the efficacy of therapy mentioned in this article. The treatment suggestions are empirical and are the personal views of the authors.

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16.) Fungal infections of the nail.
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SO - Semin Dermatol 1991 Mar;10(1):41-53
AU - Haneke E
AD - Department of Dermatology, Ferdinand-Sauerbruch-Klinikum, Elberfeld, Germany.
MJ - Dermatomycoses [microbiology]; Nail Diseases [etiology]
MN - Antifungal Agents [therapeutic use]; Dermatomycoses [drug therapy] [pathology]; Nail Diseases [drug therapy] [pathology]
MT - Human
PT - JOURNAL ARTICLE; REVIEW (75 references); REVIEW, TUTORIAL

AB - Onychomycoses represent the most frequently seen nail diseases and are the most difficult to treat of all skin mycoses. They are rare in children and increase in incidence with age. Most cases are caused by dermatophytes, in particular by Trichophyton rubrum, less frequently by T mentagrophytes and Epidermophyton floccosum. Molds may secondarily infect nails already diseased; however, some are probably capable of primary invasion of nail tissues. Yeasts, particularly Candida albicans, are mainly isolated from fingernails in chronic paronychia and onycholysis, and from nails in chronic mucocutaneous candidosis.

Mixed infections by dermatophytes, molds, and/or yeasts are not uncommon. Probably, most fungi cannot infect a healthy nail organ, and only predisposing factors such as impaired blood circulation, peripheral neuropathy, diabetes mellitus, damage from repeated minor trauma, and limited immune defects as well as AIDS make the nail susceptible to fungal infection. Most onychomycoses are secondary to a mycosis of the adjacent skin. Distallateral subungual onychomycosis starts at the hyponychium spreading proximally to the nail bed and matrix. In proximal subungual onychomycosis, the fungus infects the cuticle and eponychium to reach the matrix where it becomes enclosed into the nail plate substance.

Total dystrophic onychomycosis may result from either form or develop in chronic mucocutaneous candidosis. Superficial white onychomycosis is commonly a culture of T mentagrophytes on the surface of a toenail. Mycotic paronychia and onycholysis are usually due to C albicans.

Clinically, onychomycoses have to be differentiated from noninfectious onychodystrophy, nail psoriasis, lichen planus unguium, and chronic nail eczema. Despite a considerable number of effective antifungal drugs, treatment has remained difficult because the predisposing factors are usually not amendable to therapy.
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16.) Onychomycosis and AIDS. Clinical and laboratory findings in 62 patients.
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SO - Int J Dermatol 1990 Jun;29(5):337-9
AU - Dompmartin D; Dompmartin A; Deluol AM; Grosshans E; Coulaud JP
AD - Department of Dermatology, Hospital Claude Bernard, Paris, France.
PT - JOURNAL ARTICLE

AB - The results of a study on onychomycosis in AIDS related complex and AIDS patients presenting for dermatology consultation at an infectious diseases department are reported. The clinical results showed that most patients presented a proximal white superficial onychomycosis. The association with a clinical interdigital involvement was rare, but the association with a mycotic plantar keratoderma was more frequent.

The laboratory results showed that dermatophytes were the most frequent etiologic agents, especially Trichophyton rubrum (58%). Although most of these patients presented an oral candidiasis, Candida albicans was isolated only in seven patients' nails. Surprisingly, Pityrosporum ovale was the only etiologic organism that was found in two patients. This result was confirmed with a histologic examination.

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17.) White nails in AIDS/ARC due to Trichophyton rubrum infection.
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SO - Clin Exp Dermatol 1988 Jan;13(1):24-5
AU - Weismann K; Knudsen EA; Pedersen C

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18.) Onychomycosis.
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SO - Dermatol Clin 1985 Jul;3(3):445-60
AU - Zaias N
MJ - Onychomycosis [pathology]
PT - JOURNAL ARTICLE

AB - This article summarizes the diseases of the nail caused by fungi. The clinical appearance of the diseases are the key to understanding their causes. Therapy is updated. Specifically discussed are distal subungual onychomycosis, white superficial onychomycosis, proximal subungual onychomycosis, and onychomycosis in chronic mucocutaneous candidiasis.

