The Relationship Between Onychomycosis infections and Diabetes: Risks and Management: Review
Hubungan Antara Infeksi Onikomikosis dan Diabetes: Risiko dan Manajemen: Ulasan
DOI:
https://doi.org/10.21070/ijhsm.v2i1.147Keywords:
Onychomycosis, Diabetes, Antifungal Treatment, Diagnosis, ComplicationsAbstract
Diabetes mellitus is a very frequent chronic condition globally, presenting a substantial health issue due to its severe effects on several body processes and its correlation with different consequences. Among these problems, onychomycosis, or fungal nail infections, is a prevalent yet sometimes disregarded illness that can substantially impact patients' quality of life and general health. Onychomycosis is a fungal infection that affects the nail structure, resulting in discoloration, thickness, and occasionally total loss of the nail. The likelihood of getting onychomycosis is significantly increased in diabetic individuals due to weakened immune response, poor circulation, and consistently high blood glucose levels, which provide an optimal environment for fungal proliferation. This review seeks to examine the complex link between diabetes mellitus and onychomycosis, emphasizing the underlying processes, risk factors, and clinical consequences of this interaction. Moreover, it underscores the significance of prompt identification and efficient therapy options to alleviate the effects of this illness and enhance patient outcomes.
Highlights:
- Diabetics risk infection — 3× higher onychomycosis, ulcers, amputations risk.
- PAS stain best — 92% sensitivity, superior to culture and KOH.
- Combo therapy works — Oral terbinafine + topical boosts cure rates.
Keywords: Onychomycosis, Diabetes, Antifungal Treatment, Diagnosis, Complications
References
[1]. B. E. Elewski, A. Tosti, “Risk Factors and Comorbidities for Onychomycosis: Implications for Treatment with Topical Therapy,” PubMed, Nov. 01, 2015. https://pubmed.ncbi.nlm.nih.gov/26705439/
[2]. D. Navarro‐Pérez, A. Tardáguila‐García, S. García‐Oreja, M. López‐Moral, M. García‐Madrid, and J. L. Lázaro‐Martínez, “Onychomycosis associated with diabetic foot syndrome: A systematic review,” Mycoses, vol. 66, no. 6, pp. 459–466, Feb. 2023, doi: 10.1111/myc.13577.
[3]. S. Cathcart, W. Cantrell, and B. Elewski, “Onychomycosis and diabetes,” Journal of the European Academy of Dermatology and Venereology, vol. 23, no. 10, pp. 1119–1122, Mar. 2009, doi: 10.1111/j.1468-3083.2009.03225.x
[4]. A. J. M. Boulton and R. W. Whitehouse, “The diabetic foot,” Endotext - NCBI Bookshelf, Jul. 28, 2023. https://www.ncbi.nlm.nih.gov/books/NBK409609/
[5]. L. Trovato, M. Calvo, R. De Pasquale, G. Scalia, and S. Oliveri, “Prevalence of onychomycosis in diabetic patients: A Case-Control Study performed at University Hospital Policlinico in Catania,” Journal of Fungi, vol. 8, no. 9, p. 922, Aug. 2022, doi: 10.3390/jof8090922.
[6]. R. L, Frykberg, “Diabetic foot ulcers: pathogenesis and management,” PubMed, Nov. 01, 2002. https://pubmed.ncbi.nlm.nih.gov/12449264/
[7]. C. Hazen, R. Ayres, “Prevalence and Risk Factors of Onychomycosis in Diabetic Patients. Mycoses, vol. 55, no. 1, pp. 25-30, 2012.
[8]. A. Boulton et al., “Diagnosis and management of diabetic foot complications,” ADA Clinical Compendia, vol. 2018, no. 2, pp. 1–20, Oct. 2018, doi: 10.2337/db20182-1.
[9]. G. Akkuş, M. Evran, D. Güngör, M. Karakaş, T. Tetiker, and M. Sert, “Assessment of tinea pedis and onychomycosis frequency in diabetes mellitus patients with diabetes complications and foot ulcers. A Cross sectional – observational study,” Pakistan Journal of Medical Sciences, vol. 32, no. 4, Dec. 1969, doi: 10.12669/pjms.324.10027.
[10]. M. Lao, C. Li, J. Li, D. Chen, M. Ding, and Y. Gong, “Opportunistic invasive fungal disease in patients with type 2 diabetes mellitus from Southern China: Clinical features and associated factors,” Journal of Diabetes Investigation, vol. 11, no. 3, pp. 731–744, Nov. 2019, doi: 10.1111/jdi.13183.
