Atopic dermatitis (AD) is recognized in clinical practice as a condition that increases a patient's susceptibility to molluscum contagiosum (MC) and predisposes them to more widespread infection; however, data remain limited. To clarify the relationship between MC and AD in children, a retrospective study was conducted analyzing medical records of pediatric patients diagnosed with MC, AD, or both between September 2013 and August 2022. Collected data included demographics, clinical manifestations, and disease duration. The findings highlight a strong correlation between MC and AD in children, underscoring the need for health care professionals to acknowledge this relationship and implement proactive strategies to optimize patient care.

Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112.    doi:10.36849/JDD.7676.

Individuals with psoriatic nails often have a lower quality of life relative to their counterparts with healthy nails. Methotrexate (MTX), an anti-neoplastic agent, is a longstanding treatment option for nail psoriasis. In the current study, we compared the effects of MTX to that of a corticosteroid, namely, methylprednisolone acetate (i.e., Depo-Medrol®) across individuals with nail psoriasis. We used a cohort study design, and both agents were administered intralesionally. Outcome variables were based on the Nail Psoriasis Severity Index (NAPSI). We quantified the effect in terms of change in NAPSI, complete cure at week 16, and cure between 32 and 36 weeks. Our regressions demonstrated that reduced NAPSI scores with Depo-Medrol were, on average, greater than that with MTX by 2.27 (n = 48, P = 0.000255) at week 16. Similarly, the odds of complete cure at week 16 was greater with Depo-Medrol® than with MTX (odds ratio = 18.6, P < 0.0001). In terms of both complete cure and change in NAPSI, Depo-Medrol® was significantly more effective than MTX at a follow-up period of 32-36 weeks. Our study established that intralesional Depo-Medrol® is more effective than intralesional methotrexate for treating nail psoriasis.

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and in vitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy in vitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton , the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and in vitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole—the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes—has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug–drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy in vitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real‐world long‐term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Introduction: In onychomycosis management, excellent treatment adherence is necessary, and requires adequate medication supply. Efinaconazole 10% topical solution is available in 4- or 8-mL bottles; lacking published guidance, 4 mL is most often prescribed. The objective of this analysis was to use clinical data to determine monthly efinaconazole usage by patient demographics and clinical characteristics. Methods: In two identical, double-blind, phase 3 studies, adult participants with mild-to-moderate onychomycosis affecting 20-50% of ≥1 great (target) toenail were randomized 3:1 to once-daily treatment with efinaconazole 10% solution or vehicle for 48 weeks. Bottles of study product were weighed upon dispensation at each study visit (every 4 weeks) and upon return at the following visit. Monthly at-home efinaconazole use was analyzed post hoc based on number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Results: Efinaconazole-treated participants in both studies (n=656 and 580) had on average 3.7-3.8 affected toenails. Among those with usage data (n=1067), over 55% had ≥4 affected toenails. For the 90% of participants with ≥2 affected nails, average usage ranged from 4.39-6.36 mL/month, corresponding to 1.10-1.59 4-mL bottles; only the 10% of participants with one affected toenail used <4 mL of efinaconazole monthly. Additional subgroup analyses revealed no meaningful differences in efinaconazole usage based on target toenail involvement, BMI, or sex; average medication use was 4.69-5.29 mL/month, corresponding to 1.17-1.32 4-mL bottles monthly. Conclusions: Given that the 4-mL bottle of efinaconazole is most commonly prescribed, patients with onychomycosis of ≥2 toenails will likely run out of medication in under a month. This can lead to gaps in onychomycosis treatment, which may affect medication efficacy and increase likelihood of relapse or reinfection. The number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. Funding: Ortho Dermatologics

aCenter for Animal and Human Health in Appalachia, College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, USA; bDepartment of Dermatology, University of Mississippi Medical Center, Jackson, MS, USA; cAssociate Professor of Dermatology and Preventive Medicine, University of Mississippi Medical Center, Jackson, MS, USA Received: November 16, 2021 Accepted: November 22, 2021 Published online: January 10, 2022

Kerion is an inflammatory type of tinea capitis manifesting as boggy crusted nodules. Diagnosis of kerion is often challenging due to high rates of false‐negative mycological samples.

Background: Trachyonychia is a benign nail condition, most commonly seen in children. Trachyonychia manifests as excessive longitudinal ridging, nail roughness, and nail brittleness. Treatment is sought mainly for esthetic reasons as well as functional reasons. A number of therapeutic approaches exist, mainly based on case reports or small non-comparative case series. Aims: To report treatment outcome among patients with trachyonychia. Methods: A retrospective case-series study was conducted among patients who were treated trachyonychia between years 2017 and 2020. Patients were prescribed fluocinonide 0.05% with bifonazole 1% cream, applied with or without occlusion, and methylprednisolone 1–2 mg/nail, injected into the involved nail matrix, or oral cyclosporine 3 mg/kg. Complete response (over 90% improvement) and partial response (over 50% improvement) were assessed. Results: A total of 43 patients with trachyonychia were included [mean age 10.0 years (±5.7), 69.8% males, mean disease duration 4.7 years (±3.0)]. In 90.7% of the cases, topical fluocinonide\bifonazole cream was prescribed. Under-occlusion topical application was found to be highly effective, achieving complete response in 35.3% and partial response in an additional 52.9% of the patients. Occluded application was also found to be significantly more effective than non-occluded application. Treatment efficacy was not affected by the severity of nail roughness, trachyonychia morphology, or whether trachyonychia was idiopathic or coexisted with other dermatological conditions. Conclusion: Occluded application of fluocinonide plus bifonazole cream is efficient for the treatment of trachyonychia and should be considered a first line of treatment.