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18.) Fungal infection as a cause of skin disease in the eastern province of Saudi Arabia: prevailing fungi and pattern of infection.
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SO - Mycoses 1991 Jul-Aug;34(7-8):333-7
AU - al-Sogair SM; Moawad MK; al-Humaidan YM
AD - Directorate of Health Affairs, Ministry of Health, Dammam, Kingdom of Saudi Arabia.
MJ - Dermatomycoses [epidemiology]
MN - Adult; Child; Dermatomycoses [ethnology] [microbiology]; Incidence; Prevalence; Saudi Arabia [epidemiology]; Tinea Versicolor [epidemiology]
MT - Female; Human; Male
PT - JOURNAL ARTICLE

AB - A total of 4,294 clinically suspected cases of dermatomycoses belonging to 26 different nationalities were examined between April 1984 and April 1988. Fungi were demonstrated in routine potassium hydroxide/dimethyl sulfoxide mount in 3,814 cases (88.8%) and the etiology was determined by culture in 2,458 cases (57.2%). Tinea versicolor was the predominant fungal infection (30.9% of all infections).

Onychomycosis and paronychia ranked second in prevalence (16.8%). Candidal onychomycosis was the most common type of infection. Scalp ringworm among children ranked third (15.3%), Microsporum canis was the main etiologic agent. Tinea pedis and tinea manuum ranked fourth in prevalence (13.2%). Tinea corporis represented 10.7% of infections and M. canis was the main agent. Tinea cruris accounted for 8.7% of infections and Epidermophyton floccosum was the most common agent. Cutaneous candidosis constituted 4.3% of infections. White piedra was seen in 6 cases (0.16%). Yeasts were proved not to be unimportant as a cause of disease of skin and nail in our study.

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19.) Fungal infections of the nails in Western Australia.
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SO - Mycopathologia 1981 Feb 13;73(2):115-20
AU - McAleer R
PT - JOURNAL ARTICLE

AB - Between 1963 and 1972, 986 fungi were isolated from the nails of patients in Western Australia. Three clinical types of infections in both finger and toe nails were studied. All 3 types occurred more commonly in adults over the age of 20. Multiple infections were relatively frequent. Two hundred and fourteen of the nail infections were caused by dermatophyte fungi. Trichophyton rubrum was the predominant aetiologic agent isolated from both finger and toe nails, T. mentagrophytes and other dermatophytes were involved to a lesser degree. Paronychia of the finger nails was common and mainly caused by C. albicans. Aspergillus species were the most frequent fungi grown from superficial white onychomycosis.

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20.) A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: a multicentre study.
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Author
Gupta AK; Lynde CW; Jain HC; Sibbald RG; Elewski BE; Daniel CR 3rd; Watteel GN; Summerbell RC
Address
Department of Medicine, Sunnybrook Health Science Center, Toronto, Canada.
Source
Br J Dermatol, 136(5):786-9 1997 May

Abstract

There is some controversy about the prevalence of onychomycosis in patients with psoriasis compared to non-psoriatics. We therefore measured the prevalence of toenail onychomycosis in psoriatics and non-psoriatics attending dermatologists' offices. None of the patients had a referring diagnosis of onychomycosis. The prevalence of pedal onychomycosis in psoriatics (n = 561) was 13%. The odds of patients with psoriasis having onychomycosis was 56% greater than non-psoriatics of the same age and sex (P = 0.02). In the psoriatics, when the toenails were clinically abnormal, the prevalence of onychomycosis was 27%. The odds of developing onychomycosis increased with age (P < 0.0001) and the odds of men developing onychomycosis was 2.5 times that of women (P = 0.0001). The duration of psoriasis did not significantly affect the odds of developing onychomycosis. The fungal organisms recovered from psoriasis subjects with onychomycosis were similar to those in the normal population with onychomycosis (P = 0.58).

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21.) Onychomycosis in children: prevalence and treatment strategies.
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Author
Gupta AK; Sibbald RG; Lynde CW; Hull PR; Prussick R; Shear NH; De Doncker P; Daniel CR 3rd; Elewski BE
Address
Department of Medicine, Sunnybrook Health Science Center, Toronto, Canada.
Source
J Am Acad Dermatol, 36(3 Pt 1):395-402 1997 Mar

Abstract

BACKGROUND: Onychomycosis is observed less frequently in children than adults. Until recently management of onychomycosis in children included topical formulations, oral griseofulvin, and in some cases deferral of treatment.