[11]. S. R. Lipner, “Nail Disorders: Diagnosis and Management,” Dermatologic Clinics, vol. 39, no. 2, p. xi, Mar. 2021, doi: 10.1016/j.det.2021.01.002.
[12]. J. Queller and N. Bhatia, “The Dermatologist’s approach to onychomycosis,” Journal of Fungi, vol. 1, no. 2, pp. 173–184, Aug. 2015, doi: 10.3390/jof1020173.
[13]. R. K. Scher et al., “Onychomycosis: Diagnosis and definition of cure,” Journal of the American Academy of Dermatology, vol. 56, no. 6, pp. 939–944, Feb. 2007, doi: 10.1016/j.jaad.2006.12.019.
[14]. B. Ankad, Y. Bhat, and S. Gaikwad, “Nail disorders in skin of color: Approach to onychoscopic diagnosis,” Clinical Dermatology Review, vol. 4, no. 2, p. 92, Jan. 2020, doi: 10.4103/cdr.cdr_70_20.
[15]. P. Mayser, V. Freund, and D. Budihardja, “Toenail onychomycosis in diabetic patients,” American Journal of Clinical Dermatology, vol. 10, no. 4, pp. 211–220, Jun. 2009, doi: 10.2165/00128071-200910040-00001.
[16]. “The prevalence and management of onychomycosis in diabetic patients,” PubMed, Aug. 01, 2000. https://pubmed.ncbi.nlm.nih.gov/10882947/
[17]. J. M. Falotico and S. R. Lipner, “Updated perspectives on the diagnosis and management of onychomycosis,” Clinical Cosmetic and Investigational Dermatology, vol. Volume 15, pp. 1933–1957, Sep. 2022, doi: 10.2147/ccid.s362635.
[18]. M. ¨ Lepantalo antalo et al., “Chapter V: Diabetic foot,” in European Journal of Vascular and Endovascular Surgery, 2011, pp. S60–S74. [Online]. Available: https://www.angiolsurgery.org/society/organisations/esvs/guidelines/CLI-DF-Chapter_V.pdf
[19]. P. Robres, C. Aspiroz, A. Rezusta, and Y. Gilaberte, “Usefulness of photodynamic therapy in the management of onychomycosis,” Actas Dermo-Sifiliográficas, vol. 106, no. 10, pp. 795–805, Nov. 2015, doi: 10.1016/j.adengl.2015.10.019.
[20]. A. Mickle, G. Lozano-Ortega, V. Gaudet, E. Popoff, M. Barbeau, and S. Mathieu, “Toenail Onychomycosis with or without Diabetes in Canada: Patient Treatment Preferences and Health State Utilities,” Patient Preference and Adherence, vol. Volume 18, pp. 475–486, Feb. 2024, doi: 10.2147/ppa.s450215.
[21]. Y. Gilaberte, M. P. Robres, M. P. Frías, I. García‐Doval, A. Rezusta, and C. Aspiroz, “Methyl aminolevulinate photodynamic therapy for onychomycosis: a multicentre, randomized, controlled clinical trial,” Journal of the European Academy of Dermatology and Venereology, vol. 31, no. 2, pp. 347–354, Aug. 2016, doi: 10.1111/jdv.13842.
[22]. B. E. Elewski and A. Tosti, “Risk Factors and Comorbidities for Onychomycosis: Implications for Treatment with Topical Therapy,” Nov. 01, 2015. https://pmc.ncbi.nlm.nih.gov/articles/PMC4689496/
[23]. L. Trovato, M. Calvo, R. De Pasquale, G. Scalia, and S. Oliveri, “Prevalence of onychomycosis in diabetic patients: A Case-Control Study performed at University Hospital Policlinico in Catania,” Journal of Fungi, vol. 8, no. 9, p. 922, Aug. 2022, doi: 10.3390/jof8090922.
[24]. S. G. Khader and H. F. Okab, “Assessment of glucose metabolism in thalassemia patients with type two diabetes in Thi-Qar/ Southern of Iraq,” International Journal of Health Sciences, pp. 2929–2935, Aug. 2022, doi: 10.53730/ijhs.v6ns8.12279.
