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CORRESPONDENCE |
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| Year : 2012 | Volume
: 57
| Issue : 3 | Page : 242-243 |
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| Current clinico-mycological trends of onychomycosis in Pune |
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Ram Tainwala, YK Sharma
Department of Dermatology, Dr. D. Y. Patil Medical College, Pimpri, Pune, India
| Date of Web Publication | 16-May-2012 |
Correspondence Address:
Ram Tainwala
Department of Dermatology, Dr. D. Y. Patil Medical College, Pimpri, Pune
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.96220
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How to cite this article:
Tainwala R, Sharma Y K. Current clinico-mycological trends of onychomycosis in Pune. Indian J Dermatol 2012;57:242-3 |
Sir,
Onychomycosis encompasses all fungal infections of the nail and includes dermatophytes as well as nondermatophytes and yeasts. It is the most prevalent nail disease accounting for almost 50% of all onychopathies. Onychomycosis is a common infection accounting for 20% of all nail diseases until the late 1980s. At the turn of the century, it accounted for up to 50% of all nail disorders due to increased use of occlusive footwear and the number of immunocompromised patients, an aging worldwide population and a rise in environmental risk factors secondary to lifestyle changes.
In a prospective study conducted in the Department of Dermatology and Venereology, Dr. D. Y. Patil Medical College, Pune for 2 years from 2007 to 2009 to assess the dermatophytic infections in Pune (Maharashtra) and its association with other diseases, 40 out of 116 clinically diagnosed and untreated cases of dermatomycoses (excluding mucosal candidiasis and P. versicolor) were of onychomycoses accounting for 34.5%.
Thirty-nine (97.5%) of the 40 cases of onychomycosis in our study occurred in patients >20 years of age with the peak incidence of 11 (27.5%) cases each during the fourth decade and beyond 50 years. Nine (22.5%) cases were aged between 21 and 30 years and eight (20%) between 41 and 50 years. The only case below 20 years was aged 18 years. Several studies have shown an increasing prevalence of onychomycosis with age, the reason for which may include poor peripheral circulation, diabetes, repeated nail trauma, longer exposure to pathogenic fungi, suboptimal immune function, inactivity or the inability to cut toe nails, and maintain good foot care. [1] High prevalence (58.8%) of onychomycosis during the third decade has also been found in another study conducted in Sikkim. [2] This could be due to increased exposure to occupation-related trauma. They may also be more conscious cosmetically than during older age. [2] Grover [3] reported 56% of the cases of onychomycosis in his study belonging to 20-40 years, 16% cases were in the sixth decade and 14% cases each in the fifth and seventh decades of life. Out of the 40 cases of onychomycosis in our study, 33 (82.5%) were males and seven (17.5%) females. Whereas majority of the Indian studies support this male preponderance; one Sikkim [2] and another United Kingdom [4] study have not shown any sex difference.
Of the 40 cases of onychomysosis in our study, 26 (65%) patients had the distal subungual onychomycosis (DSO/DLSO) type. Reviews from various literatures reported DSO as the most common form of onychomycosis. The proximal subungual onychomycosis (PSO) was seen in four (10%) cases with two of them showing no signs of immunosuppression, and the other two patients being known HIV seropositive. Reports [5],[6] suggesting occurrence of PSO among human immunodeficiency virus (HIV)-infected patients are on a rise, with many suggesting it as a strong clue of AIDS. Paronychia (bacterial or candidal), usually affecting the nail plate proximally and laterally and sparing the distal free edge is known to occur. [7],[8] This is consistent with the occurrence of PSO in the two of our HIV-negative cases.
The 2 feet 1 hand syndrome (2FT-1HND) involving the dominant hand and bilateral feet was seen in four cases (10%). Total dystrophic onychomycosis (TDO) was seen in six (15%) cases.
A total of 27 (67.5%) of 40 patients showed positive fungal elements on KOH mount. Of them, five patients were also culture positive. Three patients grew dermatophytic fungi, Trichophyton rubrum. Two patients grew non dermatophytic molds (NDM), i.e., Scytalidium dimidiatum and Aspergillus species. Aspergillus sp. was isolated from the infected nails of a female farmer aged 40 years with DSO while S. dimidiatum was isolated from a 45-year-old diabetic businessman with total dystrophic onychomycosis. Onychomycosis secondary to NDM is seen most frequently in elderly, in patients with skin diseases that affect the nails and in immunocompromised patients. [5] Another study from Northeast India reported S.dimidiatum from onychomycosis, which was clinically indistinguishable from that caused by dermatophytoses. [9] Different modalities of nail invasion by molds are reported with Aspergillus presenting as DSO, PSO, or white superficial onychomycosis (WSO) whereas Scytalidium species presenting as DSO and PSO but not WSO. [10] The pattern of nail involvement by NDMs in our study correlates with the clinical presentation for the species.
Overall, NDMs constituted 5% (2/40) of the total nail cases in our study. NDMs are reported in 1.5-6% cases of onychomycosis. [11] Onychomycosis caused by molds are becoming increasingly common worldwide with NDMs accounting for up to 15% of nail infections in Bologna. [10] Ramani et al., [12] reported a 22% incidence of molds in onychomycosis with Aspergillus (86.4%) being the predominantly isolated mold in their study.
While all dermatophytes causing onychomycosis should be considered pathogens, the incidence and clinical significance of nondermatophytic fungi or molds (like Candida, Aspergillus, Fusarium, Scytalidium, etc.) causing onychomycosis in India is unknown, because they may be colonising organisms rather than pathogens. [1] Summerbell [13] suggested that nonfilamentous nondermatophytes identified in nail tissue to be considered as any of - a contaminant, commensal, transient coloniser, persistent secondary colonizer, successional invader, or primary invader, in order to increase the predictive power of diagnosis of dermatophytic invasion of a nail. Isolation of the NDM species is essential as the treatment of the mold infection depends upon the type of onychomycosis and the responsible mold. [10]
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