Clinical Characteristics and Causative Agents of Toenail Onychomycosis among Small Traders in Nghe An Province, Vietnam

Clinical Characteristics and Causative Agents of Toenail Onychomycosis among Small Traders in Nghe An Province, Vietnam | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Characteristics and Causative Agents of Toenail Onychomycosis among Small Traders in Nghe An Province, Vietnam Tran Thị Kieu-Anh, Duong Thi Khanh-Linh, Thai Doan Thang, Vu Van Du, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6438153/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To investigate the clinical presentation and causative agents of toenail onychomycosis in Vietnam. Methods A cross-sectional study was conducted across Nghe An province from March 2021 to August 2022. Toenail samples were collected from small-traders with suspected onychomycosis and underwent direct examination and culture. The isolated strains were identified by conventional and molecular techniques, including restriction fragment length polymorphism (RFLP) analysis and sequencing of the internal transcribed spacer (ITS) region. Results A total of 104 participants, aged 25 to 77 years (98.1% female), were diagnosed with toenail onychomycosis. Most lesions appeared on the first (92.4% of affected nails) and second toenails. The most common form was distal and lateral subungual onychomycosis (84.6%), followed by superficial white onychomycosis (8.7%) and proximal subungual onychomycosis (6.7%). The rates mild, moderate or severe onychomycosis were 35.6%, 39.4%, and 25.0% respectively. Yeasts accounted for the majority of infections (70.2%), with Candida being the most prevalent genus (54.8%), followed by Trichosporon (13.5%) and Geotrichum (1.9%). Aspergillus was the most prevalent mold identified (17.3%), followed by Penicillium (6.7%), Curvularia (2.9%), and Fusarium , Talaromyces , and Trichophyton (1% each). Yeast infections exhibited a significantly higher proportion of mild to moderate cases compared to mold infections (82.2% vs. 58.1%, p = 0.013). Conclusion Yeasts and non-dermatophyte molds are the leading causes of onychomycosis among traders in Nghe An province. Broad-spectrum antifungal agents appear to be a rational choice for the treatment. toenail onychomycosis yeast non-dermatophyte mold dermatophyte Vietnam Summary Vietnam has a tropical climate with high temperatures and humidity—conditions favorable for fungal growth and fungal infections, but limited data exists on onychomycosis. Objective: To investigate the clinical presentation and causative agents of toenail onychomycosis in Vietnam. Methods: A cross-sectional study was conducted across Nghe An province from March 2021 to August 2022. Toenail samples were collected from small-traders with suspected onychomycosis and underwent direct examination and culture. The isolated strains were identified by conventional and molecular techniques, including restriction fragment length polymorphism (RFLP) analysis and sequencing of the internal transcribed spacer (ITS) region. Results: A total of 104 participants, aged 25 to 77 years (98.1% female), were diagnosed with toenail onychomycosis. Most lesions appeared on the first (92.4% of affected nails) and second toenails. The most common form was distal and lateral subungual onychomycosis (84.6%), followed by superficial white onychomycosis (8.7%) and proximal subungual onychomycosis (6.7%). The rates mild, moderate or severe onychomycosis were 35.6%, 39.4%, and 25.0% respectively. Yeasts accounted for the majority of infections (70.2%), with Candida being the most prevalent genus (54.8%), followed by Trichosporon (13.5%) and Geotrichum (1.9%). Aspergillus was the most prevalent mold identified (17.3%), followed by Penicillium (6.7%), Curvularia (2.9%), and Fusarium , Talaromyces , and Trichophyton (1% each). Yeast infections exhibited a significantly higher proportion of mild to moderate cases compared to mold infections (82.2% vs. 58.1%, p = 0.013). Conclusion: Yeasts and non-dermatophyte molds are the leading causes of onychomycosis among traders in Nghe An province. Broad-spectrum antifungal agents appear to be a rational choice for the treatment. Introduction Onychomycosis , a fungal infection of the nails, is estimated to affect approximately 10% of the global population [ 1 ], [ 2 ]. The infection may lead to pain, discomfort, and physical impairment, significantly affecting patients’ quality of life [ 3 ]. Onychomycosis often persists for years and rarely spontaneously resolves, necessitating treatment [ 4 ]. The treatment decisions depend on both the severity of disease as well as the type of involved pathogen. The distribution of causative agents including dermatophytes, non-dermatophyte molds (NDMs), and yeasts varies across different geographic and demographic settings [ 5 ]. While dermatophytes have traditionally been considered the primary cause of onychomycosis [ 5 ], recent studies have reported a shift toward increasing yeast prevalence in several regions, including Europe [ 6 ], the Middle East, South America [ 7 ], and parts of Africa and Asia [ 8 ]; [ 9 ]; [ 10 ], [ 11 ], [ 12 ]; [ 13 ]. Systemic antifungal therapy remains the gold standard, particularly for more severe cases and terbinafine has been shown to have the highest mycotic cure rates among antifungals used for systemic treatment [ 4 ]. This drug is highly effective against dermatophyte but exhibits variable activity against yeasts and non-dermatophyte molds in vitro [ 14 ], [ 15 ], [ 16 ], [ 17 ]. Therefore, accurate identification of the causative agent is critical for effective treatment, but empiric therapy remains common [ 18 ]. Updated regional data on the epidemiology of onychomycosis is needed for better guide diagnosis and treatment strategies. Vietnam, located in Southeast Asia, has a tropical climate with high temperatures and humidity—conditions favorable for fungal growth. There have been reports showing that fungal skin infections are among the most common skin condition [ 19 ], data specifically focused on onychomycosis and its etiological agents remain limited [ 20 ]. This study aims to provide deeper insights into the clinical presentation and causative agents of toenail onychomycosis among traders in Nghe An province, Vietnam. Materials and methods This cross-sectional study included traders from some markets in Nghe An province who provided informed consent to participate. Participants were included if they presented with nail abnormalities such as discoloration, deformation, hypertrophy, hyperkeratosis, or subungual debris. During recruitment, demographic data and relevant medical histories were collected through structured interviews. Additionally, a dermatologist recorded detailed information regarding the characteristics of the lesions. Sampling After thoroughly cleaned with 70% alcohol, the nails samples were collected by scraping or clipping, depending on the clinical type of onychomycosis. For suspected distal and lateral subungual onychomycosis (DLSO), the abnormal nail was clipped proximally to the nail bed and the underside of the nail plate was scraped with a curette. For proximal subungual onychomycosis (PSO), samples were taken by scraping around the area of the lunula. The white spots on the nail suspected of superficial white onychomycosis (SWO) were scraped. All samples were placed in sterile, labeled containers for laboratory processing. Direct Microscopy and Fungal Culture Nail samples were first examined microscopically after treatment with 10% potassium hydroxide (KOH). Then the obtained samples were inoculated on two slants: one containing Sabouraud dextrose agar (SDA, BioMérieux, France) supplemented with gentamicin (0.02 mg/mL), and the other containing BBL Mycosel Agar (Becton, Dickinson and Company, USA). Cultures were incubated at room temperature and observed for up to five weeks. Samples showing no fungal growth after this period were considered negative and discarded. Fungal Identification Samples showing yeast growth were subcultured on CHROMagar™ Candida medium and incubated at room temperature under aerobic conditions. Yeast species were identified based on colony color and morphology, following the manufacturer’s guidelines [ 21 ]. The strains representing isolates that were identified, along with those that could not be characterized by CHROMagar were further analyzed by PCR-RFLP. Genomic DNA of these strains were extracted using the QIAamp DNA Mini Kit (Cat. No. 51304; QIAGEN, Hilden, Germany) according to the manufacturer’s protocol. PCR amplification targeted the ITS1-5.8S-ITS2 rDNA region using the primers ITS1 (5'-TCC GTA GGT GAA CCT GCG G-3') and ITS4 (5'-TCC TCC GCT TAT TGA TAT GC-3') (Integrated DNA Technologies, USA). The resulting amplicons were digested with the restriction enzyme Msp I, and species