Journal of Clinical and Aesthetic Dermatology

AUG 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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57 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY august 2017 • Volume 10 • number 8 O r i g i n a l r e s e a r c h measured by patient satisfaction and mycological tests three months after the last s ession. PATIENTS AND METHODS Inclusion criteria. inclusion criteria were presentation of clinical findings consistent with onychomycosis in the toenails, a direct mycological examination, positive culture for fungi, and the absence of prior treatment with antifungal therapy within three months. Exclusion criteria. exclusion criteria were pregnancy, age younger than 15 years, the use of anticoagulants and antifungals, and the presence of onychomycosis caused by yeasts, fingernail onychomycosis, psoriasis, lichen planus, hematomas, and other nail pathologies. Study design. this was an analytical cross-sectional study performed between December 2014 and september 2015 at the dermatology outpatient clinic of the Julio muller university hospital, federal university of mato grosso, cuiabá, in the midwest region of Brazil. it was approved by the research ethics committee under number 888.913/2014 - Brazil platform. Patient evaluation. Demographic data were retrieved from each patient participating in the study and included the following: sex, age, occupational activity, underlying diseases, and time of progression of onychomycosis. the clinical classification was subdivided as follows: total dystrophic onychomycosis (tDO), superficial white onychomycosis (sWO), distal lateral subungual onychomycosis (DlsO), and proximal subungual onychomycosis (PsO). Nail samples and fungal culture. nail fragments 1 to 2mm in size or subungual deposits were collected from the nail plates with clinical suspicion of onychomycosis. a direct mycological examination was performed (40% potassium hydroxide preparation [KOh]), and fungal structures such as arthrospores and hyphae were considered as conferring positivity in the direct examination. sabouraud's dextrose a gar (DifcO™) containing chloramphenicol (100mg/ml) and mycobiotic agar were used as media for the fungal cultures. cultures were incubated at 28˚c for three weeks until fungal colonies developed. Cure criteria. the term complete cure reflected two aspects: significant clinical improvement and negative mycological exams. the clinical improvement of the nail plate was considered based on either the clearing of the nail plate or a decrease in the area affected by the fungal disease. RESULTS Clinical onychomycosis type. in the 72 nail plates assessed, the distal subungual form was observed in 73.6 percent and the total dystrophic form in 26.4 percent of cases. the involvement of the plates was classified by the area of change: 41.7 percent of the slides showed involvement of two-thirds of the area, while 34.7 percent showed full involvement. Fungus type. Dermatophytes were observed in 90.3 percent and nondermatophytes in 9.7 percent of the assessed cases (30 patients). Of the 72 nail plates, the species were identified in the clinical samples from 41 of the nail plates. Trichophyton rubrum was observed in 65.8 percent of the clinical samples, while T. mentagrophytes and Fusarium species were each observed in 17.1 percent of the clinical samples. Patient demographic data. thirty patients, 23 women and seven men, were selected and presented with involvement of 72 nail plates. the group had an average age of 53.2 years (confidence interval [ci]=95%, 49.2–57.1). the patients were queried about their work activities: 23.3 percent were housewives/husbands exclusively, 16.7 percent were retired, and 16.7 percent were sellers. the average time of progression of the disease was 7.5 years (ci=4.1–10.9). the patients had the following associated d iseases: systemic arterial hypertension (50%), type 2 diabetes mellitus (14.8%), arthritis (7.14%), hypothyroidism (7.14%), and hypercholesterolemia (7.14%). nine patients reported prior treatment with fluconazole, and two with amorolfine nail lacquer. Mycologic cure of nail fungal infections. the patients returned 12 weeks after the last laser session for the clinical assessment and collection of control test results. the mycological tests showed persistence of infection by fungi in 66 nail plates (91.7%) and absence of infection in six nail plates. Of those cured, none were dystrophic forms. the involvement of the nail plate was classified in area of change: 41.7 percent of the nail plates presented involvement of two-thirds of the area, and 34.7 percent were fully affected. Adverse events. at the end of the laser sessions, patients reported a score for the sensation of pain, which could be 0 (painless), 1 (mild), 2 (moderate), 3 (severe), and 4 (unbearable). no patient classified the pain as intolerable, but the majority classified the pain as either mild or moderate. DISCUSSION many factors contribute to therapeutic failure in onychomycosis. these include high fungal adaptation to the keratinized tissue and chronic characteristic of the fungal infection, causing aesthetic discomfor t alone in most of the cases, without other damage to the patients. in addition to the high cost of available antifungals, adverse effects should be taken into account, especially in patients with associated diseases who receive other medications that may interact with the antifungal agents. for these reasons, laser therapy has emerged as a potential novel option.

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