OBJECTIVE: We attempted to determine the prevalence of onychomycosis in North American children 18 years old or younger attending our dermatology offices (three Canadian, two U.S.) and to report the group's experience using fluconazole, itraconazole, and terbinafine for onychomycosis.

METHODS: We undertook a prospective, multicenter survey in which all children, regardless of presenting complaint, were examined for onychomycosis by a dermatologist. In instances of clinical suspicion appropriate nail samples were obtained for light microscopy and culture.

RESULTS: A total of 2500 children under age 18 were examined in the five-center survey (1117 males and 1383 females, mean +/- S.E. age: 11.2 +/- 0.1 years). There was one child with fingernail and ten with mycologically confirmed toenail dermatophyte onychomycosis. The overall prevalence of onychomycosis was 0.44%. Considering those children whose primary or referring diagnosis was not onychomycosis or tinea pedis, the prevalence of onychomycosis was 0.16%. Outside the survey we have seen six other children with dermatophyte onychomycosis; these 17 cases form the basis for the remainder of the report.

Of the 17 children, eight (47%) had concomitant tinea pedis infection, and in 11 (65%) a sibling, parent, or grandparent had onychomycosis or tinea pedis. Management included topical terbinafine (two patients: one cured, one failed therapy), topical ketoconazole (one patient: clinical improvement), oral fluconazole (two patients: one cured, one had Down's syndrome and was noncompliant), oral itraconazole (four patients: three cured with subsequent recurrence at follow-up in one patient, one lost to follow-up), oral terbinafine (five patients: four cured with subsequent recurrence at follow-up in one patient, one failed therapy). One child received no therapy following discussion with the parents, one was lost to follow-up and one was found to have asymptomatic hepatic dysfunction with hepatitis C at pretherapy bloodwork.

CONCLUSION: The prevalence of onychomycosis in our sample of North American children 18 years old or younger was 0.44% (n = 2500). In the subset of children whose primary or referring diagnosis was not onychomycosis, the prevalence of onychomycosis was 0.16%. Children with onychomycosis should be carefully examined for concomitant tinea pedis, and their parents and siblings checked for onychomycosis and tinea pedis. The newer oral antifungal agents fluconazole, itraconazole, and terbinafine may be effective and well-tolerated in the treatment of onychomycosis in this age group. These drugs should be carefully evaluated in a larger cohort of children with onychomycosis.

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22.) Pharmacoeconomic analysis of oral therapies for onychomycosis: a US model.
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Author
Marchetti A; Piech CT; McGhan WF; Neugut AI; Smith BT
Address
Sandoz Pharmaceuticals Corporation, East Hanover, New Jersey, USA.
Source
Clin Ther, 18(4):757-77; discussion 702 1996 Jul-Aug

Abstract

An evaluation of treatment practices in 13 countries, not including the United States, has shown oral terbinafine to be more cost-effective (from a government payer perspective) than griseofulvin, itraconazole, and ketoconazole in the treatment of onychomycosis of toenails and fingernails. The purpose of this study was to evaluate the clinical and economic effects of oral griseofulvin, itraconazole, ketoconazole, and terbinafine in the treatment of onychomycosis from the perspective of a third-party payer in the United States.

A previously constructed decision-analytic model evaluating the costs of onychomycosis in 13 countries outside the United States was updated to determine the costs of treating onychomycosis in the United States. Clinical management patterns were assessed to identify and quantify physician visits, laboratory tests, and adverse drug reaction treatment components for patients with toenail and fingernail onychomycosis.

A random-effects model meta-analysis of treatment efficacy (mycologic cure) and New York Metropolitan Medicare charge data for physician fees were used in the treatment model. A sensitivity analysis assessing alternative dosing regimens and a rank order stability analysis investigating the effects of length of treatment, success rates, relapse rates, and drug acquisition costs on overall results were also conducted.

Terbinafine had the lowest cost per mycologic cure after one treatment regimen for onychomycosis in both toenail and fingernail infections ($791.00 and $454.00, respectively).

The costs of treating toenail and fingernail infections were comparatively higher for therapy with itraconazole ($1535.00 and $767.00, respectively), griseofulvin ($2385.00 and $837.00, respectively), and ketoconazole ($10,025.00 and $1512.00, respectively).