identification was determined based on the size of the PCR and RFLP products, following the method described by Mirhendi et al. (2006) [ 22 ]. All filamentous isolates were preliminarily identified and grouped based on morphological characteristics. Identification by sequencing: Isolates representing molds with similar morphological characteristics, or yeasts with consistent morphological and PCR-RFLP identification results, and those that could not be definitively identified or showed inconsistent results using morphological or PCR-RFLP methods were further analyzed by sequencing the internal transcribed spacer (ITS) regions. Resulting sequences were compared with those in the GenBank database for species identification. Representative sequences were deposited in GenBank under accession numbers OR438032, OR438022, OR437991, OR437989, OR438017, OR438023, and OR437990. Definition A diagnosis of onychomycosis caused by dermatophytes or yeasts was made if either microscopy or culture yielded a positive result. Non-dermatophyte mold (NDM) onychomycosis was diagnosed only when all of the following criteria were met: (1) a positive result on KOH microscopy, (2) isolation of a non-dermatophyte mold in culture, and (3) absence of dermatophyte growth in culture [ 23 ]. Clinical types of onychomycosis (DLSO, PSO, and SWO) were classified according to the criteria described by Hay and Baran (2011) [ 24 ]. The severity of nail involvement was based on the Onychomycosis Severity Index (OSI) score and classification system proposed by Carney et al. (2011) [ 25 ]. Result Table 1 Demographic characteristics of the participants (n = 104) Variables Frequency (%) or mean ± standart deviation Gender Male 2 (1.9) Female 102 (98.1) Age group 25–40 5 (4.8) 41–60 72 (69.2) 61–77 27 (26.0) Average age 54.50 ± 8.91 Region Plain 17 (16.3) Mountainous 26 (25.0) Coach line 61 (58.7) Education Primary school 4 (3.8) Secondary school 58 (55.8) High school 41 (39.4) Higher education 1 (1.0) Item Seafood, food, or drinks 37 (35.6) Other 67 (64.4) There were 194 traders having abnormal toenails, and onychomycosis was confirmed in 104 participants accounting for 53.6%. The majority of individuals with onychomycosis were female (98.1%), with ages ranging from 25 to 77 years old. Approximately one-third of the patients (35.6%) engaged in shelling products such as seafood, food, or drinks, which frequently exposed them to water (Table 1 ). Table 2 Clinical characteristics of the participants (n = 104) Variables Frequency (%) Number of involved toenails 1 47 (45.2) 2 48 (46.2) 3 9 (8.7) Site affected One side Right 19 (18.3) Left 31 (29.8) Both sides 54 (51.9) Clinical types of onychomycosis DSLO 88 (84.6) SWO 9 (8.7) PSO 7 (6.7) Severity of onychomycosis Mild 37 (35.6) Moderate 41 (39.4) Severe 26 (25.0) Results in Table 2 showed that onychomycosis affected nails on both sides in 54 (54.9%) cases and involved more than one nail in 57 (51.9%) cases. The frequency was higher on the left side (85 cases, 80.7%) compared to the right side (50 cases, 48.1%). Three-quarters of the participants had mild or moderate onychomycosis, with an average OSI score of 10.24 ± 8.051 (range 2–35). There were 5 individuals having paronychia two other having interdigital lessions. Table 3 The distribution of involved toenails Toenail Left Right Total Percentage 1st 84 73 157 92.35 2nd 6 4 10 5.88 3rd 1 0 1 0.59 4th 1 1 2 1.18 5th 0 0 0 0 Total 92 (54.12) 78 (45.88) 170 100 The lession mostly appeared in the 1st or the 2nd toeal nail and big toes of both feet are the most common sites of injury in toenail onychomycosis with 92.4% of nails affected (Table 3 ). Table 4 Distribution of causative agents (n = 104) Genus Species N (%) Yeast Candida C. albicans 48 (46.1) C. tropicalis 3 (2.9) C. parapsilosis 1 (1.0) C. guilliermondii 1 (1.0) Meyerozyma caribbica 1 (1.0) C. etchellsii 2 (1.9) C. cylindracea 1 (1.0) Trichosporon T. asahii 11 (10.6) T. japonicum 3 (2.9) Geotrichum G. candidum 2 (1.9) Mold Aspergillus A. flavus 8 (7.7) A. niger 4 (3.9) A. nomius 3 (2.9) A. clavatus 1 (1.0) A. sclerotiorum 1 (1.0) A. versicolor 1 (1.0) Penicillium P. citrinum 5 (4.8) P. oxalicum 1 (1.0) P. polonicum 1 (1.0) Curvularia C. lunata 3 (2.9) Fusarium F. sonata 1 (1.0) Talaromyces T. pinophilus 1 (1.0) Trichophyton T. interdigitale 1 (1.0) Yeasts were responsible for the majority of cases (70.2%) and Candida was the most prevalent genus, with 57 strains, representing 78.1% of the yeast isolates and 54.8% of the total sample. The two other yeasts were Trichosporon (14 strains, 13.5%) and Geotrichum (2 isolates, 1.9%). Among the filamentous fungi, Aspergillus was the dominant one, with 18 strains, accounting for 54.1% of the mold isolates and 17.3% of all cases. The second most common mold isolated in the current study was Penicillium (7 strains, 6.7%). There was only a single strain of dermatophyte isolated in this study (Table 4 ). Table 5 The association between yeast and mold and other clinical variables Yeast (n = 73) Mold (n = 31) p Age (mean ± standart deviation) 53.26 ± 9.29 57.42 ± 7.44 0.029* Clinical type DLSO (Frequency (%) 60 (82.2) 28 (90.3) 0.382 Other (Frequency (%) 13 (17.8) 3 (9.7) Severity Severe (Frequency (%) 13 (17.8) 13 (41.9) 0.013* Mild – moderate (Frequency (%) 60 (82.2) 18 (58.1) OSI score (mean ± standart deviation) 8.93 ± 7.66 13.32 ± 8.24 0.010* Affected sides 1 (Frequency (%) 38 (52.1) 12 (38.7) 0.284 2 (Frequency (%) 35 (47.9) 19 (61.3) Number of nails 1 (Frequency (%) 35 (47.9) 12 (38.7) 0.519 2 (> 1) (Frequency (%) 38 (52.1) 19 (61.3) * significant with p < 0.05. The average of subjects with individuals with onychomycosis caused by NDM was higher than those with yeast onychomycosis. There was no significant relationship between fungal etiology and clinical types, or the number of toenails affected by onychomycosis. However, yeast infections typically cause mild to moderate disease, whereas filamentous fungi are more commonly linked to severe illness (Table 5 ). Discussion Clinical characteristics The first objective of this study is to provide more insights into the clinical presentation of toenail onychomycosis, the most common form of onychomycosis[ 2 ] in Vietnam. The results revealed that our patients exhibited typical characteristics of toenail onychomycosis. A prevalence rate of 53.6% among individuals with suspected lesions in our study was in the commonly reported range of 50 to 60 percent of abnormal nails was onychomycosis [ 26 ]. The bilateral foot involvement[ 27 ] and predominant infection of the big toes [ 28 ],[ 5 ] coincided with several earlier reports. The predominant clinical type of DLSO (84.6%) in the current study corroborates existing data, [ 29 ], [ 27 ]. Notably, approximately three-quarters of the participants had either mild or moderate onychomycosis, with a mean OSI score of 10.24 ± 8.05. This suggests that while the condition is widespread, severe manifestations remain relatively uncommon. This observation is in line with the general understanding that onychomycosis often presents with varying degrees of severity, with mild to moderate cases being more frequently encountered in clinical settings [ 27 ]. The agent responsible for onychomycosis Yeast The second objective of this study was to identify the fungal agents responsible for onychomycosis. As shown in Table 4 , yeasts were the most frequently isolated organisms, accounting for 70.2% of cases, while molds—including dermatophytes—were responsible for the remaining 29.8%. Traditionally, dermatophytes have been regarded as the primary cause of onychomycosis [ 5 ], [ 2 ]. However, a growing number of reports from various regions, including Italy [ 6 ], Iran [ 8 ], Brazil [ 7 ], [ 11 ], Saudi Arabia [ 12 ], Senegal [ 9 ], Madagascar [ 13 ]. have documented a shift in the predominant etiological agents, with yeasts increasingly surpassing dermatophytes. The underlying reasons for this epidemiological shift remain unclear. Nevertheless, several contributing factors have been proposed. These include female gender [ 30 ], older age [ 9 ], [ 29 ], frequent exposure to moisture, chemicals, and microtraumas [ 31 ], living in warm and humid climates [ 9 ], [ 13 ], or residing in areas with hot and humid climates [ 32 ]. In the present study, the predominance of yeast infections may be attributable to the characteristics of the participants, of whom were females, older adults, and frequently exposed to moisture through occupational activities. These findings underscore the importance of accurate identification of the causative agents—not only to enhance epidemiological understanding but also to guide appropriate antifungal therapy, given the variable antifungal susceptibility among different fungal species [ 33 ], [ 16 , 17 ]. Among the three genera of yeasts isolated in this study, Candida was