nal of the
`American Academy of
`
`
`
`ADERMATOLOGY
`
`May 1998 A
`
`V()l.UMIi 38 NlHVlBI{R 5
`
`PART I
`
`
`
`0 CME article %
`
`Vitiligo %
`Stephen (). Kuvacs, Ml)
`SI. Louis. Missollri
`
`° Se1f—Assessmentexamjination f
`
`
`
`INSN 0190-‘I622
`
`B“ Mosby
`
`
`
`
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`

`
`Journal of the
`
`American Academy of
`DERMATOLOGY
`
`Copyright © 1998 by the American Academy ofDermatology, Inc.
`
`CONTENTS
`
`May, Part 1, 1998
`
`CONTINUING MEDICAL EDUCATION
`
`Vitiligo
`Stephen 0. Kovacs, MD St. Louis, Missouri
`
`CME examination
`
`Answers to CME examination (Identification
`No. 898-104), April 1998 issue of the Journal
`of the American Academy of Dermatology
`
`CLINICAL AND LABORATORY STUDIES
`
`An estimate of the annual direct cost of treating
`cutaneous melanoma
`
`Hensin Tsao, MD, PhD, Gary S. Rogers, MD, and
`Arthur J. Sober, MD Boston, Massachusetts
`
`Clinical and histologic trends of melanoma
`Timothy M. Johnson, MD, Olivia M. Dolan, MD,
`Ted A. Hamilton, MS, Melvin C. Lu, MD,
`Neil A. Swanson, MD, and Lori Lowe, MD
`Ann Arbor, Michigan
`
`Narrow band UVB (311 nm) phototherapy and
`PUVA photochemotherapy: A combination
`Piergiacomo Calzavara-Pinton, MD Brescia, Italy
`
`Contact hypersensitivity to tixocortol pivalate
`Michael E. Lutz, MD,
`Rokea A. el—Azhary, MD, PhD,
`Lawrence E. Gibson, MD, and
`Anthony F. Fransway, MD Rochester, Minnesota
`
`Mycosis fungoides in young patients: Clinical
`characteristics and outcome
`
`Jeffrey J. Crowley, MD, Anthony Nikko, MD,
`Anna Varghese, BA, Richard T. Hoppe, MD, and
`Youn H. Kim, MD Stanford, California
`
`Nfl Mosby
`
`Continued on page 7A
`
`Editor
`Richard L. Dobson, MD
`Associate Editor
`Bruce H. Thiers, MD
`Editorial Oflice
`Department of Dermatology
`Medical University of South Carolina
`171 Ashley Ave.
`Charleston, SC 29425-2215
`803-792-9155
`Assistant Editors
`Elizabeth A. Abel, MD
`Mountain Wew, Califomia
`Jeffrey D. Bernhard, MD
`Worcester, Massachusetts
`Michael E. Bigby, MD
`Boston, Massachusetts
`Jeffrey P. Callen, MD
`Louisville, Kentucky
`Clay J. Cockerell, MD
`Dallas, Texas
`Mark V. Dahl. MD
`Minneapolis, Minnesota
`Madeleine Duvic, MD
`Houston, Texas
`Mary Maloney, MD
`Hershey, Pennsylvania
`Brian Nickoloff, MD
`Ann Arbor; Michigan
`Amy S. Paller, MD
`Chicago, Illinois
`Neal S. Penneys, MD
`St. Louis, Missouri
`Stuart J. Salasche, MD
`Tucson, Arizona
`Robert A. Schwartz, MD
`Newark, New Jersey
`Elizabeth Sherertz, MD
`Winston—Salem, North Carolina
`Alvin R. Solomon, MD
`Atlanta, Georgia
`Kenneth J. Tomecki, MD
`Cleveland, Ohio
`
`Founding Editor
`J. Graham Smith, Jr., MD
`Mobile, Alabama
`Vol. 38, No. 5, Part 1, May 1998, the Journal of the
`American Academy of Dermatology (ISSN 0190-9622) is
`published monthly (six issues per volume, two volumes
`per year) by Mosby, Inc., 11830 Westline Industrial Dr.,
`St. Louis, MO 63146-3318. Periodicals postage paid at St.
`Louis, Missouri,
`and additional mailing offices.
`Postmaster: Send address changes to Journal of the
`American Academy of Dermatology, Mosby, Inc., 11830
`Westline Industrial Dr., St. Louis. MO 63146-3318.
`Annual subscription rates: $155.00 for individuals,
`$268.00 for institutions. Subscription prices effective
`through Sept. 30, 1998. Printed in the U.S.A. Copyright ©
`1998 by the American Academy of Dermatology, lnc.,
`PO. Box 4014, Schaumburg, IL 60168-4014.
