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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 69, Num. 5, 2003, pp. 361-362
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Untitled Document
Indian Journal of Dermatology, Venerelogy & Leprology, Vol 69, No.
5 ,Sept-Oct, 2003, pp. 361-362
Letters to Editor
Clinico-mycological evaluation of onychomycosis at Bangalore and Jorhat
V. Ramesh
Department of Dermatology & STD, Deen Dayal Upadhyaya
Hospital, Hari Nagar, New Delhi -110064, India.
Code Number: dv03063
Sir,
The significance of this article1 lies in the fact that the rate
of recovery of fungi from the nails in culture is better when compared to
other studies, and surprisingly the rate of recovery of non-dermatophytic fungi
is
also high, almost as much as the dermatophytes. An explanation for the former
is given (the drying procedure of Milne), but scant regard has been paid
to the latter. Non-dermatophytes are generally considered to be weak pathogens
and have thus been usually recovered from the toenails in a predominantly
shoe
wearing population. In this setting the toenails are enclosed and hence kept
moist, a situation that is conducive for the fungi to invade nails. Though
occlusive footwear has been mentioned in the article,1 nothing
is known about the site from where the non-dermatophytes were recovered on
culture.
This is very important when seen in the light that the study was restricted
to soldiers. This high rate of recovery of non-dermatophytes cannot simply
be attributed to hot and humid weather since these factors favor dermatophytes
which are the dominant pathogens. Soldiers comprise a healthy population
and it would have been more informative to correlate the isolation of non-dermatophytes
with the type, site and number of nails involved. Normally non-dermatophytes
infect one or a few nails (often the toenails) and cause superficial infection;
multiple nail involvement, particularly when both fingernails and toenails
are involved, is not a usual occurrence. Having noted this high rate of non-dermatophyte
infection, the author must have at some point in the study adopted the stringent
criteria2 quoted in the article, one of which states that at least
5 out of 20 inocula should grow the non-dermatophyte organism in the absence
of a dermatophyte. This criteria too has been revised to ensure that the
non-dermatophyte has caused the nail infection and has been discussed in
a recent commentary.3
No mention has been made at all of the associated cutaneous fungal infection.
Dermatophytic onychomycosis is a source of repeated attacks of tinea anywhere
on the glabrous skin, a feature not shared by the non-dermatophytes. This history
is important for the clinician who cannot always resort to culture to differentiate
a dermatophyte from a non-dermatophyte, though rarely the latter too has been
implicated in skin involvement. Instead, the author has mentioned that younger
patients were cosmetically conscious. This is not completely true. Younger
people do not have much time to concentrate on asymptomatic and trivial conditions
like onychomycosis, unless many nails are affected. In my experience, such
patients, especially with one or two infected fingernails, are often detected
when they come to us for fungal skin infections.
The classification of the clinical presentations of onychomycosis
is also not clear. These types have been well described.4,5 Three
points should have been addressed by the author:
1. The mention of proximal superficial onychomycosis in the
abstract and text of the article is confusing. There is no such picture described
in the previous literature unless the author wants to draw our attention to
some new observation.
2. The clinical picture could also have been correlated with
the fungus isolated since some fungi are also known to be frequently associated
with a particular type of nail infection.
3. Paronychia has been listed as a morphological pattern of
onychomycosis. Chronic paronychia is seen in those doing `wet' occupations
and as such it is not considered as a clinical type of onychomycosis.4 Candidal
onychomycosis includes the one caused by direct invasion of the nail plate
in defective immune states like chronic cutaneous candidiasis. In paronychia
the nail fold and later the cuticle of the nail plate are eroded, resulting
in invasion by yeasts and bacteria. This process ultimately involves the nail
matrix and causes the nail dystrophy. In the absence of nail dystrophy one
is not justified to classify paronychia under onychomycosis. Though secondary,
at least significant nail involvement must be present
in chronic paronychia when it is included in a
study of onychomycosis.
References
- Grover S. Clinico-mycological
evaluation of onychomycosis at Bangalore and Jorhat. Indian J Dermatol
Venereol Leprol 2003;69:284-6.
- English MP. Nails and fungi. Br J Dermatol 1976;94:697-701.
- Gupta AK, Ryder JE, Summerbell C. The diagnosis of non-dermatophyte
mold onychomycosis. Int J Dermatol 2003;42:272-3.
- Zaias N. Onychomycosis.
Arch
Dermatol 1972;105:263-74.
- Gupta AK, Baran R. Ciclopirox nail lacquer
solution 8% in the 21st century. J Am Acad Dermatol 2000;43:96-102.
Copyright 2003 - Indian Journal of Dermatology, Venereology & Leprology.
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