1. Non-Dermatophyte Molds are not pure Contaminants in Onychomycosis
Ranthilaka R. Ranawaka
Consultant Dermatologist
General Hospital Kalutara, Sri Lanka

2. Background
Onychomycosis is caused by dermatophytes, non- dermatophyte molds (NDM) and Candida spp.
NDM are saprophytic molds, which are widely distributed as soil and plant pathogens.
In routine practice -the prevalence of NDM onychomycosis was much higher in our setting than reported in the literature.
High prevalence of NDM onychomycosis has been reported from India (22%), Malaysia (35.5%), Thailand (51.6%) and Pakistan (68%), too.

3. Two studies were conducted in Sri Lanka,
2004 (128 patients) and
2012 (178 patients)
In both studies mycology was performed at Department of Microbiology, Faculty of Medicine Karapitiya, Galle.

4. What ever the causative fungus onychomycosis was clinically indistinguishable
30, man, chemist, gardening, Aspergillus flavus isolated
36,housewife, with dystrophic big toe nails for two years. Fusarium dimerum isolated.
55, labourer woman, 10 years,
Penicillium spp isolated

5. Dermatophytic and non-dermatophytic onychomycosis was clinically indistinguishable in our case series.
56, farmer, Trichophyton metagrophytes isolated
67, male, gardening, Epidermophyton spp isolated
54, mid wife, Epidermophyton spp isolated

6. Concomitant paronychia in 2004 2012
NDM
61%
66.6%
Candida
38%
56.6%
52, manual labourer, Fusarium oxysporum isolated.
34, man, mechanic, Aspergillus flavus isolated

7. Diagnosis Microscopy – High false negative results
Culture -'gold standard' of mycological diagnostics. approximately 30% false negative results
Histology- PAS stain
Periodic acid-Schiff (PAS) stained nail clippings - second line diagnostic tool.
Information concerning the vitality of the fungi and accurate identification of the specific pathogen is not available through this investigation alone.

8. Sample collection
Correct sample collection is important to get high microscopy positive results
The positivity rate for the shaving method was 96.8%, while the rate for the conventional method (nail clipping) was 48.4%.
Reference-
HKTA Gunasekera, A Nagahawatta, N de Silva. An alternative technique for collecting nail specimens for mycological investigations. Sri Lankan Journal of Infectious Diseases 2011 Vol.1 (1); DOI:

9. Treatments Itraconazole pulse therapy Terbinafine pulse therapy
Itraconazole 200mg b.i.d for 7 days per month
Terbinafine pulse therapy
Terbinafine 250mg b.i.d for 7 days per month
2 pulses for finger nails and 3 pulses for toe nails
Topical antifungal (3% thymol or clotrimazole lotion) continued twice a day application for total of 12 months

10. Primary end point
At the end of 2 or 3 pulses
Secondary end point
At the end of 12 months follow-up period

11. Table. Isolated fungi in 128 patients with onychomycosis (2004)
Species
Total fungal isolates
Both microscopy and culture positive
Microscopy negative, culture positive
Dermatophytes
Trichophyton rubrum
T. mentagophytes 17 11 6
17 (20)
11 (12.9)
6 (7) -
Yeasts
Candida albicans
Other Candida sp
Other yeasts 31 4 20 7
29(34.1)
2 (2.35)
20(23.5)
7 (8.2) 2
Non- Dermatophyte Molds (NDM)
Aspergillus niger
A.flavus
A.terreus
Penicillium sp
Fusarium sp
Cladosporium sp
Rhizopus sp
Acremonium sp
Paecilomycis sp
Cylindrocarpon sp 68 47 12 8 1
39(45.8)
19(22)
5(6)
2(2.35)
3(3.5) 3 29 18
No growth
Mixed infections
8 (6%)
Total
128
85(66.4)
31(24.2%)
Species
Total fungal isolates
Both microscopy and culture positive
Microscopy negative, culture positive
Dermatophytes Trichophyton spp Mentagrophytes spp Epidermophyton spp 15 8 5 2
12 (17.6) 6 4 1 -
Candida species
Candida albicans
Non-albicans 32 13 19
21 (30.9) 11
Non-dermatophyte molds Aspergillus niger
flavus
Aspergillus spp
Penicillium spp
Fusarium spp
Scopulariopsis brevicaulis
Cladosporium spp
Paecilomyces spp
101 44 9 3
35 (51.5)
10 (14.7)
3 (4.4)
8 (11.7)
1 (1.5)
2 (2.9) 66 34 22
Bacterial growth
No growth
Missing reports 7 18
Total
178
68 (45.9)
80 (54.0)