`
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`5A
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`CFAD v. Anacor, IPR2015-01776 ANACOR EX. 2064 - 2/9
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`

`
`Contents
`
`continued
`
`Effect of onychomycosis on quality of life
`Lynn A. Drake, MD, Richard K. Scher, MD, Edgar B. Smith, MD,
`Gerald A. Faich, MD, MPH, Shondra L. Smith, MD, Joseph J. Hong, MD, and
`Matthew J. Stiller, MD Boston, Massachusetts; New York, New York;
`Galveston, Texas; and Narbelh, Pennsylvania
`
`THERAPY
`
`Once-daily tazarotene gel versus twice-daily fluocinonide cream in the
`treatment of plaque psoriasis
`Mark Lebwohl, MD, Ernest Ast, MD, Jeffrey P. Callen, MD,
`Stanley 1. Cullen, MD, Steven R. Hong, MD, Carol L. Kulp—Shorten, MD,
`Nicholas J. Lowe, MD, Tania J. Phillips, MD, Theodore Rosen, MD,
`David I. Wolf, MD, Janine M. Quell, BS, John Sefton, PhD, John C. Lue, MS,
`John R. Gibson, MD, and Roshantha A. S. Chandraratna, PhD
`New York and Great Neck, New York; Louisville, Kentucky; Gainesville, Florida;
`Boulder, Colorado; Boston, Massachusetts; Houston, Texas; and
`Santa Monica, Wsta, and Irvine, California
`
`Intrauterine epidermal necrosis: Report of three cases
`Ramon Ruiz-Maldonado, MD, Carola Duran-McKinster, MD,
`Daniel Carrasco—Daza, MD, Lourdes Tamayo—Sz’1nchez, MD, and
`Maria de la Luz Orozco—Covarrubias, MD Mexico City, Mexico
`
`CLINICAL REVIEWS
`
`Ocular melanomas and melanocytic lesions of the eye
`Jennifer M. Grin, MD, Jane M. Grant—Kels, MD, Caron M. Grin, MD,
`Adrienne Berke, MD, and Barry D. Kels, MD Farmington, Connecticut
`
`Advances in melanoma therapy
`Timothy M. Johnson, MD, Alan M. Yahanda, MD, Alfred E. Chang, MD,
`Darrell J. Fader, MD, and Vernon K. Sondak, MD Ann Arbor: Michigan
`
`CURRENT ISSUES
`
`The multidisciplinary melanoma clinic: A cost outcomes analysis of
`specialty care
`Darrell J. Fader, MD, Christopher G. Wise, PhD, MHA, Daniel P. Normolle, PhD,
`and Timothy M. Johnson, MD Ann Arbor, Michigan
`
`What promotes skin self-examination?
`June K. Robinson, MD, Darrell S. Rigel, MD, and Rex A. Amonette, MD
`Chicago, Illinois, New York, New York, and Memphis, Tennessee
`
`PEARLS OF WISDOM
`
`Surgical Pearl: The “unsuture” technique for skin grafts
`Ida Orengo, MD, Min—Wci Christine Lee, MD, MPH Houston, Texas
`
`Statements and opinions expressed in the articles and communications herein are those of the z1uthor(s) and notneccssatily those of the Editor(s), publisher, or Academy,
`and the Editor(s), publisher, and Academy disclaim any responsibility or liability for such material. Neither the Editor(s), publisher, nor the Academy guarantees, war-
`rants, or endorses any product or service advertised in this publication. nor do they guarantee any claim made by the manufacturer of such product or service.
