Evaluation of improvement of onychomycosis in HIV‐infected patients after initiation of combined antiretroviral therapy without antifungal treatment

Abstract

Onychomycosis in HIV-infected patients has a prevalence of 20-44% and is more frequently seen with CD4(+) T cell counts ≤450 cel μl(-1). There are case reports of improvement in onychomycosis after initiation of combined antiretroviral therapy (cART), but there are no prospective studies that prove the existence and frequency of this phenomenon. The aim of this study was to evaluate if HIV-infected patients with onychomycosis who begin cART improve and/or cure without antifungal treatment. We included HIV-infected patients with onychomycosis who had not started cART and nor received antifungal therapy during 6 months prior to the study. We evaluated affected the nails with the Onychomycosis Severity Index (OSI); nail scrapings were collected and direct microscopy with potassium hydroxide (KOH) as well as mycological culture were performed. We repeated these procedures at 3 and 6 months to assess changes. CD4 T cell counts and HIV viral load were obtained. A total of 16 patients were included, with male gender predominance (68.7%); distal and lateral subungual onychomycosis (DLSO) was the most common form (31.3%). Trichophyton rubrum was the most frequently isolated microorganism. OSI decreased 21.5% at 3 months and 40% at 6 months after initiation of antiretrovirals (P = 0.05). We found a non-significant tendency towards improvement with higher CD4(+) T cell counts and with viral loads <100 000 copies ml(-1). This could be due to the increase in CD4(+) T cells, decreased percentage of Treg (CD4(+)CD25(+)) among CD4(+) Tcells and/or a decreased viral load; further studies are necessary to prove these hypothesis.

Subclinical Onychomycosis: Not Present in HIV-Positive Population?

“…Nonetheless, in published studies it remains up to four times more frequent in these individuals than in the general population [1], with a prevalence of 34.8% and most frequently found in toenails, with only 5% in fingernails and always associated with toenail involvement [10]. In addition, males are predominantly affected (68.7%), with a male:female ratio of 2.2: 1 [2]. These reports may need to be updated, as the treatment options are much better now, and the diagnosis and infection detection are being done earlier.…”

“…The incidence of onychomycosis has changed since the use of prophylactic antifungal therapy with fluconazole or itraconazole and the introduction of cART [1, 2], which may improve onychomycosis even without antifungal therapy just by restoration of the immune function [2]. Nonetheless, in published studies it remains up to four times more frequent in these individuals than in the general population [1], with a prevalence of 34.8% and most frequently found in toenails, with only 5% in fingernails and always associated with toenail involvement [10].…”

“…A study reports predisposing factors for onychomycosis in HIV-infected patients. These include: CD4 cell count < 370, tinea pedis, and walking barefoot around pools and other recreational areas such as gymnasiums, which are mostly the same for the non-HIV population [2]. …”

“…It is a chronic fungal nail infection which tends to gradually destruct the nail plate and is considered a source of dissemination for skin dermatophytosis [2]. …”

Accelerated nail growth rate in HIV patients

“…They are also useful for precision movements, by increasing sensitivity of fingertips through counterpressure, can act as a tool because of their hardness and, of course, they also have cosmetic (and thus, social) functions. 4,8,9 Material and methods We also included control patients matched by age and gender. According to evidence, some factors can influence the nail growth: all references show that younger age is associated with faster growth as well as onychophagia, pregnancy and being in warm weather, gender (male), geographic location, physical activity, and handedness.…”