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Sir, only be obtained from the surface of the nail plate; all of these grew T. rubrum. Onychomycosis may be caused by dermatophytes, yeasts or molds. About 80% of the cases are caused by dermatophytes, In the last 4 patients with positive culture the nails were in varying degrees thickened, friable and discoloured. primarily Trichophyton rubrum, which infect toenails more frequently than fingernails. In all the remaining cases samples were taken from the underside as well. In 6 of these, cultures were positive from The majority of the yeast infections are caused by Candida albicans, and fingernails are far more commonly involved than both the surface of the nail plate and the underside, but the fungus identified was the same from both sides of the nail. In toenails. Yeast infection constitutes about 17% of the cases, and molds constitute 3–5% of the cases, although some of the 3 cases culture was positive from the underside but negative from the surface of the nail plate. latter are secondary to dermatophyte infections or trauma (1). Onychomycosis is frequently seen in HIV patients, and several studies have reported up to 12% (2, 3). The increased susceptiDISCUSSION bility of HIV patients to ordinary superficial fungal infections, especially candidosis, may have increased their risk of infection Tinea pedis is the most common form of dermatophytosis in with more unusual opportunistic species. For this reason we HIV-positive patients. In AIDS patients, however, onychomade a study of nail changes in HIV patients, with special mycosis becomes the predominant form, often with no evidence reference to demonstration of the presence of molds which of dermatophytosis elsewhere on the skin. Onychomycosis might contribute to therapy resistance. commonly appears with a CD4 cell count of <450 cells/mm3 . We examined 22 HIV-positive patients with abnormal nails With disease progression there is no clear increase in occurin order to identify pure or mixed infections with dermatorence of dermatophytosis, but the clinical picture becomes phytes, molds or yeast. more severe and often more resistant to therapy (4–6). PWSO, which represents 90% of the cases of onychomycosis MATERIAL AND METHODS in AIDS patients, is unusual in the general population (7–9). Just as in the non HIV-positive population, T. rubrum is the Twenty-two HIV-positive patients with nail changes, referred to the most common cause (10). In our material T. rubrum was dermatological outpatient clinic because of skin diseases, were seen demonstrated in 8 of 12 of the positive cultures, and in 4 of consecutively during the period 1/9 93 to 1/7 94 and examined for these the clinical manifestation was PWSO (33.3%). In 4 onychomycosis.The material comprised 21 men, mean age 44 years (31–57) and one African woman, 36 years old. All were HIV-positive patients the infected nails were absolutely dystrophic, which with AIDS-related complex (ARC) or AIDS, but the CD4 cell count made it impossible to decide if it had started as PWSO. was not available. Non-dermatophytes were not isolated in this study. However, they account for only a few per cent of the cases of Mycology onychomycosis, and the number of patients in our study is small. Material was obtained from the top and underside of the infected nail Pierard et al. (11) have demonstrated how histology and with a small curette after thorough cleaning with alcohol. No samples immunohistochemistry in combination with culture can reveal were taken from the skin. Microscopy was performed in a fluorescent different fungi within the same nail section. For instance, thick microscope after addition of blankophor 10%. All specimens were fungal hyphae in the upper nail plate and thinner filaments in cultured on 3 agar plates, one containing Sabouraud’s dextrose agar the deep part of the nail plate were identified by culture to be with chloramphenicol (0, 005%) and 2 also containing cycloheximide 0.05%. The specimens were incubated at 24°C for up to 5 weeks. The T. rubrum and Aspergillus species, respectively. agar plates were read daily. Typing was performed according to In the 6 cases where growth was found on the surface of microscopical features. the nail plate as well as on the underside, the cultures were identical. Thus, we found no signs of ‘‘mixed infections’’. RESULTS Our results correspond with previous studies, as dermatophytes, primarily T. rubrum, were found in all the positive Twenty-one patients had toenail changes and one had fincultures, except for one case of Candida albicans. gernail changes. Dermatophytes were demonstrated in 12 of the 22 HIV-infected patients (54.5%). Candida albicans infection was seen in one patient, T. rubrum in 8, T. mentagrophytes REFERENCES in one, T. violaceum in one, T. tonsurans in one, and in one 1. Clayton YM. Clinical and mycological diagnostic aspects of patient both T. rubrum and T. mentagrophytes were found. T. onychomycoses and dermatomycoses. Clin Exp Dermatol 1992; violaceum was demonstrated in the patient from Africa, the 17(Suppl.1): 37–40. only patient with fingernail involvement. Nine patients had 2. Sindrup JH, Weismann K, Petersen CS, Rindum J, Pedersen C, negative cultures, so infection due to molds was not demonMathiesen, et al. Skin and oral mucosal changes in patients strated. One patient suffered from psoriasis with nail changes, infected with human immunodeficiency virus. Acta Derm Venereol but culture was negative. No other patients had skin diseases (Stockh) 1988; 68: 440–443. with nail involvement. 3. Goodman DS, Teplitz ED, Wishner A, Klein RS, Burk PG, The clinical type PWSO was demonstrated in 4 of the HIVHershenbaum E. Prevalence of cutaneous disease in patients with infected patients and T. rubrum cultured from these. Nail acquired immunodeficiency syndrome (AIDS) or AIDS-related complex. J Am Acad Dermatol 1987; 17: 210–220. dystrophy was so advanced in 4 patients that specimens could

Malignant skin lesions on the legs and feet at a dermatological leg ulcer clinic during five years