As a primary treatment choice, terbinafine also had the lowest overall expected cost per patient for both toenail and fingernail infections ($977.00 and $550.00, respectively). Griseofulvin had expected costs ($1543.00 and $822.00, respectively) similar to itraconazole ($1588.00 and $894.00, respectively), whereas ketoconazole was the most expensive primary treatment choice ($2359.00 and $1287.00, respectively).

This study demonstrates that terbinafine is an economical and cost-effective treatment for patients with dermatophytic onychomycosis, supporting European and Canadian studies. Except for the rank order of griseofulvin and itraconazole, sensitivity analyses show that these results are fairly stable.
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23.) Update on the management of onychomycosis: highlights of the Third Annual International Summit on Cutaneous Antifungal Therapy [see comments]
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Author
Elewski BE; Hay RJ
Address
University Hospitals of Cleveland, Ohio, USA.
Source
Clin Infect Dis, 23(2):305-13 1996 Aug

Abstract

Onychomycosis is an increasingly common fungal infection of the nail, which has traditionally been difficult to diagnose and treat and has physical and psychological consequences for the patient. Onychomycosis can be caused by dermatophytes, nondermatophytic filamentous fungi, and yeasts. The relative percentages of cases due to these etiologic agents vary with geographic location; however, in the United States, dermatophytes are the most common pathogens. Toenails are affected four times as often as fingernails. Microscopy and culture are the diagnostic "gold standards" for onychomycosis, although biopsy of the nail may be required to obtain a definitive diagnosis when conditions that mimic onychomycosis, such as psoriasis, are suspected.

The treatment of onychomycosis includes a combination of topical therapy, surgical or chemical nail avulsion, and systemic therapy. The new generation of systemic agents (itraconazole, fluconazole, and terbinafine) is associated with a higher cure rate and shorter courses of treatment than are the older systemic antifungal drugs (i.e., griseofulvin and ketoconazole); these characteristics have sparked new interest in onychomycosis. Of these newer antifungals, itraconazole and terbinafine are the only agents currently approved by the U.S. Food and Drug Administration for the treatment of onychomycosis.

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24.) Prevalence of dermatophyte onychomycosis in Spain: a cross-sectional study.
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Author
Sais G; Jucgl`a A; Peyr´i J
Address
Department of Dermatology, Hospital Pr´inceps d'Espanya, Universitat de Barcelona, Spain.
Source
Br J Dermatol, 132(5):758-61 1995 May

Abstract

To evaluate the prevalence of dermatophyte onychomycosis in Spain, a cross-sectional study was conducted between 1992 and 1993. A total of 10,007 subjects over the age of 15 years were interviewed (using the computer-assisted telephone interview system), completed a directed questionnaire, and reviewed a series of photographs of diverse nail disorders. The period prevalence of onychomycosis was 2.6% and the point prevalence 1.7%. The prevalence of onychomycosis was higher in women (1.8%) than in men (0.8%). Age group distribution showed a higher onychomycosis prevalence (1.2%) in the oldest age group (> 55 years).

With regard to localization, the prevalence of toenail onychomycosis was higher than that of fingernail onychomycosis and of concurrent infection in both sites. The results of this study suggest that 802,893 inhabitants of Spain have, or have previously suffered from dermatophyte onychomycosis. Only 38.6% have sought medical advice, and only 14% of those who did so consulted a dermatologist.

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25.) Economic evaluation of antifungal agents in the treatment of toenail onychomycosis in Germany.
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Author
Van Doorslaer EK; Tormans G; Gupta AK; Van Rossem K; Eggleston A; Dubois DJ; De Doncker P; Haneke E
Address
Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
Source
Dermatology, 193(3):239-44 1996

Abstract

BACKGROUND: The strategies for the management of onychomycosis have changed since the availability of the newer generation of antifungal agents, particularly, itraconazole and terbinafine. Itraconazole (1-week pulse) therapy may have higher efficacy and an improved adverse-effects profile compared to the continuous therapy regimen.

OBJECTIVE: We performed a pharmacoeconomic evaluation of the most commonly used treatments in Germany for toenail onychomycosis from a health care payer perspective.

