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

2. 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%

3. Modern etiology of onychomycosis
Our study: 3075 cultures from samples from onychomycosis patients in , 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.)

4. 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

5. 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

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

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

8. 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?

9. 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?

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

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

12. 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%

13. 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

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

15. 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

16. Index SCIO to assess severity and predict outcome

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

18. SCIO: calculation utilities
Special device: SCIO ruler

19. SCIO: calculation utilities
Electronic calculator
Internet

20. 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

21. 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

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

23. 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

24. 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 ( vs )
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)

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

26. SCIO and life quality

27. More about SCIO?