`
`May, Part 1, 1998 7A
`Journal of the American Academy of Dermatology
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`Continued on page 9A
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`CFAD v. Anacor, IPR2015-01776 ANACOR EX. 2064 - 3/9
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`

`
`Contents
`
`continued
`
`Iotaderma #52
`
`Jeffrey D. Bernhard, MD Worcester, Massachusetts
`
`BRIEF COMMUNICATIONS
`
`Worsening of lichen myxedematosus during interferon alfa-2a therapy for
`chronic active hepatitis C
`Franco Rongioletti, MD, and Alfredo Rebora, MD Genoa, Italy
`
`Herpes zoster after varicella immunization
`Marilyn G. Liang, MD, Karen A. Heidelberg, MD, Robert M. Jacobson, MD,
`and Marian T. MCEvoy, MB, MRCPI Rochester, Minnesota
`
`Lasting immunity to varicella in doctors study (L.I.V.l.D. Study)
`Barry A. Solomon, MD, Athena G. Kaporis, MD, Alan T. Glass, MD,
`Steven 1. Simon, MD, and Hilary E. Baldwin, MD
`Brooklyn and Long Beach, New York
`
`Severe neutropenia associated with oral terbinafine therapy
`Aditya K. Gupta, MD, FRCPC, Gamini S. Soori, MD, James Q_. Del Rosso, DO,
`Paul B. Bartos, MD, and Neil H. Shear, MD, FRCPC Toronto, Ontario, Canada;
`Omaha, Nebraska; Las Vegas, Nevada; and Canton, Ohio
`
`Multiple basal cell carcinomas of the limb after adjuvant treatment of
`melanoma with isolated limb perfusion
`Philina M. Lamb, BS, Gregg M. Menaker, MD, and Ronald L. Moy, MD
`Los Angeles, California
`
`Spontaneous clearing of psoriasis after stroke
`Alexander J. Stratigos, MD, Alexander K. Katoulis, MD, and
`Nicholas G. Stavrianeas, MD Boston, Massachusetts, and Athens, Greece
`
`Lichen planus associated with Becker’s nevus
`Patrick Terheyden, MD, Barbara Hornschuh, MD, Susanne Karl, MD,
`Jiirgen C. Becker, MD, and Eva-B. Brocker, MD Wiirzbitrg, Germany
`
`Chevron nail
`
`Martin N. Zaiac, MD, Brad P. Glick, DO, MPH, PA, and Nardo Zaias, MD
`Miami Beach and Margate, Florida
`
`MEETING REPORT
`
`Executive summary of the national “Sun Safety: Protecting Our Future”
`Conference: American Academy of Dermatology and Centers for Disease
`Control and Prevention, New York, New York, May 1 and 2, 1997
`June K. Robinson, MD, Rex Amonetle, MD, Stephen W. Wyatt, DMD,
`Barbara A. Bewerse, MN, MPH, Wilma F. Bergfeld, MD, and
`Patricia K. Farris, MD
`
`Continued on page IIA
`
`Journal of the American Academy of Dermatology
`
`May, Part I, 1998 9A
`
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`

`
`Contents
`
`continued
`
`CORRESPONDENCE
`
`Penile lentiginosis
`Athena Kaporis, MD, and Yelva Lynfield, MD Brooklyn, New York
`
`Reply
`MAJ Joseph C. English III, MC, USAR, CPT
`Richard A. Laws, MC, USAR, CPT George C. Keough, MC, USAR, CPT
`Joseph L. Wilde, MC, USAR, LTC John P. Foley, MC, USA, and
`LTC Dirk M. Elston, MD, USA Fort Sam Houston, Texas
`
`Hydroxyurea-induced dermopathy: A unique lichenoid eruption complicating
`long-term therapy with hydroxyurea
`Brian Kirby, MB, MRCPI, and Sarah Rogers, MSC, FRCP, FRCPI
`Lancashire, England, and Dublin, Ireland
`
`Reply
`Mark R. Pittelkow, MD, and Lawrence E. Gibson, MD Rochester: Minnesota
`
`Melanoma and levodopa
`Frans Rampen, MD, Oss, The Netherlands
`
`Reply
`Wolfgang Pfutzner, MD, and Bernhard Pryzbilla, MD Munchen, Germany
`
`Antimicrobial agents for the dermatologist. I. B-Lactam antibiotics and
`related compounds
`Stuart L. Shear, MD Los Angeles, California
`
`Cutaneous nodular reaction to oral mercury
`Jeffrey Suchard, MD, Kevin Wallace, MD, Kimberlie Graeme, MD,
`Frank LoVecchio, DO, Delilah Stephens, MD, Laura Harrington-Zautra, MD,
`and Steven Curry, MD Phoenix, Arizona
`
`Phenytoin-like hypersensitivity associated with lamotrigine
`Patrick Tugendhaft, MD, and Thierry Simonart, MD Brussels, Belgium
`
`Immunohistochemical characterization of dermatofibrosarcoma protuberans
`with practical applications for diagnosis and treatment
`COL Kathleen J. Smith, MC, USA, CAPT Padman Menon, MC, USN, and
`Henry Skelton, MD Bethesda, Maryland, and Herndon, Virginia
`
`BOOK REVIEWS
`
`Primary care dermatology. Kenneth A. Arndt, MD, Bruce U. Wintroub, MD,
`June K. Robinson, MD, and Phillip E. LeBoit, MD, editors
`Reviewed by Barry Hainer, MD Charleston, South Carolina
`
`Facial surgery: Plastic and reconstructive. Mack Cheney, editor
`Reviewed by Joel Cook, MD Charleston, South Carolina
`
`Continued on page 13A
`
`Journal of the American Academy of Dermatology
`
`May, Part 1, 1998 11A
