Onychomycosis An update on epidemiology, clinical evaluation and treatment effectiveness Alexey Sergeev All-Russian National Academy of Mycology

Onychomycosis in a modern dermatology clinic Skin tumors 16% Onychomycosis 24% All skin mycoses 31% All other skin diseases 53% Prevalence vs. geography Other skin mycoses 7%

Modern etiology of onychomycosis Our study: 3075 cultures from 12617 samples from onychomycosis patients in 1997-2001, CCH Moscow Dermatophytes: 73% from all cultures T. mentagrophytes var. interdigitale (6%) T. tonsurans, T. violaceum, M. canis T. rubrum (93%) Molds: 17% Aspergillus spp. (38%) Scopulariopsis brevicaulis (38%) Others: Fusarium, Acremonium, Alternaria spp. Candida spp. 9.6% После этой пленки показываем слайды грибов (около 10 шт.)

Etiology of fingernail and toenail onychomycosis Molds 14.3% Molds 16.5% Candida spp. 5.3% Dermatophytes 38.4% Dermatophytes 79.9% Candida spp. 44.8% toenails fingernails

Common treatment problems 42% of patients had been treated from onychomycosis previously 38% had been treated from tinea pedis previously but developed onychomycosis 34% of patients do not believe in successful treatment 25.7% do not seek treatment afraid of nail avulsion 11.4% are not ready for treatment expenses The remaining 26% have a motivation to treat onychomycosis

Three questions in onychomycosis systemic therapy How effective are current therapies? What defines effectiveness? Can clinician predict outcome?

Onychomycosis may be different even in clinical trials = Should we treat and compare these as equal?

Clinical features and treatment approach Clinical form Where in the nail is fungus? Is it reachable by means of: topical treatments? systemic therapy? may be unreachable?

Clinical features and treatment approach Length of involvement (distal form) How far is fungus from matrix area? How long it will take to move it out of the nail?

Clinical features and treatment approach Degree of hyperkeratosis (distal form) May topical preparations reach the nail bed? May systemic antifungals reach the nail plate?

What is inside the thickened nail? Videoscopic picture of hyperkeratotic onychomycosis

What is the modern presentation of onychomycosis? Clinical form Superficial 3.5% Distal 92.4% Proximal 4.1% Length of involvement More than 2/3 of the nail length in 54.4% Hyperkeratosis Moderate in 38.3% and severe in 37.5%

Growth of the nail and treatment approach Location Toenails grow about 2-3 times slower than fingernails Thumbnails and big toenails grow slower than on II-V digits Age Nail growth rate decreases with age (up to 25%) The concept of V

Growth rate and the outcome  > 0 Treatment Fast growing nail Slow growing nail Cure Delayed cure, relapse possible  < 0   0

How to count and arrange all relevant factors? Assign each a numeric value Build a grading scale Make equation where Get the range of values Index = Severity  Growth rate

Index SCIO to assess severity and predict outcome

Index SCIO to assess severity and predict outcome Scoring Clinical Index for Onychomycosis

SCIO: calculation utilities Special device: SCIO ruler

SCIO: calculation utilities Electronic calculator Internet calculator @ http://www.onychoindex.com

SCIO for clinician Easy treatment approach Guide to treatment duration Nail avulsion 30 Easy treatment approach Guide to treatment duration Assessment of cure Systemic therapy 15 Topical treatment 1

SCIO for investigator Single stratification criterion Same or close values in a group Possibility for small studies Reference point measuring severity Possibility for pharmacoeconomic studies

Experience with SCIO 82,6% 78,3% 14,9 14,3 Itraconazole Terbinafine Clinical cure at 18 month Terbinafine Baseline SCIO

Three questions in onychomycosis treatment Current systemic treatments for onychomycosis are highly effective when fit indications Severity defines effectiveness Clinician can expect outcome knowing baseline severity and growth rate of the nails

Measuring with SCIO: several facts SCIO values correlate (p < 0.001) with number of involved nails and duration of disease (about 6 points each 5 years) SCIO is significantly (p = 0.001) higher in diabetic patients (21.0+8 vs.16.2+8.3) vascular pathology (18.6 vs. 16.0) foot pathology (19.2 vs. 16.0) Previously treated patients have higher SCIO values (17.7 vs. 15.3)

SCIO in population: how severe is modern onychomycosis? Mean SCIO value = 16.37

SCIO and life quality

More about SCIO? http://www.onychoindex.com