Toenail alterations in chronic venous disease patients are not always of mycotic origin

Abstract

Objective The prevalence of toenail alterations in chronic venous disease has only rarely been studied. We aimed to establish the frequency and clinical characteristics of toenail onychomycosis in chronic venous disease. Methods We included 80 adult patients, in all stages of chronic venous disease. Onychomycosis was confirmed by mycological examination. The clinical type of onychomycosis and the onychomycosis severity index were determined. Clinical characteristics of non-fungal nail changes were also analyzed. Results We included 58 women and 22 men, with a mean age of 67.0 years. Pathological toenail changes were observed in 83.8% of patients. Onychomycosis was confirmed in 33.8% of all patients and was more frequent in higher clinical stages of chronic venous disease (p = 0.009). Trichophyton rubrum was the leading causative pathogen. Disto-lateral onychomycosis was most commonly present. Average onychomycosis severity index was 23.1. Conclusion Onychomycosis accounted for 40% of all toenail alterations. Patients with chronic venous disease often have severe and difficult to treat toenail onychomycosis.

Global prevalence of onychomycosis in general and special populations: An updated perspective

“…Sufficient data were available from clinically un‐suspected patients to determine the risks of onychomycosis in special populations relative to the general population 11,18,20,22,23,27,28,31–45 . A significantly higher risk ( p < .05) was found in the following special populations (Figure 2) (in decreasing order): knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0–16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7–8.1]), kidney transplant patients (RR: 4.7 [95% CI: 3.3–6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4–4.9]), HIV‐positive patients (RR: 3.7 [95% CI: 2.9–4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2–6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4–3.3]), hemodialysis patients (RR: 2.8 [95% CI: 1.9–4.0]) and psoriasis patients (RR: 1.6 [95% CI: 1.2–2.1]).…”

“…Patients with diabetes are at a higher risk (RR: 2.8) due to its effect on peripheral circulation that can lead to macroangiopathy, microangiopathy, neuropathy and ulceration, which increase the risk of fungal infections 44 . Abnormal nail changes such as brittleness associated with chronic venous disease can also increase infection risk (RR: 5.6) 40,42 …”

“…Sufficient data were available from clinically un-suspected patients to determine the risks of onychomycosis in special populations relative to the general population. 11,18,20,22,23,27,28,[31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] A significantly higher risk (p < .05) was found in the following special populations (Figure 2 A significantly lower risk of onychomycosis was found in the pediatric population (RR: 0.1 [95% CI: 0.1-0.2]; p < .05). This finding was congruent with the results obtained from population-based surveys conducted at primary schools, of which toenail dermatophytes were detected in 0.02%-0.8% of children.…”

“…44 Abnormal nail changes such as brittleness associated with chronic venous disease can also increase infection risk (RR: 5.6). 40,42 Although psoriasis has been recognized as a clinical risk factor for onychomycosis, 120 a previous systematic review was inconclusive in determining its correlation. 115 In psoriasis patients, dystrophic nail changes and abnormal capillaries, as well as taking of immunosuppressive agents, can increase the risk of onychomycosis 115,121 ; however, an upregulated pro-inflammatory immune response and faster nail turnover rates may offset the risk of infection.…”