12. Results Fusarium onychomycosis
Itraconazole
Terbinafine
Total number of patients treated (n=9) 6 3
Total number of nails treated (n=45) 25 20
Cured at the end of Rx (number of nails)
none
Clinical cure at 12 months
52%
50%
Mycological cure
66.6%
Recurrence in 3 months
30.7% (4/13)
Recurrence in 12 months
61.5% (8/13)
Ranawaka RR, de Silava N, Ragunathan RW. Onychomycosis caused by Fusarium sp p in Sri Lanka: prevalence, clinical features and response to itraconazole pulse therapy in six cases. J Dermatolog Treat.2008;19(5):308-12
Ranawaka RR, Nagahawatte A, Gunasekara TA. Fusarium Onychomycosis: prevalence, clinical presentations, response to itraconazole and terbinafine pulse therapy and one-year follow-up in 9 cases. Accepted for publication in International Journal of Dermatology

13. Treated with two pulses of terbinafine.
Complete cure after 12 months
Recurrence of nail destruction after 19 months
Before treatments
68, woman, only left thumb nail, for 4 yrs, Fusarium dimerum isolated.
Terbinafine additional pulse given.
Continued topical 3% thymol
Normal nail growing underneath- 21 months

14. Before treatments
43-year-old pre-school teacher with nail dystrophy on 4th & 5th finger nails on L/hand and 1st, 4th & 5th nails on R/hand.
Fusarium oxysporum was isolated.
After 12 months
After 12 months of follow-up, 3 nails on R/ hand cured.
Additional pulse of terbinafine given.

15. Results- cont.. NDM onychomycosis
Itraconazole
Terbinafine
Total number of patients completed the study (n=57) 30 27
Total number of nails treated (n=249)
152 97
Cured at the end of Rx (number of nails) (n=16 nails)
14 (9.2%)
2 (2.0%)
Clinical cure at 12 months (n=148 nails)
95 (62.5%)
53 (54.6%)
Recurrence within 12 months (n=14)
10 (6.57%)
4 (4.1%)
Side effects
Exacerbated gastritis n=2
Stopped Rx
Nausea on two, but continued Rx
Ranthilaka RR, de Silva N, Ragunathan RW. Non-dermatophyte mold onychomycosis in Sri Lanka. Dermatology Online Journal 2010; 18 (1): 7
Ranawaka RR, Nagahawatte A, Gunasekara TA, Weerakoon HS. Randomized, double blind, comparative study on efficacy and safety of itraconazole pulse therapy and terbinafine pulse therapy on Non-Dermatophyte Mold onychomycosis (on publication process)

16. Treatment response in different NDM species
Aspergillus spp (n=46)
Fusarium spp (n=8)
Penicillium spp (n=2)
Scopulariopsis spp
Treatments I T
Total number of patients completed the study 21 25 6 2 - 1
Total number of nails completed Rx
107 89 24 8 13
Clinical cure rate (number of nails)
73/107 (68.22%)
49/89
(55.05%)
12/24
(50%)
4/8
11/13
(84.6%)
No cure
Recurrence within 12 months
6/107
(5.6%)
5/89
2/24
(8.3%)
1/8
(12.5%)
I- Itraconazole pulse therapy, T- Terbinafine pulse therapy

17. Cured at 12 months
54, house wife, gardening, Aspergillus flavus isolated. Treated with 3 pulses of Terbinafine. .
Toe nails were not cured

18. 32, House wife, 3 years, Aspergillus niger isolated.
Treated with itraconazole.
70% clinical improvement at12 months
One finger nail was also affected which did not improve with treatments

19. 62-year old retired clerk, who engaged in gardening on bare hand, had this nail destruction for >6 years.
Aspergillus niger was isolated.
She was treated with three pulses of Itraconazole.
After 12 months of follow-up her finger nails were completely cured.
She also had Candida infection in finger webs.