the most prevalent, accounting for 54.8% of all isolates—consistent with findings from numerous previous studies [ 10 ], [ 11 ], [ 6 ]. The other genera identified were Trichosporon (13.5%) and Geotrichum (1.9%). Trichosporon is an emerging opportunistic yeast increasingly recognized for its role in skin and mucosal infections [ 34 ]. Notably, a study by Mireya M. et al. (2011) reported Trichosporon species in 50% of toenail onychomycosis cases [ 35 ]. Similarly, the involvement of Geotrichum candidum in onychomycosis has been documented in other studies [ 10 ], [ 36 ]. At the species level, Candida albicans was the most frequently isolated yeast, representing 46.2% of all cases, aligning with data from studies elsewhere [ 9 ], [ 36 ], [ 11 ]. Additionally, several rare non- albicans Candida species were identified, including Meyerozyma caribbica (anamorph Candida fermentati ), Starmerella etchellsii ( Candida etchellsii ), and Candida cylindracea . These species are also considered as non-albicans Candida infectious yeast and have been reported elsewhere [ 37 ], [ 38 ]. The predominance of C. albicans has practical clinical implications, as this species is generally more susceptible to commonly used antifungal agents compared to many non- albicans Candida species [ 33 ], [ 39 ]. Mold Almost all filamentous fungi isolated in this study were non-dermatophyte molds (NDMs), accounting for 96.67% of the cases (Table 4 ). NDMs have been increasingly recognized as significant causative agents of toenail onychomycosis, with their prevalence varying widely depending on geographic region and population characteristics. For instance, a study of Chadeganipour et al (2016) reporting a notable increase of NDMs over a seven-year period [ 11 ], while in Ethiopia, Iran NDMs were found to be the leading cause of onychomycosis, responsible for 61.1% and 44.4% of cases [ 36 ], [ 40 ]. The significant prevalence of NDM-associated onychomycosis in this study is worthy of mention, as these infections are often more difficult to treat than those caused by dermatophytes [ 41 ], [ 11 ]. Regarding mold genera, Aspergillus was the most frequently isolated, which is consistent with findings in Morocco and Iran [ 42 ], [ 43 ]. Penicillium was the second most common mold identified, accounting for 22.6% of mold isolates and 6.7% of total onychomycosis cases. Similarly, a retrospective Canadian study reported Penicillium species in 47 out of 655 positive tests (7.18%) [ 27 ]. In the current study, three Penicillium species identified were P. citrinum [ 44 ], P. polonicum [ 40 ], and P. oxalicum which have been reported in causing onychomycosis or isolated from clinical samples [ 45 ]. Other NDMs identified in this study included Curvularia lunata and Fusarium species, both of which have been well-documented as etiological agents of onychomycosis [ 46 ]. The rarely of dermatophyte in the current study may be related to demographic characteristics of the participants. Almost of the individuals are female (98%) and at the average age of 54.50 years old, subjects that are considered less likely to be affected by dermatophyte [ 30 ], [ 40 ]. The relatioship between fungal etiology and clinical variables The results in Table 5 show that molds seem to affect the older subjects than yeast. Older age is considered a significant factor contracting toenail onychomycosis and the distribution of different causative agents across different age groups can vary [ 9 ], [ 29 ]. The more frequence of mold in older people can be explained by the fact that most of mold isolated in the current study was NDM. Epidemiological studies have found that dermatophyte found to be common in younger adults, while older age appears to be a significant risk factor for onychomycosis caused by both yeasts and NDM [ 30 ]. Future studies should focus more on the risk of onychomycosis caused by different etiology in different age groups to guide treatment approach. One of the most notable findings of this study is that yeast infections seem to be associated with milder forms of onychomycosis, compared to those caused by dermatophytes or non-dermatophyte molds (NDMs). This observation is in line with the study by Dubljanin et al. (2021), which reported higher mean SCIO index values in onychomycosis caused by dermatophytes (17.37) and NDMs (10.75), compared to yeast infections (8.66) [ 28 ]. These findings are further supported by Gupta AK et al. (2024) who found that yeast infections, particularly those caused by Candida species, often result in milder clinical manifestations [ 30 ]. Recognizing the link between mild clinical presentation and the potential involvement of yeasts may help guide empirical treatment decisions, a common approach in clinical practice [ 18 ]. In such cases, clinicians may consider selecting antifungal agents with better activity against yeasts—such as azoles—instead of relying on empiric treatment with terbinafine, which has limited efficacy against Candida species [ 4 ]. This study has some limitations. Diagnosis was based on fungal culture and microscopy, which, although widely used, may have lower sensitivity compared to methods like Periodic Acid-Schiff (PAS) staining or Polymerase Chain Reaction (PCR) [ 47 ]. These advanced techniques could be considered in future studies to enhance diagnostic accuracy. Conclusion Our study revealed that among traders in Nghe An province, toenail onychomycosis commonly presented with typical clinical features, with most cases being mild to moderate in severity. Yeasts, mainly Candida species, were the predominant causative agents and typically associated with milder disease, whereas non-dermatophyte molds, though less common, often caused more severe cases. Notably, dermatophytes, typically a leading cause, were rare, with only one isolate. This etiological diversity underscores the need for accurate identification of causative agents. Broad-spectrum antifungal therapies effective against both yeasts and non-dermatophyte molds appear to be a rational choice. Further research is needed to explore optimal treatment strategies for onychomycosis, especially for severe cases, which often caused by non-dermatophyte molds - agents presenting more therapeutic challenges. Declarations Acknowledgements Ethical approval: The study is part of thesis work for the fulfillment of Doctor of Philosophy in Health Studies and obtained clearance from the ethics committee of the Vietnam National Institute of Malariology, Parasitology and Entomology (NIMPE) in March 2019 (303/QD-VSR). This has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Authors’ contribution TTKA, CBL and LTA designed the study, analyzed, interpreted the data and drafted the manuscript. DTKL, TDT and VVD collected clinical data. DNA, LTA collected the microbiological data and identified species. CBL and LTA revised the manuscript critically. All authors read and approved the final manuscript. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. This work was partially supported by the TTH Group. The funding agency does not have any role in data collection, analysis, and writing of the manuscript. References Gupta AK, Taborda VBA, Taborda PRO, Shemer A, Summerbell RC, Nakrieko K-A. High prevalence of mixed infections in global onychomycosis. PLoS One. 2020;15:e0239648. Sigurgeirsson B, Baran R. The prevalence of onychomycosis in the global population – A literature study. Journal of the European Academy of Dermatology and Venereology. 2014;28:1480–91. Gupta AK, Mays RR. 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Prevalence, Risk Factors and Treatment of Occupational Onychomychosis among Carpet Manufacture Workers in Egypt. Med J Cairo Univ. 2022;90:2549–56. Gupta AK, Versteeg SG, Shear NH. Onychomycosis in the 21st Century: An Update on Diagnosis, Epidemiology, and Treatment. J Cutan Med Surg. 2017;21:525–39. Pfaller MA, Diekema DJ, Turnidge JD, Castanheira M, Jones RN. Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997–2016. Open Forum Infect Dis. 2019;6:S79–94. Mehta V, Nayyar C, Gulati N, Singla N, Rai S, Chandar J. A Comprehensive Review of Trichosporon spp.: An Invasive and Emerging Fungus. Cureus. 2021;13:e17345. Mireya M, Elena R. Trichosporon spp as a Causative Agent of Onychomycosis. Kasmera [online]. 2011, vol.39, n.1, pp.26-30. ISSN 0075-5222. Kasmera. 2011;39:26–30. Bitew A, Osman F, Yassin S. Non-Dermatophyte Mold Dominated Onychomycosis in Patients Attending a Rank Higher Specialized Dermatology Clinic in Addis Ababa, Ethiopia. Clin Cosmet Investig Dermatol. 2022;15:507–18. Chaves ALS, Trilles L, Alves GM, Figueiredo-Carvalho MHG, Brito-Santos F, Coelho RA, et al. A case-series of bloodstream infections caused by the Meyerozyma guilliermondii species complex at a reference center of oncology in Brazil. Med Mycol. 