Introduction: Pernio-like lesions were reported as dermatologic manifestations of COVID-19 as early as May of 2020. Since mRNA COVID-19 vaccines were introduced in December 2020, 9 reports of vaccine-associated pernio-like lesions have been presented in the medical literature. Case Presentation: A male in his 60s developed pernio-like lesions on the bilateral toes approximately 1 week after receiving the second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. His symptoms resolved in 6 weeks. Conclusion: The rising number of reports of pernio-like lesions associated with COVID-19 vaccination underlines the importance of the pathophysiological state of the vaccinated patient and how it relates to dermatological manifestations. Pernio-like lesions are thought to represent a robust host immune antiviral response related to production of interferon-1 in the setting of primary infection; incidences occurring after vaccination further support this theory. Unfortunately, media-generated reports of such reactions have the potential to inflame distrust and fear of the vaccine among the general public. Given the previous media interest in reporting pernio-like lesions with primary COVID-19 infection, it is reasonable to expect overrepresentation of pernio-like lesions with vaccination. There appears to be a general increase in patient distrust of evidence-based medicine and thus “COVID toes” represent an important intersection at which the clinician can capture the patient’s trust by providing education and counseling.

BACKGROUND Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Congenital malalignment of the great toenails (CMGTs) may result in onychocryptosis, a disappearing nail bed, paronychia, Beau lines, onychomadesis, retronychia, or erosion of the nail bed.1,2 Onychomadesis is a spontaneous arrest of the nail plate that leads to nail shedding and is a more severe manifestation of the same pathophysiologic process that produces Beau lines.3 Onychomadesis is commonly seen as a delayed onset effect of hand, foot, and mouth disease.4 Infectious diseases, trauma, autoimmune/systemic diseases, and medications may also injure the nail matrix, leading to onychomadesis.

IMPORTANCE:Congenital malalignment of the great toenail (CMGT) is an idiopathic deviation of the nail apparatus. CMGT predisposes patients to recurrent stress forces, microtrauma, and secondary complications. The purpose of this study was to review the current published photographs to determine the relationship between variants of CMGT and the disappearing nail bed (DNB).OBSERVATIONS:A search in PubMed and Google using the terms congenital malalignment of the great toenail, disappearing nail bed, and lateral nail deviation was performed. Of the 53 photographs found in a total of 35 articles, 23 were disqualified due to low picture resolution or poor angle. The remaining 30 photographs were evaluated. Pure nail malalignment with associated dystrophy and DNB was found in 22 of 30 photographs. Four of 30 cases demonstrated pure deviation of the distal phalanx, with nail dystrophy but minimal DNB. The remaining 4 cases demonstrated a combination of toe deviation and nail unit deviation with varying degrees of DNB.CONCLUSIONS AND RELEVANCE:DNB was associated with all forms of pure CMGT. Moreover, a variant of malalignment of the distal phalanx was noted in 8 photographs. This has potential implications for further studies and treatment to correct secondary complications.

Background: Onychomycosis affects around 14% of individuals in North America and Europe and is undertreated. Treatment is challenging as toenail growth can take 12-18 months, the nail plate may prevent drug penetration, and disease recurrence is common. National guidelines/consensus documents on onychomycosis diagnosis and treatment were last published more than 5 years ago and updated medical guidance is needed. Methods:This document aims to provide recommendations for the diagnosis and pharmaceutical treatment of toenail onychomycosis following a roundtable discussion with a panel of dermatologists, podiatrists, and a microbiologist specializing in nail disease. Results: There was a general consensus on several topics regarding onychomycosis diagnosis, confirmatory laboratory testing, and medications. Onychomycosis should be assessed clinically and confirmed with microscopy, histology, and/or culture. Terbinafine is the primary choice for oral treatment and efinaconazole 10% for topical treatment. Efinaconazole can also be considered for off-label use for maintenance to prevent recurrences. For optimal outcomes, patients should be counseled regarding treatment expectations as well as follow-up care and maintenance post-treatment. Conclusions: This article provides important updates to previous guidelines/consensus documents to assist dermatologists and podiatrists in the diagnosis and treatment of toenail onychomycosis.

Background Tinea capitis is a common fungal infection in Israel, most commonly caused by the dermatophyte Trichophyton tonsurans. Objectives To investigate the effectiveness of oral antifungal monotherapy in producing clinical or complete cure. We also evaluated the impact of topical therapy (bifonazole 1% shampoo and/or betamethasone valerate 0.1% solution), prior to oral treatment, on patients' likelihood of clinical or complete cure. Methods A retrospective chart review was conducted. Patients with mycologically confirmed tinea capitis were treated with one of four regimens: (1) terbinafine (greater than 40 kg: 250 mg/day, 20 to 40 kg: 125 mg/day, less than 20 kg: 62.5 mg/day), (2) itraconazole 5 mg/kg daily, (3) fluconazole 6 mg/kg daily, or (4) griseofulvin 20 mg/kg daily. We used generalized linear models (GLM) to determine whether there was a significant association between the odds of cure and choice of treatment. Results The causative species was Trichophyton tonsurans in all but 6 cases that grew T violaceum. For pediatric patients, the odds of having complete or clinical cure within 6 weeks was greater if they used terbinafine compared to itraconazole, fluconazole, or griseofulvin (odds ratio [OR] = 9.06, P = .047). The likelihood of complete or clinical cure within 8 weeks of oral therapy was lower if topical steroids were previously used compared to if topical antifungals were used prior to systemic treatment (OR = 0.29, P = .046). Conclusions Our findings substantiate prior literature demonstrating that terbinafine is non-inferior to griseofulvin, itraconazole, and fluconazole in the therapy of pediatric tinea capitis caused by T tonsurans.