Coexistence of onychomycosis and nail psoriasis and its correlation with systemic treatment

Abstract

Background Epidemiological studies indicate that onychomycosis may affect up to 79% of psoriatic patients. Onychomycosis in psoriatic patients is more commonly caused by yeasts comparing with non‐psoriatic. Objectives Evaluate the prevalence of fungi in nail psoriasis. Evaluate the association between direct mycological examination (DME) and mycological culture, Nail Psoriasis Severity Index (NAPSI) and systemic treatment for psoriasis. Methods Of 133 nails from 20 patients with nail psoriasis were evaluated as follows: 9 patients were using topical treatment and 11 were on systemic treatment. The assessment of psoriasis severity using NAPSI was performed in all psoriatic nails. The presence of fungi was confirmed in DME and culture. Results DME showed the presence of fungal elements in 45 nails (33.83%) with a predominance of blastoconidia (95.5%) No septate hyphae were seen. Mycological culture was positive in 36 (27.06%) samples. Among them, Candida grew in 31 (86.1%): Candida parapsilosis in 15 (48.38%), Candida spp in 14 (45.16%). No growth of dermatophytes was observed. Patients with systemic treatment showed a higher frequency of positive test (DME and culture) for fungi when compared to topic treatment (p:.006). There was a positive correlation between NAPSI, mycological culture and systemic treatment (p:.0063); the risk was four times higher (OR:4.0). Limitation of the study Sample size. Conclusion These results are consistent with some previous reports, Candida was the fungus with higher frequency on the psoriatic nails, however, the role of these fungi is controversial (contamination x colonisation x infection). The fact that the immunosuppressive treatment increases the chance of fungal infection leads us to a greater attention to this patient profile, to prevent the intensification of nail psoriasis (Köbner phenomenon).

Factors affecting onychomycosis in patients with psoriasis

“…The lower prevalence in patients using acitretin (8.3%), ustekinumab (20%), secukinumab (15.4%) compared to the untreated group (31.3%) was remarkable. In a few studies, it has been reported that the use of systemic therapy increases the risk of onychomycosis compared to the use of only topical therapy, but no significant data can be presented on the specific treatment agent 23,32 . Some studies have reported that methotrexate significantly slows nail growth 10 and increases the risk of onychomycosis 10,33 .…”

“…In a few studies, it has been reported that the use of systemic therapy increases the risk of onychomycosis compared to the use of only topical therapy, but no significant data can be presented on the specific treatment agent. 23,32 Some studies have reported that methotrexate significantly slows nail growth 10 and increases the risk of onychomycosis. 10,33 In the study of Al-Mutairi et al patients who received etanercept, infliximab, adalimumab and those who did not receive any biologic agents were compared in terms of onychomycosis risk.…”

Increased risk of superficial fungal infections among psoriasis patients receiving systemic treatment: A nationwide retrospective population-based cohort study

“…Whether psoriasis predisposes patients to super cial fungal infection remains controversial. The immunomodulatory effects of systemic treatments, microbiota dysbiosis of the skin and nails, and immunologic disturbance of capillary units are contributing factors, while the abundance of antimicrobial peptides and fast turnover of the skin and nails are inhibitory factors [1][2][3] . Previous meta-analyses or large cohort studies were limited to onychomycosis or mucocutaneous candidiasis 2,4,5 .…”

Pecularities of onychomycosis and psoriasis in railway transport workers

“…В различных исследованиях онихомикоз стоп у больных псориазом был выявлен в 21,5-90% случаев [6][7][8][9][10][11][12][13][14].…”

“…К грибковому поражению ногтей у больных псориазом предрасполагают: длительность течения заболевания псориазом более 10 лет, распространенный кожный процесс, псориатический артрит, проведение системной иммуносупрессивной терапии, выраженные нарушения кровоснабжения конечностей [12][13][14].…”