2021;59:235–43. Cortés JA, Valderrama-Rios MC, Peçanha-Pietrobom PM, Júnior MS, Diaz-Brochero C, Robles-Torres RR, et al. Evidence-based clinical standard for the diagnosis and treatment of candidemia in critically ill patients in the intensive care unit. The Brazilian Journal of Infectious Diseases. 2025;29:104495. Sinh CT, Loi CB, Minh NTN, Lam NN, Quang DX, Quyet D, et al. Species Distribution and Antifungal Susceptibility Pattern of Candida Recovered from Intensive Care Unit Patients, Vietnam National Hospital of Burn (2017–2019). Mycopathologia. 2021;186:543–51. Razavyoon T, Hashemia SJ, Mansouri P, Rafat Z, Saboor-Yaraghi AA, Kamali Sarvestani H, et al. The epidemiology and etiology of onychomycosis in 2 laboratory centers affiliated to Tehran university of medical sciences during 2019-2020. Iran J Microbiol. 2022;14:268–75. Leeyaphan C, Chai‐Adisaksopha C, Tovanabutra N, Phinyo P, Bunyaratavej S. Prognostic factors for mycological cure in patients with onychomycosis caused by Neoscytalidium dimidiatum: A retrospective cohort study. Mycoses. 2023;66:497–504. Hajoui F-ZM, Zeroual Z, Ghfir B, Moustachi A, Lyagoubi M, Aoufi S. Les onychomycoses à moisissure au Maroc : à propos de 150 cas isolés en 20 ans. J Mycol Med. 2012;22:221–4. Motamedi M, Ghasemi Z, Shidfar MR, Hosseinpour L, Khodadadi H, Zomorodian K, et al. Growing Incidence of Non-Dermatophyte Onychomycosis in Tehran, Iran. Jundishapur J Microbiol. 2016;9. Verrier J, Pronina M, Peter C, Bontems O, Fratti M, Salamin K, et al. Identification of Infectious Agents in Onychomycoses by PCR-Terminal Restriction Fragment Length Polymorphism. J Clin Microbiol. 2012;50:553–61. Becker PT, de Bel A, Martiny D, Ranque S, Piarroux R, Cassagne C, et al. Identification of filamentous fungi isolates by MALDI-TOF mass spectrometry: clinical evaluation of an extended reference spectra library. Med Mycol. 2014;52:826–34. Summerbell RC, Cooper E, Bunn U, Jamieson F, Gupta AK. Onychomycosis: a critical study of techniques and criteria for confirming the etiologic significance of nondermatophytes. Med Mycol. 2005;43:39–59. Gupta AK, Venkataraman M, Quinlan EM. Onychomycosis in the Twenty-First Century: An Update on Epidemiology and Diagnosis. Dermatophytes and Dermatophytoses. Cham: Springer International Publishing; 2021. p. 41–64. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6438153","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":450526726,"identity":"0f28c7f3-4c7b-4126-aa27-145916e5c96b","order_by":0,"name":"Tran Thị Kieu-Anh","email":"","orcid":"","institution":"Vinh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tran","middleName":"Thị","lastName":"Kieu-Anh","suffix":""},{"id":450526727,"identity":"84a83503-d46e-45dc-a748-150919dd0998","order_by":1,"name":"Duong Thi Khanh-Linh","email":"","orcid":"","institution":"Thai Thuong Hoang hospital","correspondingAuthor":false,"prefix":"","firstName":"Duong","middleName":"Thi","lastName":"Khanh-Linh","suffix":""},{"id":450526728,"identity":"187c8242-871b-4b86-9aa0-662a7981ea6f","order_by":2,"name":"Thai Doan Thang","email":"","orcid":"","institution":"Thai Thuong Hoang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Thai","middleName":"Doan","lastName":"Thang","suffix":""},{"id":450526729,"identity":"e7d5abb9-3be3-4a78-9569-c3416327d3d1","order_by":3,"name":"Vu Van Du","email":"","orcid":"","institution":"National Hospital of Obsteric and Gynecology","correspondingAuthor":false,"prefix":"","firstName":"Vu","middleName":"Van","lastName":"Du","suffix":""},{"id":450526730,"identity":"579ea7ed-b3c3-45dc-be95-891cf3c8753a","order_by":4,"name":"Do Ngoc Anh","email":"","orcid":"","institution":"Vietnam Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Do","middleName":"Ngoc","lastName":"Anh","suffix":""},{"id":450526731,"identity":"6ce862bd-db7b-44d9-9f8b-5bd9d82a92b2","order_by":5,"name":"Cao Ba Loi","email":"","orcid":"","institution":"National Institute of Malariology Parasitology and Entomology","correspondingAuthor":false,"prefix":"","firstName":"Cao","middleName":"Ba","lastName":"Loi","suffix":""},{"id":450526732,"identity":"dec5b840-ce0c-4a25-a37c-fb94e2a4fb8f","order_by":6,"name":"Tran-Anh Le","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYFACHgaGBww2UA4bsVoSEtJI13KYBC38s3sPMCT+OJ+4dtoZA4YPZYcZDG434NcicedcAtCW24nbbucYMM44B9Ry5wABa27kGIC0GJsBtTDzth1mkJyRgF+HPETLOYiWv8RoMYBoOSAH1sII1MIvQUCLIVhLWjJQS1rBwZ5z6TwEtciBtHywseMxu5288cGPMms5NkJagID9B4x1gAEcTaNgFIyCUTAKKAYAa55BLLJFw8YAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-4919-1739","institution":"Vietnam Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"Tran-Anh","middleName":"","lastName":"Le","suffix":""}],"badges":[],"createdAt":"2025-04-13 08:44:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6438153/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6438153/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85278567,"identity":"c7aa02f9-4991-4bfc-903b-9a8e0b83eafd","added_by":"auto","created_at":"2025-06-24 07:47:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":718537,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6438153/v1/13ed1e8b-c254-42a7-be32-55b6d532db3e.pdf"}],"financialInterests":"","formattedTitle":"Clinical Characteristics and Causative Agents of Toenail Onychomycosis among Small Traders in Nghe An Province, Vietnam","fulltext":[{"header":"Summary","content":"\u003cp\u003eVietnam has a tropical climate with high temperatures and humidity\u0026mdash;conditions favorable for fungal growth and \u0026nbsp;fungal infections, but limited data exists on onychomycosis. Objective: To investigate the clinical presentation and causative agents of toenail onychomycosis in Vietnam.\u003c/p\u003e\n\u003cp\u003eMethods: A cross-sectional study was conducted across Nghe An province from March 2021 to August 2022. Toenail samples were collected from small-traders with suspected onychomycosis and underwent direct examination and culture. The isolated strains were identified by conventional and molecular techniques, including restriction fragment length polymorphism (RFLP) analysis and sequencing of the internal transcribed spacer (ITS) region.\u003c/p\u003e\n\u003cp\u003eResults: A total of 104 participants, aged 25 to 77 years (98.1% female), were diagnosed with toenail onychomycosis. Most lesions appeared on the first (92.4% of affected nails) and second toenails. The most common form was distal and lateral subungual onychomycosis (84.6%), followed by superficial white onychomycosis (8.7%) and proximal subungual onychomycosis (6.7%). The rates mild, moderate or severe onychomycosis were 35.6%, 39.4%, and 25.0% respectively. Yeasts accounted for the majority of infections (70.2%), with \u003cem\u003eCandida\u003c/em\u003e being the most prevalent genus (54.8%), followed by \u003cem\u003eTrichosporon\u003c/em\u003e (13.5%) and \u003cem\u003eGeotrichum\u003c/em\u003e (1.9%). \u003cem\u003eAspergillus\u003c/em\u003e was the most prevalent mold identified (17.3%), followed by \u003cem\u003ePenicillium\u003c/em\u003e (6.7%), \u003cem\u003eCurvularia\u003c/em\u003e (2.9%), and \u003cem\u003eFusarium\u003c/em\u003e, \u003cem\u003eTalaromyces\u003c/em\u003e, and \u003cem\u003eTrichophyton\u0026nbsp;\u003c/em\u003e(1% each). Yeast infections exhibited a significantly higher proportion of mild to moderate cases compared to mold infections (82.2% vs. 58.1%, p = 0.013).\u003c/p\u003e\n\u003cp\u003eConclusion: Yeasts and non-dermatophyte molds are the leading causes of onychomycosis among traders in Nghe An province. Broad-spectrum antifungal agents appear to be a rational choice for the treatment. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003e \u003cb\u003eOnychomycosis\u003c/b\u003e, a fungal infection of the nails, is estimated to affect approximately 10% of the global population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The infection may lead to pain, discomfort, and physical impairment, significantly affecting patients\u0026rsquo; quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Onychomycosis often persists for years and rarely spontaneously resolves, necessitating treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The treatment decisions depend on both the severity of disease as well as the type of involved pathogen. The distribution of causative agents including dermatophytes, non-dermatophyte molds (NDMs), and yeasts varies across different geographic and demographic settings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While dermatophytes have traditionally been considered the primary cause of onychomycosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], recent studies have reported a shift toward increasing yeast prevalence in several regions, including Europe [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the Middle East, South America [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and parts of Africa and Asia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Systemic antifungal therapy remains the gold standard, particularly for more severe cases and terbinafine has been shown to have the highest mycotic cure rates among antifungals used for systemic treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This drug is highly effective against dermatophyte but exhibits variable activity against yeasts and non-dermatophyte molds in vitro [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, accurate identification of the causative agent is critical for effective treatment, but empiric therapy remains common [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Updated regional data on the epidemiology of onychomycosis is needed for better guide diagnosis and treatment strategies.