Dermatophytomas: Clinical Overview and Treatment

Abstract

Dermatophytomas are characterized as a hyperkeratotic fungal mass in the subungual space, showing as dense white or yellow, typically in longitudinal streaks or patches. Masses can be visualized by traditional microscopy or histology. Newer technologies such as dermoscopy and optical coherence tomography also provide visual features for dermatophytoma diagnosis. The density of fungal mass, and lack of adherence to the nail structures, as well as possible biofilm development, may play a role in the reduction in drug penetration and subsequent lack of efficacy with traditional oral therapies such as terbinafine and itraconazole. A combination of drug treatment with mechanical or chemical debridement/avulsion has been recommended to increase efficacy. The topical antifungal solutions such as tavaborole, efinaconazole, and luliconazole may reach the dermatophytoma by both the transungual and subungual routes, due to low affinity for keratin and low surface tension. Current data indicates these topicals may provide efficacy for dermatophytoma treatment without debridement/avulsion. Similarly, fosravuconazole (F-RVCZ) has an improved pharmacological profile versus ravuconazole and may be an improved treatment option versus traditional oral therapies. The availability of improved treatments for dermatophytomas is crucial, as resistance to traditional therapies is on the increase.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents

“…107,132 Efinaconazole and, to a lesser degree, tavaborole have shown efficacy in the treatment of dermatophytomas, which are particularly resistant to oral antifungals. 64,133 Efinaconazole has also demonstrated effectiveness in treating onychomycosis cases that did not respond to terbinafine. 134 Although cost and access can be barriers to treatment with efinaconazole and tavabarole, 135 they may be effective treatment options in the face of terbinafine-or itraconazole-resistant dermatophytes or patient characteristics that contraindicate oral antifungals.…”

“…For both mycological and complete cure, success rates with efinaconazole were roughly similar to those seen with oral itraconazole, but lower than with oral terbinafine 107,132 . Efinaconazole and, to a lesser degree, tavaborole have shown efficacy in the treatment of dermatophytomas, which are particularly resistant to oral antifungals 64,133 . Efinaconazole has also demonstrated effectiveness in treating onychomycosis cases that did not respond to terbinafine 134 .…”

The potential role and mechanism of circRNA/miRNA axis in cholesterol synthesis

“…The FDPS inhibitors include alendronate 56 , incadronate (INC, also named cimadronate or YM-175) 56 , 57 , ibandronate 56 , 58 , 59 , minodronate 56 , risedronate 56 , pamidronate 56 , zoledronate 56 . The CYP51 inhibitors include albaconazole (also named stiefel or UR-9825) 60 , 61 , arasertaconazole nitrate 62 , 63 , Bifonazole (also named B3LYP) 64 - 67 , butoconazole (BTZ) 68 , 69 , clotrimazole 70 , dapaconazole 71 , 72 , eberconazole (EBZ) 73 , econazole (also named EcoNai™, SEPA, Spectazole, Ecostatin, or Pevaryl) 74 , 75 , efinaconazole (also named KP-103 or Jublia) 41 , 76 , 77 , fluconazole 78 , flutrimazole 79 , 80 , fosravuconazole (F-RVCZ, the prodrug of ravuconazole (also named E1224)) 81 - 86 , genaconazole (also named SCH 39304, a racemic mixture that contains 50% of the SCH 42427 and 50% of SCH 42426 enantiomers) 87 , 88 , HCP002 (a phosphate-modified derivative of voriconazole) 89 , IDP113 90 , isavuconazole (ISA, the prodrug of isavuconazole (BAL 4815)) 91 , 92 , ketoconazole (KTC) 93 - 95 , levoketoconazole 95 , 96 , itraconazole 97 , luliconazole 85 , 98 , miconazole 99 , opelconazole (also named PC945) 100 , 101 , oteseconazole (also named VT-1161) 102 , posaconazole 84 , 103 , pramiconazole (also named R126638) 104 - 107 , quilseconazole (also named VT-1129) 108 , 109 , SSY726 110 , 111 , voriconazole ...…”

Diagnostic clue for dermatophytoma using the dermatophyte test strip

“…Although there is no standardized method for diagnosing dermatophytomas, confirmation of the presence of dermatophytes by KOH direct microspectroscopy or culture is mandatory. 5 In the future, dermoscopy and optical coherence tomography might be used for the diagnosis. In these six cases, additional sampling from deep in the nail beds and the KOH method proved the presence of dermatophytomas in all six cases (Figure 1c, the brownish mass is the mass of the fungus), (Figure 1d, the cluster of thick and short hyphae and large spores).…”