METHODS: A 5-step approach was used. Firstly, the purpose of the study, the comparator drugs, their dosage regimens and the time frame of the analysis were defined. Next, the medical practice and resource consumption patterns associated with the treatment of onychomycosis were identified. In step III, a meta-analysis was used to determine the relative efficacy of the comparator drugs. In step IV, a decision tree of the treatment algorithms was constructed for each comparator. The expected cost analysis and cost-effectiveness analysis were also performed. Finally, a sensitivity analysis was carried out.

RESULTS: For the four main comparator drugs used to treat toenail onychomycosis in Germany, the clinical response rates (clinical cure plus marked improvement) at the end of the follow-up period (month 12 after starting therapy) were, for itraconazole (1-week pulse dosing): 89.8 +/- 3% (mean +/- SE), terbinafine: 79.4 +/- 10%, itraconazole (continuous dosing): 77.5 +/- 9%, and ciclopirox nail varnish: 55 +/- 5%. Itraconazole (1-week pulse dosing) was most cost-effective at DM 1,107 per successful treatment, followed by oral terbinafine at DM 1,224, ciclopirox nail varnish and itraconazole (continuous dosing). Sensitivity analyses indicated that itraconazole (1-week pulse dosing) and terbinafine had similar cost-effectiveness ratios.

CONCLUSION: Itraconazole is an effective, broad-spectrum triazole used as continuous or pulse therapy in the treatment of onychomycosis. Itraconazole (1-week pulse) and terbinafine are the most cost-effective therapies for toenail onychomycosis.

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26.) Onychomycosis. Going for cure.
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Author
Gupta AK; Shear NH
Address
Department of Medicine, Sunnybrook Health Science Centre.
Source
Can Fam Physician, 43():299-305 1997 Feb

Abstract

OBJECTIVE: To review onychomycosis with an emphasis on the traditional and newer antifungal agents available to treat onychomycosis.

QUALITY OF EVIDENCE: We searched MEDLINE for the years 1966 to 1995. We excluded case reports from our analysis. MAIN FINDINGS: For treating onychomycosis, newer antifungal agents (such as terbinafine, itraconazole, and fluconazole) are more cost-effective than the traditional agents griseofulvin and ketoconazole. Of the newer agents, only terbinafine is currently approved in Canada for treating onychomycosis.

CONCLUSIONS: The new generation of drugs is an important addition to the armamentarium of therapies available for treating onychomycosis. At the moment, in Canada, terbinafine is the drug of choice and more cost-effective than griseofulvin for treating dermatophyte-induced onychomycosis.

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27.) Itraconazole therapy is effective for pedal onychomycosis caused by some nondermatophyte molds and in mixed infection with dermatophytes and molds: a multicenter study with 36 patients.
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Author
De Doncker PR; Scher RK; Baran RL; Decroix J; Degreef HJ; Roseeuw DI; Havu V; Rosen T; Gupta AK; Pi´erard GE
Address
Clinical Research Department, Janssen Research Foundation, Beerse, Belgium.
Source
J Am Acad Dermatol, 36(2 Pt 1):173-7 1997 Feb

Abstract

BACKGROUND: Onychomycosis of the toenail caused by nondermatophyte molds alone or in combination with dermatophytes is difficult to eradicate with standard antifungal therapy.

OBJECTIVE: Our purpose was to determine the effectiveness of itraconazole in the treatment of toenail onychomycosis caused by molds alone or in combination with dermatophytes.

METHODS: We treated 36 patients with this drug given as continuous dosing (100 or 200 mg/ day) for 6 to 20 weeks or as a 1-week pulse dosing (200 mg twice daily for 1 week per month) for two to four pulses.

RESULTS: Patients with toenail onychomycosis with the following organisms were treated: Aspergillus spp. (eight patients), Fusarium spp. (four patients), Scopulariopsis brevicaulis (23 patients), and Alternaria spp. (one patient). Nineteen patients had onychomycosis with a mixed origin. At follow-up, 12 months after therapy was initiated, clinical and mycologic cure was achieved in 15 of 17 patients (88%) with onychomycosis caused by a single mold. In patients with mixed infection, a clinical cure was obtained in 16 of 19 patients (84%) and a mycologic cure in 13 of 19 patients (68%).

