Distribution of the initial site of infection in diabetic foot and associated initiating etiologies

Background: Diabetic foot is a very common condition responsible for a major bulk of surgical admissions and out-patient visits. Lack of awareness of many factors influencing the incidence of this disease complex has led to loss of life, limb and quality of life. The site-specific incidence of initial site and initiating factor has not been studied in diabetic foot.Methods: A study has been done over a period of one and a half years which looked into the distribution of initial site of infection in diabetic foot and associated initiating etiologies. The study was cross sectional. History, general inspection of foot, dermatological, neuropathic and vascular assessments were done, in addition to making careful notes about the site and cause of infection.Results:60.7% of patients were >60 years old, 55.3% were male patients. 63.3% of patients had diabetes for more than 10 years. In 29.3% the initial site of infection was the big toe, 22% in the ball of foot, 18% in the other 4 toes together, 14.7% in the interdigital spaces, 10.7% in the heel and 5.3% in the mid foot. In most of the cases the etiology is multifactorial, trauma in 56%, musculoskeletal deformities in 47.3%, callosities in 41.3%, cracks and fissures in 16.7%, fungal infection in 7.3%, nail infection in 6%, no initiating introduction of infection identified in 10.7%.Conclusions: Awareness of and thus particular stress being place on identification of specific site and cause of infection should help in care of the foot in diabetics.

Understanding the drug delivery through nails: a comprehensive review

The nail unit is the largest cutaneous musculo-skeletal appendage. The management of nail disorders is an onerous task owing to the disease manifestations and anatomical structure of the nail plate. The topical treatment of nail infections/disorders has been a centerpiece of nail research in the past few decades as it offers a much safer and focused alternative to conventional oral therapy. However, transungual delivery had its challenges. This necessitated a lookout for novel approaches that enhanced treatment efficacy and reduced treatment time. Moreover, curing the nail condition using topical delivery has been challenging due to the lack of a validated animal model to determine the efficacy of the formulation and to establish a mathematical model that can help in predicting the desirable attributes of the formulation and permeation of various molecules through the nail plate. This review is based on publications retrieved by a selective search in PubMed. The purpose of this review is to provide an overview of nail anatomy and its disorders, factors affecting nail delivery, diagnostic procedures, current approaches, and promising approaches to treat nail infections/disorders including nail lacquers and the role of permeation enhancers, in-vitro models. This review also covers current available treatments and treatments under clinical trial. Keywords: Musculo-skeletal, Nail infection, Transungual, Mathematical model, In-vitro models.

Subclinical Onychomycosis in Apparently Healthy Adults

<b><i>Introduction:</i></b> Onychomycosis is a frequent chronic nail infection, with a worldwide prevalence of 5.5% making it the most common nail disease, and its incidence increases with age. Clinically, it causes discoloration and thickening of the nail plate and may be accompanied by onycholysis. However, little is known of the subclinical infection. <b><i>Methods:</i></b> We studied adult male and female outpatients auto-referred as healthy and that had healthy appearing toenails. Nail distal clippings were obtained from the right first toenail. This sample was stained with PAS and observed by an expert dermatopathologist searching for fungal structures. <b><i>Results:</i></b> A total of 32 samples were included: 8 from men (25%) and 24 from women (75%), with ages ranging from 27 to 66 years (mean age of 43 years). Twenty-four patients did not present any histopathological finding suggestive of infection (75%), while 7 patients had a single finding (spores or hyphae) (21.8%), and 1 patient had both findings (3.12%). <b><i>Discussion/Conclusion:</i></b> We found 4 patients with yeasts, 3 with hyphae, and 1 patient with a combined infection with both yeasts and hyphae (3.1%). These add up to 25% of the clinically apparent healthy nails. Our results show that we still have much to learn from the initial stages of onychomycosis and that our population probably has higher incidence of this nail disease, so we must be alert to subtle nail changes. As our participants signed an informed consent, we will contact those that resulted positive for follow up consultations.

Green Nail Syndrome, A Rare Infection of Pseudomonas aeruginosa in The Nail

ObjectiveA nail infection is a common case caused by fungal infection, thus can make any bacterial correlated infection in the nail can be under-diagnosed. However, Pseudomonas aeruginosa can cause nail infection known as green nail syndrome (chromonychia). Method A 3 years old girl presented with greenish discoloration on the nail plate of the right toenail since previous a month. She came from well-educated family, but the water resource at their home was not good enough. The specimen of nail scraping was sent to the microbiology laboratory. The Gram from nail scraping didn’t show any significant result. After 24 hours, a greenish colony, non-lactose fermenter on the Mac Conkey and a dominant blue-green color colony on the blood sheep agar had grown. The colonies are beta hemolytic, flat and spreading. They were also positive to oxidase and catalase. Result The Gram result from the colony was showed as basil negative Gram. Identification from Vitex 2® concluded as Pseudomonas aeruginosa that resistant to all penicillin derivate and 2nd generation of cephalosporin. However the isolate was still sensitive to ceftazidime, carbapenems, quinolones and amino-glycosides. The treatment was decided using topical fluoroquinolone nadifloxacin, and gave a significant result in a month Conclusion Green nail syndrome that is caused by P. aeruginosa infection could be treated by topical fluoroquinolone for 1-2 months