[25]. P. Mayser, V. Freund, and D. Budihardja, “Toenail onychomycosis in diabetic patients,” American Journal of Clinical Dermatology, vol. 10, no. 4, pp. 211–220, Jun. 2009, doi: 10.2165/00128071-200910040-00001.
[26]. S. K. Helal, W. A. Ali, H. I. Ghazzay, “The study of fungal infections and diabetic foot ulcer in Iraqi patients,” sifisheriessciences.com, Apr. 2023, doi: 10.17762/sfs.v10i3S.1217.
[27]. Us Dermatology Partners, “Skin fungal infection treatment | U.S. Dermatology Partners,” U.S. Dermatology Partners, Mar. 30, 2021. https://www.usdermatologypartners.com/services/general-dermatology/skin-fungal-infection-treatment/
[28]. S. M. S. Lim, M. Sinnollareddy, and F. B. Sime, “Challenges in antifungal therapy in diabetes mellitus,” Journal of Clinical Medicine, vol. 9, no. 9, p. 2878, Sep. 2020, doi: 10.3390/jcm9092878.
[29]. I. Joao, H. Bujdáková, and L. Jordao, “Opportunist coinfections by nontuberculous mycobacteria and fungi in immunocompromised patients,” Antibiotics, vol. 9, no. 11, p. 771, Nov. 2020, doi: 10.3390/antibiotics9110771.
[30]. M. Lao, C. Li, J. Li, D. Chen, M. Ding, and Y. Gong, “Opportunistic invasive fungal disease in patients with type 2 diabetes mellitus from Southern China: Clinical features and associated factors,” Journal of Diabetes Investigation, vol. 11, no. 3, pp. 731–744, Nov. 2019, doi: 10.1111/jdi.13183.
[31]. L. Prompers et al., “High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study,” Diabetologia, vol. 50, no. 1, pp. 18–25, Nov. 2006, doi: 10.1007/s00125-006-0491-1.
[32]. S.S Jain, A. K. Gupta, “The prevalence and management of onychomycosis in diabetic patients,” PubMed, Aug. 01, 2000. https://pubmed.ncbi.nlm.nih.gov/10882947/
[33]. L. Farndon et al., “Clinical audit of core podiatry treatment in the NHS,” Journal of Foot and Ankle Research, vol. 2, no. 1, Jan. 2009, doi: 10.1186/1757-1146-2-7.
[34]. A. Bonifaz, P. Cruz-Aguilar, and R. M. Ponce, “Onychomycosis by molds. Report of 78 cases.,” PubMed, vol. 17, no. 1, pp. 70–2, Feb. 2007, doi: 10.1684/ejd.2007.0092.
[35]. I. A. Ameen and H. F. Okab, “Evaluation of immune and inflammatory response in diabetic foot patients and patients presenting diabetes only in Thi-Qar Province / Iraq,” Лабораторная Диагностика Восточная Европа, vol. 13, no. 2, May 2024, doi: 10.34883/pi.2024.13.2.016.
[36]. H. F. Okab, et al, “Estimation of Immunological and Physiological Parameters in Diabetic Patients with COVID-19” Bionatura, vol. 8, no. 2, 2023.
[37]. A. K. Gupta, S. G. Versteeg, and N. H. Shear, “Confirmatory testing prior to initiating onychomycosis therapy is Cost-Effective,” Journal of Cutaneous Medicine and Surgery, vol. 22, no. 2, pp. 129–141, Sep. 2017, doi: 10.1177/1203475417733461.
[38]. P. Mayser, V. Freund, and D. Budihardja, “Toenail onychomycosis in diabetic patients,” American Journal of Clinical Dermatology, vol. 10, no. 4, pp. 211–220, Jun. 2009, doi: 10.2165/00128071-200910040-00001.
[39]. B. A. Habtemariam et al., “Single‐Dose pharmacokinetics and pharmacodynamics of transthyretin targeting N‐acetylgalactosamine–Small interfering ribonucleic acid conjugate, Vutrisiran, in healthy subjects,” Clinical Pharmacology & Therapeutics, vol. 109, no. 2, pp. 372–382, Jun. 2020, doi: 10.1002/cpt.1974.
[40]. M. Lao, C. Li, J. Li, D. Chen, M. Ding, and Y. Gong, “Opportunistic invasive fungal disease in patients with type 2 diabetes mellitus from Southern China: Clinical features and associated factors,” Journal of Diabetes Investigation, vol. 11, no. 3, pp. 731–744, Nov. 2019, doi: 10.1111/jdi.13183.