CONCLUSION: Itraconazole appears to be effective and safe for the treatment of toenail onychomycosis caused by some nondermatophyte molds alone or in combination with dermatophytes.

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28.) A questionnaire study on the management of onychomycosis: a Canadian
perspective.
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Author
Gupta AK; Shear NH
Address
Department of Medicine, Sunnybrook Health Science Center, Toronto, Canada. [email protected]
Source
Int J Dermatol, 37(6):457-60 1998 Jun

Abstract

BACKGROUND: Onychomycosis of the toenails is a condition that responds poorly to griseofulvin. The introduction of terbinafine in Canada in May 1993 resulted in a marked shift in the choice of treatment for pedal onychomycosis.

METHODS: A questionnaire survey was carried out in 1996 among Canadian dermatologists regarding the management of onychomycosis. RESULTS: There were 160 respondents from the roughly 350 practicing dermatologists. The dermatologists saw 8 +/- 0.6 patients per week (average +/- standard error (SE) with suspected or diagnosed onychomycosis, with 5 +/- 0.5 patients per week consulting the dermatologists for the first time. Most dermatologists performed mycological testing prior to starting treatment for onychomycosis. The management options for onychomycosis (mean +/- SE) were oral systemic antifungal therapy 51 +/- 3%, no therapy 31 +/- 3%, and nondrug therapy 9 +/- 2%.

The majority of dermatologists (83%) used terbinafine as first-line therapy if, indeed, they used oral antifungal agents. In contrast, griseofulvin and ketoconazole were used as first-line therapy in 5% and 1% of cases, respectively. In Canada, there are no monitoring requirements when using oral terbinafine for onychomycosis.

Therefore, it is not surprising that only 30% of dermatologists performed monitoring with terbinafine. In contrast, the frequency of monitoring with griseofulvin and ketoconazole was 40% and 80%, respectively. The subset of dermatologists who reported monitoring carried it out in only a fraction of their patients: 47%, 53% and 83% for terbinafine, griseofulvin, and ketoconazole, respectively. Therefore, the overall number of patients in whom regular monitoring was performed was 14.1% 21.2%, and 71.4% for terbinafine, griseofulvin, and ketoconazole, respectively. The perceived cure rates with terbinafine and griseofulvin (mean +/- SE) were 83.7 +/- 1% and 41 +/- 3.1%, respectively.

CONCLUSIONS: In May 1996, within three years of the introduction of terbinafine to Canada, this agent has become the drug of choice for the treatment of pedal onychomycosis (at the time of the survey neither itraconazole or fluconazole were approved for onychomycosis). Terbinafine has been found to be very effective and safe, and only a minority of dermatologists perform regular monitoring with this drug.

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29.) Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the fingernail.
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Author
Drake L; Babel D; Stewart DM; Rich P; Ling MR; Breneman D; Scher RK; Martin AG; Pariser DM; Pariser RJ; Ellis CN; Kang S; Katz HI; McDonald CJ; Muglia J; Savin RC; Webster G; Elewski BE; Leyden JJ; Bucko AD; Tschen EH; Hanifin JM; Morman MR; Shupack JL; Greer DL; et al
Address
Dermatology Clinical Investigations Unit, Massachusetts General Hospital, Boston 02114-2698, USA.
Source
J Am Acad Dermatol, 38(6 Pt 2):S87-94 1998 Jun

Abstract

BACKGROUND: Onychomycosis is a prevalent infection of the nail caused primarily by dermatophytes. Fluconazole is active in vitro against the most common pathogens, penetrates into the nail bed, and is clinically effective in the treatment of a wide variety of fungal infections.

OBJECTIVE: The purpose of this study was to assess the safety and efficacy of oral fluconazole 150, 300, and 450 mg administered once weekly compared with placebo in the treatment of distal subungual onychomycosis of the fingernail caused by dermatophytes.

METHODS: This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 349 patients with onychomycosis of the fingernails. Clinical and mycologic efficacy as well as measures of safety were assessed monthly for a maximum of 9 months of treatment, with additional safety visits occurring at weeks 2 and 6. For inclusion, patients were required to have clinically and mycologically documented onychomycosis of the fingernail caused by dermatophytes with at least 25% involvement of the target fingernail.