\u003c/p\u003e \u003cp\u003eVietnam, located in Southeast Asia, has a tropical climate with high temperatures and humidity\u0026mdash;conditions favorable for fungal growth. There have been reports showing that fungal skin infections are among the most common skin condition [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], data specifically focused on onychomycosis and its etiological agents remain limited [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This study aims to provide deeper insights into the clinical presentation and causative agents of toenail onychomycosis among traders in Nghe An province, Vietnam.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e This cross-sectional study included traders from some markets in Nghe An province who provided informed consent to participate. Participants were included if they presented with nail abnormalities such as discoloration, deformation, hypertrophy, hyperkeratosis, or subungual debris. During recruitment, demographic data and relevant medical histories were collected through structured interviews. Additionally, a dermatologist recorded detailed information regarding the characteristics of the lesions.\u003c/p\u003e \u003cp\u003eSampling\u003c/p\u003e \u003cp\u003eAfter thoroughly cleaned with 70% alcohol, the nails samples were collected by scraping or clipping, depending on the clinical type of onychomycosis. For suspected distal and lateral subungual onychomycosis (DLSO), the abnormal nail was clipped proximally to the nail bed and the underside of the nail plate was scraped with a curette. For proximal subungual onychomycosis (PSO), samples were taken by scraping around the area of the lunula. The white spots on the nail suspected of superficial white onychomycosis (SWO) were scraped. All samples were placed in sterile, labeled containers for laboratory processing.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDirect Microscopy and Fungal Culture\u003c/h2\u003e \u003cp\u003eNail samples were first examined microscopically after treatment with 10% potassium hydroxide (KOH). Then the obtained samples were inoculated on two slants: one containing Sabouraud dextrose agar (SDA, BioM\u0026eacute;rieux, France) supplemented with gentamicin (0.02 mg/mL), and the other containing BBL Mycosel Agar (Becton, Dickinson and Company, USA). Cultures were incubated at room temperature and observed for up to five weeks. Samples showing no fungal growth after this period were considered negative and discarded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFungal Identification\u003c/h3\u003e\n\u003cp\u003eSamples showing yeast growth were subcultured on CHROMagar™ Candida medium and incubated at room temperature under aerobic conditions. Yeast species were identified based on colony color and morphology, following the manufacturer’s guidelines [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The strains representing isolates that were identified, along with those that could not be characterized by CHROMagar were further analyzed by PCR-RFLP. Genomic DNA of these strains were extracted using the QIAamp DNA Mini Kit (Cat. No. 51304; QIAGEN, Hilden, Germany) according to the manufacturer’s protocol. PCR amplification targeted the ITS1-5.8S-ITS2 rDNA region using the primers ITS1 (5'-TCC GTA GGT GAA CCT GCG G-3') and ITS4 (5'-TCC TCC GCT TAT TGA TAT GC-3') (Integrated DNA Technologies, USA). The resulting amplicons were digested with the restriction enzyme \u003cem\u003eMsp\u003c/em\u003eI, and species identification was determined based on the size of the PCR and RFLP products, following the method described by Mirhendi et al. (2006) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll filamentous isolates were preliminarily identified and grouped based on morphological characteristics.\u003c/p\u003e \u003cp\u003eIdentification by sequencing:\u003c/p\u003e \u003cp\u003eIsolates representing molds with similar morphological characteristics, or yeasts with consistent morphological and PCR-RFLP identification results, and those that could not be definitively identified or showed inconsistent results using morphological or PCR-RFLP methods were further analyzed by sequencing the internal transcribed spacer (ITS) regions. Resulting sequences were compared with those in the GenBank database for species identification. Representative sequences were deposited in GenBank under accession numbers OR438032, OR438022, OR437991, OR437989, OR438017, OR438023, and OR437990.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDefinition\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eA diagnosis of onychomycosis caused by dermatophytes or yeasts was made if either microscopy or culture yielded a positive result. Non-dermatophyte mold (NDM) onychomycosis was diagnosed only when all of the following criteria were met: (1) a positive result on KOH microscopy, (2) isolation of a non-dermatophyte mold in culture, and (3) absence of dermatophyte growth in culture [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Clinical types of onychomycosis (DLSO, PSO, and SWO) were classified according to the criteria described by Hay and Baran (2011) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The severity of nail involvement was based on the Onychomycosis Severity Index (OSI) score and classification system proposed by Carney et al. (2011) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e "},{"header":"Result","content":"\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the participants (n = 104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eFrequency (%) or mean ± standart deviation\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(1.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(98.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25–40\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(4.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41–60\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(69.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61–77\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(26.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage age\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e54.50 ± 8.91\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlain\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(16.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMountainous\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(25.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoach line\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(58.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(55.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(39.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeafood, food, or drinks\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(35.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(64.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eThere were 194 traders having abnormal toenails, and onychomycosis was confirmed in 104 participants accounting for 53.6%. The majority of individuals with onychomycosis were female (98.1%), with ages ranging from 25 to 77 years old. Approximately one-third of the patients (35.6%) engaged in shelling products such as seafood, food, or drinks, which frequently exposed them to water (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of the participants (n = 104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of involved toenails\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(45.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(46.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(8.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite affected\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne side\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(18.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(29.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth sides\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(51.