Microbiological picture of onychopathy in psoriatic patients

Objective. To evaluate the incidence of onychomycosis and bacterial contamination of onychopathy in patients with psoriasis.Material and methods. The study included 86 patients with skin psoriasis and abnormal nail plates or isolated nail psoriasis. Patients nail plates examined in laboratory using direct microscopy with 20 % KOH, mycological culture Sabourauds Dextrose Agar with chloramphenicol and сycloheximide, and bacteriological culture with indetification using the MALDI-TOF mass spectrometer.Results. Out of 86 patients, 27 (31.4 %) had onychomycosis (KOH-positive or KOH-negative with a positive result for dermatophytes in a culture study). Of the 27 patients with onychomycosis, 9 caused by pathogenic fungi, and 18 caused by opportunistic fungi. Of the 54 patients with nail psoriasis, 9 (16.7 %) had onychomycosis, 3 had dermatophytes, and 6 had opportunistic micromycetes. A total of 97 microbiological studies were conducted in 86 patients, in which the following microorganisms were detected: Staphylococcus caprae – 28 strains, Staphylococcus lugdunensis – 26, Staphylococcus epidermidis – 26, Staphylococcus haemolyticus – 15, Staphylococcus pettenkoferi – 13, Staphylococcus simulans – 11, Staphylococcus warneri – 8, Staphylococcus aureus – 5, Staphylococcus piscifermentans – 4, corinebacteria spp. – 3, Staphylococcus hominis – 3, Staphylococcus capitis – 3, Pseudomonas aeruginosa – 3, Staphylococcus pasteuri – 1, Staphylococcus cohnii – 1, Kocuria spp. – 1, Klebsiella pneumonia – 1.Conclusion. In our study, onychomycosis was detected in 31.4 % of patients with psoriasis who have onychodystrophy. In psoriatic onychia, onychomycosis occurred in 16.7 % cases. Pseudomonas nail infection was observed in two patients, one in combination with nail psoriasis.

Activity of Metal-Azole Complexes Against Biofilms of Candida albicans and Candida glabrata

Background: Onychomycosis is a chronic nail infection caused by fungi frequently resistant to antifungal treatments. Recalcitrance in nail infections is a result of reduced antifungal penetration due to biofilm formation, combined with poor patient compliance with the treatment, which can be as long as 18 months. Objective: Metal-drug complexation is a widely used strategy to increase drug efficacy. Therefore, the aim of this work was to evaluate the antifungal and anti-biofilm activity of several metal-azole complexes against Candida albicans and Candida glabrata. Methods: Susceptibility assays and scanning electron microscopy were performed to determine the anti-biofilm activity of eight metal-azole complexes in vitro and ex-vivo, using human nail fragments. Results: In vitro susceptibility assays showed that complexation of both Au(I) and Zn(II) to clotrimazole and ketoconazole improved the anti-biofilm activity compared to the azole alone. Using an ex-vivo model of biofilm formation on fragments of human nails, we also demonstrate the improved efficacy of metal-azole complexes against biofilms of C. albicans and C. glabrata that resembles the onychomycosis structure. Noteworthy, biofilms of C. glabrata were more susceptible to the optimized complexes than those of C. albicans. Conclusion: In conclusion, metal-azole complexes used in this work show promising anti-biofilm activity and further clinical studies should confirm its potential for the treatment of Candida-associated onychomycosis.

Emerging Optical Techniques for the Diagnosis of Onychomycosis

Onychomycosis is the most prevalent nail infection. Although it is not a life-threatening condition, it impacts the quality of life for many patients and often imposes a challenging diagnostic problem. The causative agents are dermatophytes, yeasts and non-dermatophytic moulds. Accurate and early diagnosis, including the identification of the causative species, is the key factor for rational therapy. Still, early diagnosis is not optimal as the current gold standard for the differentiation of the infectious agents is culture-based approaches. On the other hand, noninvasive optical technologies may enable differential diagnosis of nail pathologies including onychomycosis. When light penetrates and propagates along the nail tissue, it interacts in different ways with the components of either infected or healthy nail segments, providing a wealth of diagnostic information upon escaping the tissue. This review aims to assess alternative optical techniques for the rapid diagnosis of onychomycosis with a potential to monitor therapeutic response or even identify the fungal agent non-invasively and in real time in a clinical setting.

The assessment of beauty salon client awareness of risk factors relating to skin and nail fungal infections of the feet

Introduction: Fungal infections of the skin and nails are one of the most common skin diseases in the world. The ever-growing number of fungal infections is caused by genetic factors, lack of prevention and insufficient knowledge about risk factors relating to fungal infections.The aim of the project was to assess the awareness of beauty salon clients to fungal infections of the skin and nails of the feet, with a particular emphasis on the factors contributing to infection.Materials and methods: The study was conducted among 125 clients of beauty salons.The data was collected via an anonymous questionnaire comprising 30 questions.Results: The majority of respondents (84% of women and 70% of men) considered the swimming pool as the main risk factor for fungal infection of the feet. The respondents listed specialists to whom they would turn after noticing suspicious skin changes on their feet. These were dermatologists (18% of responding women and 38% of responding men) as well as podologist (35% of responding women and 23% of responding men). However, the majority of respondents (45% of responding men and 33% of responding women) would use an over-the-counter antifungal medicine, easily obtained in a pharmacy, in case of suspected fungal nail infection (onychomycosis), without consulting a physician.Conclusions: Most respondents know the risk factors contributing to fungal infections. However, a high percentage of them have low awareness of the actions to be taken when onychomycosis is suspected.