After end of therapy, patients with improved or cured fingernails entered a blinded 6-month follow-up without drug treatment during which efficacy was assessed every 2 months. Efficacy was assessed by clinical (visual) and mycologic (microscopic and culture) measures. Clinical measures included assessments of the percentage of target nail involvement, measurement of the distance from the nail fold to the proximal onychomycotic border, and signs and symptoms of onychomycosis.

RESULTS: Fluconazole was significantly superior to placebo in eradicating clinical and mycologic symptoms of onychomycosis, both at the end of active treatment and at 6 months after treatment (p=0.0001 for all efficacy measures). At the end of therapy, 91% to 100% of patients in the fluconazole groups were judged clinical successes, defined as reduction of the affected area of the target nail to less than 25% or cure, compared with 8% for placebo. Clinical cure rates at end of therapy were 76%, 85%, and 90% for fluconazole 150, 300, and 450 mg, respectively, compared with 3% for placebo.

These clinical success and cure rates were largely maintained or improved during follow-up. Clinical relapse in cured patients during the follow-up period was very low (1.5% to 3.3%). Fluconazole demonstrated mycologic eradication rates of 89% to 100% at the end of treatment and 90% to 99% at the end of follow-up; for placebo the rates were 8% and 12%, respectively.

CONCLUSION: Fluconazole administered once weekly is safe and effective in eradicating distal subungual onychomycosis of the fingernail caused by dermatophytes.

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30.) Antifungal pulse therapy for onychomycosis. A pharmacokinetic and pharmacodynamic investigation of monthly cycles of 1-week pulse therapy with itraconazole.
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Author
De Doncker P; Decroix J; Pi´erard GE; Roelant D; Woestenborghs R; Jacqmin P; Odds F; Heremans A; Dockx P; Roseeuw D
Address
Department of Dermatology, University of Antwerp, Wilrijk, Belgium.
Source
Arch Dermatol, 132(1):34-41 1996 Jan

Abstract

BACKGROUND AND DESIGN: In the treatment of onychomycosis, oral therapies have generally been given as a continuous-dosing regimen. For example, the suggested dose of itraconazole for the treatment of onychomycosis has thus far been 200 mg/d for 3 months.

Based on the advances in our understanding of the pharmacokinetics of itraconazole, we investigated the efficacy and nail kinetics of intermittent pulse-dosing therapy with oral itraconazole in patients who were suffering from onychomycosis. Fifty patients with confirmed onychomycosis of the toenails, predominantly Trichophyton rubrum, were recruited and randomly assigned to three (n = 25) or four (n = 25) pulses of 1-week itraconazole therapy (200 mg twice daily for each month).

Clinical and mycological evaluation of the infected toenails, and determination of the drug levels in the distal nail ends of the fingernails and toenails, were performed at the end of each month up to month 6 and then every 2 months up to 1 year. RESULTS: In the three-pulse treatment group, the mean concentration of itraconazole in the distal ends of the toenails ranged from 67 (month 1) to 471 (month 6) ng/g, and in the distal ends of the fingernails, it ranged from 103 (month 1) to 424 (month 6) ng/g.

At month 11, the drug was still present in the distal ends of the toenails at an average concentration of 186 ng/g. The highest individual concentrations of 1064 and 1166 ng/g were reached at month 6 for toenails and fingernails, respectively. At end-point follow-up, toenails in 84% of the patients were clinically cured with a negative potassium hydroxide preparation and culture in 72% and 80% of the patients, respectively. In the four-pulse treatment group, the mean concentration of itraconazole in the distal ends of the toenails ranged from 32 (month 1) to 623 (month 8) ng/g, and in the distal ends of the fingernails, it ranged from 42 (month 1) to 380 (month 6) ng/g.

The highest individual concentrations of 1549 and 946 ng/g were reached at month 7 for toenails and at month 9 for fingernails, respectively. At month 12, the drug was still present in the distal ends of the toenails at an average concentration of 196 ng/g. At end-point follow-up, toenails in 76% of the patients were clinically cured with a negative potassium hydroxide preparation and culture in 72% and 80% of the patients, respectively. There were no significant intergroup differences between the three- and four-pulse treatment groups for the primary efficacy parameters. The drug was well tolerated with no significant side effects in either patient group.

