Significance of non-dermatophyte moulds and yeasts in onychomycosis

In a multicentre, randomised, double-blind, 48-week clinical trial, 118 patients with toe-nail onychomycosis were given terbinafine (250 mg daily) or placebo for 12 weeks, followed by 12 weeks of observation. Non-responders were offered 12 further weeks of terbinafine (250 mg daily) from week 28. Each patient had 8-12 consecutive nail specimens collected from the same nail, allowing for an assessment of the fungal nail flora from 1,321 nail specimens. By week 48, the overall mycological cure rate for terbinafine patients was 94%. 64% of patients had an underlying dermatophyte infection with at least 1 non-dermatophyte mould or yeast isolated from at least 1 specimen. These contaminants often overgrow or mask the presence of a dermatophyte. In only 2.5% of all patients was the same non-dermatophyte isolated from 2 or more consecutive specimens, probably representing secondary colonisation which exploits nutrients released by the underlying dermatophyte. The presence of incidental non-dermatophyte contaminants or secondary colonisers did not affect treatment outcome, and in this study treatment of the primary dermatophyte pathogen with terbinafine cleared the nails from infection in all cases. 80% of patients remained mycologically negative after 2 years.