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical types of onychomycosis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDSLO\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(84.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSWO\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(8.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePSO\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(6.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSeverity of onychomycosis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(35.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(39.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(25.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eResults in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e showed that onychomycosis affected nails on both sides in 54 (54.9%) cases and involved more than one nail in 57 (51.9%) cases. The frequency was higher on the left side (85 cases, 80.7%) compared to the right side (50 cases, 48.1%). Three-quarters of the participants had mild or moderate onychomycosis, with an average OSI score of 10.24 ± 8.051 (range 2–35). There were 5 individuals having paronychia two other having interdigital lessions.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe distribution of involved toenails\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToenail\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.35\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.88\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (54.12)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (45.88)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eThe lession mostly appeared in the 1st or the 2nd toeal nail and big toes of both feet are the most common sites of injury in toenail onychomycosis with 92.4% of nails affected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of causative agents (n = 104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGenus\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecies\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYeast\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCandida\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. albicans\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(46.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. tropicalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(2.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. parapsilosis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. guilliermondii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eMeyerozyma caribbica\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. etchellsii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. cylindracea\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTrichosporon\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eT. asahii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(10.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eT. japonicum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(2.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGeotrichum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eG. candidum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMold\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eAspergillus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. flavus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(7.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. niger\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(3.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. nomius\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(2.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. clavatus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. sclerotiorum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eA. versicolor\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePenicillium\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP. citrinum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(4.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP. oxalicum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP. polonicum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCurvularia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eC. lunata\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(2.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFusarium\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eF. sonata\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTalaromyces\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eT. pinophilus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTrichophyton\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eT. interdigitale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eYeasts were responsible for the majority of cases (70.2%) and \u003cem\u003eCandida\u003c/em\u003e was the most prevalent genus, with 57 strains, representing 78.1% of the yeast isolates and 54.8% of the total sample. The two other yeasts were \u003cem\u003eTrichosporon\u003c/em\u003e (14 strains, 13.5%) and \u003cem\u003eGeotrichum\u003c/em\u003e (2 isolates, 1.9%). Among the filamentous fungi, \u003cem\u003eAspergillus\u003c/em\u003e was the dominant one, with 18 strains, accounting for 54.1% of the mold isolates and 17.3% of all cases. The second most common mold isolated in the current study was \u003cem\u003ePenicillium\u003c/em\u003e (7 strains, 6.7%). There was only a single strain of dermatophyte isolated in this study (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe association between yeast and mold and other clinical variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYeast (n = 73)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMold (n = 31)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (mean ± standart deviation)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.26 ± 9.29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.42 ± 7.44\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.029*\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical type\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDLSO (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (82.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (90.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (17.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (9.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (17.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (41.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013*\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild – moderate (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (82.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (58.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOSI score (mean ± standart deviation)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.93 ± 7.66\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.32 ± 8.24\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.010*\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAffected sides\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (52.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (47.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (61.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of nails\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (47.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (\u0026gt; 1) (Frequency (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (52.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (61.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e* significant with p \u0026lt; 0.05.\u003c/p\u003e\u003cp\u003eThe average of subjects with individuals with onychomycosis caused by NDM was higher than those with yeast onychomycosis. There was no significant relationship between fungal etiology and clinical types, or the number of toenails affected by onychomycosis. However, yeast infections typically cause mild to moderate disease, whereas filamentous fungi are more commonly linked to severe illness (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eClinical characteristics\u003c/p\u003e \u003cp\u003eThe first objective of this study is to provide more insights into the clinical presentation of toenail onychomycosis, the most common form of onychomycosis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] in Vietnam. The results revealed that our patients exhibited typical characteristics of toenail onychomycosis. A prevalence rate of 53.6% among individuals with suspected lesions in our study was in the commonly reported range of 50 to 60 percent of abnormal nails was onychomycosis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The bilateral foot involvement[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and predominant infection of the big toes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e],[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] coincided with several earlier reports. The predominant clinical type of DLSO (84.6%) in the current study corroborates existing data, [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Notably, approximately three-quarters of the participants had either mild or moderate onychomycosis, with a mean OSI score of 10.24\u0026thinsp;\u0026plusmn;\u0026thinsp;8.05. This suggests that while the condition is widespread, severe manifestations remain relatively uncommon. This observation is in line with the general understanding that onychomycosis often presents with varying degrees of severity, with mild to moderate cases being more frequently encountered in clinical settings [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe agent responsible for onychomycosis\u003c/p\u003e \u003cp\u003eYeast\u003c/p\u003e \u003cp\u003eThe second objective of this study was to identify the fungal agents responsible for onychomycosis. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, yeasts were the most frequently isolated organisms, accounting for 70.2% of cases, while molds\u0026mdash;including dermatophytes\u0026mdash;were responsible for the remaining 29.8%. Traditionally, dermatophytes have been regarded as the primary cause of onychomycosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, a growing number of reports from various regions, including Italy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], Iran [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], Brazil [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], Saudi Arabia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], Senegal [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Madagascar [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. have documented a shift in the predominant etiological agents, with yeasts increasingly surpassing dermatophytes. The underlying reasons for this epidemiological shift remain unclear. Nevertheless, several contributing factors have been proposed. These include female gender [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], older age [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], frequent exposure to moisture, chemicals, and microtraumas [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], living in warm and humid climates [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], or residing in areas with hot and humid climates [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the present study, the predominance of yeast infections may be attributable to the characteristics of the participants, of whom were females, older adults, and frequently exposed to moisture through occupational activities. These findings underscore the importance of accurate identification of the causative agents\u0026mdash;not only to enhance epidemiological understanding but also to guide appropriate antifungal therapy, given the variable antifungal susceptibility among different fungal species [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the three genera of yeasts isolated in this study, \u003cem\u003eCandida\u003c/em\u003e was the most prevalent, accounting for 54.8% of all isolates\u0026mdash;consistent with findings from numerous previous studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The other genera identified were \u003cem\u003eTrichosporon\u003c/em\u003e (13.5%) and \u003cem\u003eGeotrichum\u003c/em\u003e (1.9%). \u003cem\u003eTrichosporon\u003c/em\u003e is an emerging opportunistic yeast increasingly recognized for its role in skin and mucosal infections [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Notably, a study by Mireya M. et al. (2011) reported \u003cem\u003eTrichosporon\u003c/em\u003e species in 50% of toenail onychomycosis cases [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Similarly, the involvement of \u003cem\u003eGeotrichum candidum\u003c/em\u003e in onychomycosis has been documented in other studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. At the species level, \u003cem\u003eCandida albicans\u003c/em\u003e was the most frequently isolated yeast, representing 46.2% of all cases, aligning with data from studies elsewhere [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, several rare non-\u003cem\u003ealbicans Candida\u003c/em\u003e species were identified, including \u003cem\u003eMeyerozyma caribbica\u003c/em\u003e (anamorph \u003cem\u003eCandida fermentati\u003c/em\u003e), \u003cem\u003eStarmerella etchellsii\u003c/em\u003e (\u003cem\u003eCandida etchellsii\u003c/em\u003e), and \u003cem\u003eCandida cylindracea\u003c/em\u003e. These species are also considered as non-albicans \u003cem\u003eCandida\u003c/em\u003e infectious yeast and have been reported elsewhere [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The predominance of \u003cem\u003eC. albicans\u003c/em\u003e has practical clinical implications, as this species is generally more susceptible to commonly used antifungal agents compared to many non-\u003cem\u003ealbicans Candida\u003c/em\u003e species [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMold\u003c/p\u003e \u003cp\u003eAlmost all filamentous fungi isolated in this study were non-dermatophyte molds (NDMs), accounting for 96.67% of the cases (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). NDMs have been increasingly recognized as significant causative agents of toenail onychomycosis, with their prevalence varying widely depending on geographic region and population characteristics. For instance, a study of Chadeganipour et al (2016) reporting a notable increase of NDMs over a seven-year period [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], while in Ethiopia, Iran NDMs were found to be the leading cause of onychomycosis, responsible for 61.1% and 44.4% of cases [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The significant prevalence of NDM-associated onychomycosis in this study is worthy of mention, as these infections are often more difficult to treat than those caused by dermatophytes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding mold genera, \u003cem\u003eAspergillus\u003c/em\u003e was the most frequently isolated, which is consistent with findings in Morocco and Iran [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. \u003cem\u003ePenicillium\u003c/em\u003e was the second most common mold identified, accounting for 22.6% of mold isolates and 6.7% of total onychomycosis cases. Similarly, a retrospective Canadian study reported \u003cem\u003ePenicillium\u003c/em\u003e species in 47 out of 655 positive tests (7.18%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the current study, three \u003cem\u003ePenicillium\u003c/em\u003e species identified were \u003cem\u003eP. citrinum\u003c/em\u003e [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], \u003cem\u003eP. polonicum\u003c/em\u003e [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and \u003cem\u003eP. oxalicum\u003c/em\u003e which have been reported in causing onychomycosis or isolated from clinical samples [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Other NDMs identified in this study included \u003cem\u003eCurvularia lunata\u003c/em\u003e and \u003cem\u003eFusarium\u003c/em\u003e species, both of which have been well-documented as etiological agents of onychomycosis [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The rarely of dermatophyte in the current study may be related to demographic characteristics of the participants. Almost of the individuals are female (98%) and at the average age of 54.50 years old, subjects that are considered less likely to be affected by dermatophyte [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe relatioship between fungal etiology and clinical variables\u003c/p\u003e \u003cp\u003eThe results in Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e show that molds seem to affect the older subjects than yeast. Older age is considered a significant factor contracting toenail onychomycosis and the distribution of different causative agents across different age groups can vary [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The more frequence of mold in older people can be explained by the fact that most of mold isolated in the current study was NDM. Epidemiological studies have found that dermatophyte found to be common in younger adults, while older age appears to be a significant risk factor for onychomycosis caused by both yeasts and NDM [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Future studies should focus more on the risk of onychomycosis caused by different etiology in different age groups to guide treatment approach. One of the most notable findings of this study is that yeast infections seem to be associated with milder forms of onychomycosis, compared to those caused by dermatophytes or