20. 73, house wife, R/middle finger dystrophy for one year, A
73, house wife, R/middle finger dystrophy for one year, A. niger isolated.
Rx- Itraconazole 3 pulses
R/ middle finger cured after 12 months
She also had B/L big toe nails involved, which were not cured.

21. Summary
NDM and Candida are the prevalent fungi in onychomycosis in our setting
These fungi earlier thought to be related to immune suppression or diabetes is disputed
Nail shavings gives higher microscopic positivity than nail clippings
NDM showed almost equal efficacy to both Itraconazole and Terbinafine pulses (I>T)
Both treatments showed only 50-60% cure rate
Recurrence was common with itraconazole

22. Summary – cont….
Additional pulse recommended depending on the response
Aspergillus spp and Penicillium spp showed better response to Itraconazole
Therefore species identification prior to therapy may help to select the effective drug
Both Itraconazole (SLR per week) and Terbinafine (SLR 1300 per week) are expensive therefore before starting treatments you may educate patients on efficacy of current antifungal available
Future research should focus on finding more effective antifungal for the treatment of non dermatophyte onychomycosis.

23. J Am Acad Dermatol. 2000 Feb;42:217-24 Fusarium spp 26 combination 40%
Authors
Journal
Species
patients Rx
Clinical cure
Gianni C1
Dermatology. 2004;209(2):104-10
Aspergillus spp 34
Terbinafine
88%
Tosti A
J Am Acad Dermatol Feb;42:217-24
Fusarium spp 26
combination
40% 7
100%
S brevicaulis 17
69.2%
Br J Dermatol Nov;135(5):
Scopulariopsis 6
3-itraconazole
3- terbinafine
One patient
Gupta AK
Dermatology. 2001;202(3):235-8 59
itraconazole
terbinafine
12/12
J Cutan Med Surg May-Jun;5(3):206-10 5
2/4
0/1 2
1/1
3/6
Cohen AD
J Dermatolog Treat Dec;14(4):237-42
toenail onychomycosis (dermatophytes)
117
43-itraconazole
74-Terbinafine
No difference in MC or CC
Combination- combining different treatments (systemic itraconazole, systemic terbinafine, topical terbinafine after nail plate avulsion, and ciclopirox nail lacquer)

24. Authors
Journal
Species
Shemer A
Dermatol Ther Nov-Dec;25(6):582-93
Dermatophytes
Terbinafine is superior to itraconazole for dermatophyte onychomycosis
Gupta AK
Am Acad Dermatol Oct;43(4 Suppl):S70-80
Ciclopirox nail lacquer for the treatment of finger and toe onychomycosis
Dermatology. 2001;202(3):235-8
NDM
Griseofulvin is ineffective against toe onychomycosis caused by S. brevicaulis
Ketoconazole is not recommended for toe onychomycosis given its potential for adverse effects
Yin Z
J Dermatolog Treat Dec;23(6):449-52
toenail onychomycosis
Itraconazole therapy is more likely to produce mycological recurrence compared with terbinafine therapy.
J Cutan Med Surg May-Jun;17(3):201-6
Dermatophytes- followed-up for 1.25 to 7 years
Itraconazole therapy was associated with higher RRs than terbinafine therapy
Additional pulses administered depending upon the response

25. Thank you Dr Ajith Nagahawatte (co-investigator)
Dr Nelum de Silva (co-investigator)
Mr. Aravinda Gunasekara (co-investigator)
Department of Microbiology, Faculty of Medicine, Karapitiya, Galle.