[41]. G. R. Thompson, J. Cadena, and T. F. Patterson, “Overview of antifungal agents,” Clinics in Chest Medicine, vol. 30, no. 2, pp. 203–215, Apr. 2009, doi: 10.1016/j.ccm.2009.02.001.
[42]. M. Jarratt, et al., “Efficacy and safety of a new triple-combination agent for the treatment of facial melasma,” PubMed, Jul. 01, 2003. https://pubmed.ncbi.nlm.nih.gov/12889718/
[43]. E. Haneke, “Achilles foot screening project: preliminary results of patients screened by dermatologists,” PubMed, Sep. 01, 1999. https://pubmed.ncbi.nlm.nih.gov/10509935/
[44]. F. Sparber and S. LeibundGut-Landmann, “Interleukin-17 in antifungal immunity,” Pathogens, vol. 8, no. 2, p. 54, Apr. 2019, doi: 10.3390/pathogens8020054.
[45]. A. Bonifaz, P. Cruz-Aguilar, and R. M. Ponce, “Onychomycosis by molds. Report of 78 cases.,” PubMed, vol. 17, no. 1, pp. 70–2, Feb. 2007, doi: 10.1684/ejd.2007.0092.
[46]. A. K. Gupta, S. G. Versteeg, and N. H. Shear, “Onychomycosis in the 21st Century: An update on diagnosis, Epidemiology, and treatment,” Journal of Cutaneous Medicine and Surgery, vol. 21, no. 6, pp. 525–539, Jun. 2017, doi: 10.1177/1203475417716362.
[47]. P. Mayser, V. Freund, and D. Budihardja, “Toenail onychomycosis in diabetic patients,” American Journal of Clinical Dermatology, vol. 10, no. 4, pp. 211–220, Jun. 2009, doi: 10.2165/00128071-200910040-00001.
[48]. K. Harada, S. Yamamoto, and K. Kato, “Pembrolizumab for the treatment of advanced esophageal cancer,” Future Oncology, vol. 18, no. 18, pp. 2311–2319, Apr. 2022, doi: 10.2217/fon-2022-0108.
[49]. Y. Wei et al., “Complete response of advanced esophageal squamous cell carcinoma with first-line chemotherapy combined with immunotherapy: a Case report,” Frontiers in Immunology, vol. 16, Mar. 2025, doi: 10.3389/fimmu.2025.1511663.
[50]. S. R. Lipner, “Nail Disorders: Diagnosis and Management,” Dermatologic Clinics, vol. 39, no. 2, p. xi, Mar. 2021, doi: 10.1016/j.det.2021.01.002.
[51]. M. Cuenca-Estrella, “Antifungal drug resistance mechanisms in pathogenic fungi: from bench to bedside,” Clinical Microbiology and Infection, vol. 20, pp. 54–59, Dec. 2013, doi: 10.1111/1469-0691.12495.
[52]. C. Schneider, N. M. Williams, B. W. Morrison, and A. Tosti, “Nail disorders in skin of color: A retrospective chart review over a 5-year period,” Journal of the American Academy of Dermatology, vol. 89, no. 6, pp. 1315–1317, Sep. 2023, doi: 10.1016/j.jaad.2023.08.065.
[53]. S. Evrard et al., “New Diagnostic Strategy for Onychomycosis: First-Line Utilization of DermaGenius® PCR and Calcofluor Microscopy Combined with Selective Culturing,” Journal of Fungi, vol. 10, no. 8, p. 515, Jul. 2024, doi: 10.3390/jof10080515.
[54]. M. Eckhard, A. Lengler, J. Liersch, R. G. Bretzel, and P. Mayser, “Fungal foot infections in patients with diabetes mellitus – results of two independent investigations,” Mycoses, vol. 50, no. s2, pp. 14–19, Aug. 2007, doi: 10.1111/j.1439-0507.2007.01425.x.
[55]. S. M. S. Lim, M. Sinnollareddy, and F. B. Sime, “Challenges in antifungal therapy in diabetes mellitus,” Journal of Clinical Medicine, vol. 9, no. 9, p. 2878, Sep. 2020, doi: 10.3390/jcm9092878.
[56]. C. Carney, “A new classification system for grading the severity of onychomycosis,” Archives of Dermatology, vol. 147, no. 11, p. 1277, Nov. 2011, doi: 10.1001/archdermatol.2011.267.
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