non-dermatophyte molds (NDMs). This observation is in line with the study by Dubljanin et al. (2021), which reported higher mean SCIO index values in onychomycosis caused by dermatophytes (17.37) and NDMs (10.75), compared to yeast infections (8.66) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These findings are further supported by Gupta AK et al. (2024) who found that yeast infections, particularly those caused by \u003cem\u003eCandida\u003c/em\u003e species, often result in milder clinical manifestations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Recognizing the link between mild clinical presentation and the potential involvement of yeasts may help guide empirical treatment decisions, a common approach in clinical practice [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In such cases, clinicians may consider selecting antifungal agents with better activity against yeasts\u0026mdash;such as azoles\u0026mdash;instead of relying on empiric treatment with terbinafine, which has limited efficacy against \u003cem\u003eCandida\u003c/em\u003e species [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has some limitations. Diagnosis was based on fungal culture and microscopy, which, although widely used, may have lower sensitivity compared to methods like Periodic Acid-Schiff (PAS) staining or Polymerase Chain Reaction (PCR) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These advanced techniques could be considered in future studies to enhance diagnostic accuracy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study revealed that among traders in Nghe An province, toenail onychomycosis commonly presented with typical clinical features, with most cases being mild to moderate in severity. Yeasts, mainly \u003cem\u003eCandida\u003c/em\u003e species, were the predominant causative agents and typically associated with milder disease, whereas non-dermatophyte molds, though less common, often caused more severe cases. Notably, dermatophytes, typically a leading cause, were rare, with only one isolate. This etiological diversity underscores the need for accurate identification of causative agents. Broad-spectrum antifungal therapies effective against both yeasts and non-dermatophyte molds appear to be a rational choice. Further research is needed to explore optimal treatment strategies for onychomycosis, especially for severe cases, which often caused by non-dermatophyte molds - agents presenting more therapeutic challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eThe study is part of thesis work for the fulfillment of Doctor of Philosophy in Health Studies and obtained clearance from the ethics committee of the Vietnam National Institute of Malariology, Parasitology and Entomology (NIMPE) in March 2019 (303/QD-VSR). This has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTTKA, CBL and LTA designed the study, analyzed, interpreted the data and drafted the manuscript. DTKL, TDT and VVD collected clinical data. DNA, LTA collected the microbiological data and identified species. CBL and LTA revised the manuscript critically. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest concerning this article.\u003c/p\u003e\n\u003cp\u003eThis work was partially supported by the TTH Group. The funding agency does not have any role in data collection, analysis, and writing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGupta AK, Taborda VBA, Taborda PRO, Shemer A, Summerbell RC, Nakrieko K-A. High prevalence of mixed infections in global onychomycosis. PLoS One. 2020;15:e0239648. \u003c/li\u003e\n\u003cli\u003eSigurgeirsson B, Baran R. The prevalence of onychomycosis in the global population \u0026ndash; A literature study. Journal of the European Academy of Dermatology and Venereology. 2014;28:1480\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eGupta AK, Mays RR. The Impact of Onychomycosis on Quality of Life: A Systematic Review of the Available Literature. Skin Appendage Disord. 2018;4:208\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eFrazier W, Santiago-Delgado Z, Stupka K. Onychomycosis: Rapid Evidence Review. 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Prognostic factors for mycological cure in patients with onychomycosis caused by Neoscytalidium dimidiatum: A retrospective cohort study. Mycoses. 2023;66:497\u0026ndash;504. \u003c/li\u003e\n\u003cli\u003eHajoui F-ZM, Zeroual Z, Ghfir B, Moustachi A, Lyagoubi M, Aoufi S. Les onychomycoses \u0026agrave; moisissure au Maroc : \u0026agrave; propos de 150 cas isol\u0026eacute;s en 20 ans. J Mycol Med. 2012;22:221\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eMotamedi M, Ghasemi Z, Shidfar MR, Hosseinpour L, Khodadadi H, Zomorodian K, et al. Growing Incidence of Non-Dermatophyte Onychomycosis in Tehran, Iran. Jundishapur J Microbiol. 2016;9. \u003c/li\u003e\n\u003cli\u003eVerrier J, Pronina M, Peter C, Bontems O, Fratti M, Salamin K, et al. Identification of Infectious Agents in Onychomycoses by PCR-Terminal Restriction Fragment Length Polymorphism. J Clin Microbiol. 2012;50:553\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eBecker PT, de Bel A, Martiny D, Ranque S, Piarroux R, Cassagne C, et al. Identification of filamentous fungi isolates by MALDI-TOF mass spectrometry: clinical evaluation of an extended reference spectra library. Med Mycol. 2014;52:826\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eSummerbell RC, Cooper E, Bunn U, Jamieson F, Gupta AK. Onychomycosis: a critical study of techniques and criteria for confirming the etiologic significance of nondermatophytes. Med Mycol. 2005;43:39\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eGupta AK, Venkataraman M, Quinlan EM. Onychomycosis in the Twenty-First Century: An Update on Epidemiology and Diagnosis. Dermatophytes and Dermatophytoses. Cham: Springer International Publishing; 2021. p. 41\u0026ndash;64. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"toenail onychomycosis, yeast, non-dermatophyte mold, dermatophyte, Vietnam","lastPublishedDoi":"10.21203/rs.3.rs-6438153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6438153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo investigate the clinical presentation and causative agents of toenail onychomycosis in Vietnam.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted across Nghe An province from March 2021 to August 2022. Toenail samples were collected from small-traders with suspected onychomycosis and underwent direct examination and culture. The isolated strains were identified by conventional and molecular techniques, including restriction fragment length polymorphism (RFLP) analysis and sequencing of the internal transcribed spacer (ITS) region.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 104 participants, aged 25 to 77 years (98.1% female), were diagnosed with toenail onychomycosis. Most lesions appeared on the first (92.4% of affected nails) and second toenails. The most common form was distal and lateral subungual onychomycosis (84.6%), followed by superficial white onychomycosis (8.7%) and proximal subungual onychomycosis (6.7%). The rates mild, moderate or severe onychomycosis were 35.6%, 39.4%, and 25.0% respectively. Yeasts accounted for the majority of infections (70.2%), with \u003cem\u003eCandida\u003c/em\u003e being the most prevalent genus (54.8%), followed by \u003cem\u003eTrichosporon\u003c/em\u003e (13.5%) and \u003cem\u003eGeotrichum\u003c/em\u003e (1.9%). \u003cem\u003eAspergillus\u003c/em\u003e was the most prevalent mold identified (17.3%), followed by \u003cem\u003ePenicillium\u003c/em\u003e (6.7%), \u003cem\u003eCurvularia\u003c/em\u003e (2.9%), and \u003cem\u003eFusarium\u003c/em\u003e, \u003cem\u003eTalaromyces\u003c/em\u003e, and \u003cem\u003eTrichophyton\u003c/em\u003e (1% each). Yeast infections exhibited a significantly higher proportion of mild to moderate cases compared to mold infections (82.2% vs. 58.1%, p\u0026thinsp;=\u0026thinsp;0.013).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eYeasts and non-dermatophyte molds are the leading causes of onychomycosis among traders in Nghe An province. Broad-spectrum antifungal agents appear to be a rational choice for the treatment.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics and Causative Agents of Toenail Onychomycosis among Small Traders in Nghe An Province, Vietnam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 14:19:34","doi":"10.21203/rs.3.rs-6438153/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e9248f6-0058-4342-91e5-bdacad44f069","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-24T07:39:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 14:19:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6438153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6438153","identity":"rs-6438153","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}