CONCLUSIONS: Following pulse therapy with itraconazole (400 mg/d given for 1 week each month for 3 to 4 months), the drug has been detected in the distal ends of nails after the first pulse, and it has reached therapeutic concentrations with further therapy. After stopping the last pulse, the drug remains in the nail plate at levels above 300 ng/g for several months. Clinical cure rates between 76% and 84% and negative mycological examination findings between 72% and 80%, respectively, were observed in toenail onychomycosis. The data suggest that pulse therapy with itraconazole is an effective and safe treatment option for onychomycosis.

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31.) Measuring health-related quality of life in onychomycosis.
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Author
Lubeck DP
Address
Technology Assessment Group, San Francisco, CA 94107, USA.
Source
J Am Acad Dermatol, 38(5 Pt 3):S64-8 1998 May

Abstract

BACKGROUND: Patients with onychomycosis may experience physical impairment and psychological and social limitations related to their infection.

OBJECTIVE: The object of this study was to compare health-related quality-of-life scores of patients with onychomycosis with those of a control group.

METHODS: The interview instrument included scales of general measures, disease-specific factors, and issues specifically related to onychomycosis symptoms; the onychomycosis group also was questioned about past treatment and attitude towards treatment.

RESULTS: A total of 299 persons with onychomycosis and 381 controls were interviewed. Demographic factors were similar except for gender and age. Analyses adjusted for these differences. All general quality-of-life scores but one were significantly lower in the onychomycosis group. For responses to questions related specifically to nails, the onychomycosis group reported significantly more problems with physical appearance than did controls (p < 0.001); the greatest absolute differences were for physical activities involving the feet. The majority (88%) of the onychomycosis group indicated they would take oral medication even if it had short-term side effects.

CONCLUSION: Onychomycosis affects generic health-related quality-of-life measures less than other variables. The greatest impact is on onychomycosis-specific measures. Because patients are willing to try treatment, many of these quality-of-life concerns can be addressed by newer oral treatments.

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32.) Prevalence and epidemiology of unsuspected onychomycosis in patients visiting dermatologists' offices in Ontario, Canada--a multicenter survey of 2001 patients.
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Author
Gupta AK; Jain HC; Lynde CW; Watteel GN; Summerbell RC
Address
Department of Medicine, Sunnybrook Health Sciences Center, Toronto, Canada.
Source
Int J Dermatol, 36(10):783-7 1997 Oct

Abstract

BACKGROUND: Questionnaire studies have been used to determine the prevalence of onychomycosis in the United Kingdom and Europe. One disadvantage of this methodology is that the patient self-diagnoses the onychomycosis. There have been very few large studies involving clinical examination of the nails of subjects, followed by mycological confirmation of the onychomycosis. We therefore determined the prevalence of onychomycosis in patients visiting dermatologists' offices in Ontario, Canada.

METHODS: In a prospective, multicenter study, the finger- and toenails of all new patients presenting to dermatologists' offices were examined by a board-certified dermatologist. If there was clinical suspicion of onychomycosis, then nail samples were obtained for mycological examination at a central laboratory. Patients referred specifically for the management of onychomycosis were excluded.

RESULTS: Toenails appeared abnormal in 455 (22.7%) of 2001 patients. Mycologically-confirmed pedal onychomycosis was present in 182 (9.1%) of the 2001 patients. The estimated value of the prevalence of onychomycosis in Ontario is 6.86% (95% confidence interval (CI): 5.8-8.0%), when corrected for age and sex of the general population using census data. Onychomycosis increased with age (P < 0.0001). The odds of males having onychomycosis was 84.3% greater than females of the same age (P = 0.0003). The distribution of organisms in the 141 patients with pedal onychomycosis who were culture positive was: dermatophytes 131 (92.9%), Candida species 4 (2.8%) and non-dermatophyte molds 6 (4.3%).

CONCLUSIONS: The prevalence of mycologically-confirmed toenail onychomycosis was 9.1%, with the estimated prevalence in Ontario being 6.86%. The majority of patients with abnormal-appearing nails were unaware they might have onychomycosis, that it is infectious and potentially treatable, suggesting that there is potential for increased public awareness and education.

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DATA-MÉDICOS/DERMAGIC-EXPRESS No (16) 12/11/98 DR. JOSÉ LAPENTA R.
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