简介:长期以来,人们一直认为创伤是甲癣最重要和最常见的诱发因素之一。然而,直接创伤在真菌指甲感染发病机制中的作用直到最近才在一系列32例创伤后单指甲真菌病中得到阐明。很少研究由于脚和脚趾异常引起的反复创伤的重要性。研究目的:这是一项在三个国家的专业指甲诊所进行的为期6年的多中心单作者观察研究。在此期间,作者拍摄的所有患者照片均经过脚趾甲改变筛查,检查所有的脚趾甲癣病例是否包含足够的信息来评估潜在的足部和脚趾异常。特别注意了外翻的存在,外翻指间,hallux直立人,大脚趾向内旋转,小脚趾向外旋转,以及张开的脚。只有通过两种组织病理学明确证明真菌指甲感染的病例,真菌学文化,或聚合酶链反应(PCR)被接受。结果:1653例,185个是甲癣,通过真菌学文化证明,PCR,或组织病理学。其中,179涉及至少一个大脚趾甲,和6影响一个或多个较小的脚趾甲。三个病人向我们咨询了另一种脚趾甲疾病,甲癣被诊断为第二种疾病。八名患者有明显的癣。相对较少的患者具有正常的大脚趾位置(n=9)。大多数病例有轻度至明显的外翻(HV)(105)和拇指外翻(HVI)(143),在43例患者中观察到了直立肌,观察到HV和HVI的组合83次。讨论:脚和脚趾变形的百分比非常高,令人惊讶。可以假设这不仅是一个重要的致病因素,而且可能在真菌感染的定位中起重要作用。因为在仅影响小脚趾的甲癣中没有发现明显的拇指偏差。由于甲癣的管理是一个复杂的过程,涉及确定病原真菌的确切诊断,指甲的生长速度,甲癣的类型,它的持续时间,和诱发因素,脚趾位置的异常可能很重要。最常见的诱发因素是外周循环功能不全,静脉淤滞,周围神经病变,免疫缺陷,和医源性免疫抑制,而足部问题没有得到足够的重视。不幸的是,许多诱发因素和加重因素难以治疗或纠正。一般来说,在向患者解释甲癣的治疗方法时,这些矫形改变的重要性没有得到充分讨论,或者只是没有得到充分讨论。鉴于治疗趾甲霉菌病所遇到的问题,应该改变这种态度,以使患者理解为什么尽管在实验室中具有出色的最低抑制药物浓度,但治愈率却如此低。
Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.