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`

`
`Contents
`
`continued
`
`Body contouring: The new art of liposculpture. William P. Coleman III, MD,
`C. William Hanke, MD, William R. Cook, MD, and Rhoda S. Narins, MD
`Reviewed by Ronald L. Moy, MD Los Angeles, California
`
`A color guide to diagnosis and treatment. Lowell A. Goldsmith, MD,
`Gerald S. Lazarus, MD, FACP, and Michael D. Tharp, MD
`Reviewed by Lesly S. Davidson, MD Melbourne Beach, Florida
`
`SELF-ASSESSMENT
`
`Self-Assessment examination of the American Academy of Dermatology
`(Identification No. 898-205)
`
`Answers to ‘Self-Assessment examination of the American Academy of
`Dermatology
`May 1998 issue of the Journal of the American Academy of Dermatology
`
`ANNOUNCEMENTS
`
`Attention Authors
`
`Call for Patients with Inherited Diseases of the Skin
`
`National Registry for Ichthyosis and Related Disorders
`
`READER SERVICES
`
`Information for authors
`
`Information for readers
`
`Dermatology opportunities
`
`Instructions for Category I CME credit
`
`Instructions for Category I CME credit (Self-Assessment)
`
`CME examination answer sheet
`
`CME examination answer sheet (Self-Assessment)
`
`Statement of advertising in the Journal
`
`Index to advertisers
`
`20A, 21A, and 22A
`
`24A
`
`114A
`
`28A
`
`28A
`
`35A
`
`109A
`
`22A
`
`120A
`
`Complimentary subscriptions to the Journal of the American Academy of Dermatology are
`available to dermatology residents, fellows, and osteopathic trainees in the United States and
`Canada as an educational service by Westwood Squibb Pharmaceuticals, a division of
`Bristol—Myers Squibb Company.
`
`journal of the American Academy of Dermatology
`
`May, Part 1, 1998
`
`13A
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`

`
`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`Effect of onychomycosis on quality of life
`
`Lynn A. Drake, MD,‘1 Richard K. Scher, MD,b Edgar B. Smith, MD,‘3
`Gerald A. Faich, MD, MPH,d Shondra L. Smith, MD,a Joseph J. Hong, MD,3 and
`Matthew J. Stiller, MDa Boston, Massachusetts; New York, New York; Galveston, Texas;
`
`and Narbetlz, Pennsylvania
`
`Background: Onychomycosis impairs normal nail functions, causes considerable pain,
`interferes with daily activities, and has negative psychosocial effects.
`Objective: Our purpose was to determine patients’ perception of onychomycosis on the
`quality of life.
`Methods: A total of 258 patients with confirmed onychomycosis were surveyed by tele-
`phone at three centers. Responses to a standardized quality-of-life questionnaire were ana—
`lyzed for patient demographics, physical and functional impact, psychosocial impact, and
`economic impact.
`Results: Highest positive responses were nail-trimming problems (76%), embarrassment
`(74%), pain (48%), nail pressure (40%), and discomfort wearing shoes (38%). Ability to
`pick up small objects was impaired in 41% of subjects with fingernail involvement. More
`than 58 onychomycosis—related sick days and 468 medical visits (1.8 per subject) were
`reported during a 6-month period.
`Conclusion: Onychomycosis has significant social, psychologic, health, and occupational
`effects. Relevance of quality—of-life issues to overall health, earning potential, and social
`functioning should prompt reconsideration of the value of aggressive treatment of and
`financial coverage for onychomycosis.
`(J Am Acad Dermatol l998;38:702—4.)
`
`Onychomycosis is the most common nail dis-
`ease, and the number of persons affected appears
`to be rising, especially among the elderly. In one
`year (1989 to 1990), 662,000 Medicare patients
`(older than 65 years) made nearly 1.3 million vis-
`its to physicians for the treatment of onychomyco—
`sis, resulting in a cost of more than $43 million}
`Spontaneous remission of onychomycosis after
`treatment is rare, and recurrence is common?
`
`Medications used in the past have been limited by
`the need for prolonged treatment periods and low
`
`the Cutaneous Biology
`From the Department of Dermatology,
`Research Center, and the Wellman Laboratories of Photomedicine
`at Massachusetts General Hospital, Harvard Medical School,
`Boston“; the Department of Dermatology, Columbia University,
`New York“: the Department of Dermatology, University of Texas
`Medical Branch, Galvestonc:
`and Pharmaceutical Safety
`Assessments, Inc., Narbethfl
`Supported in part by an
`Pharmaceutica, Inc.
`Accepted for publication Feb. 18, 1998.
`Reprint requests: Lynn A. Drake, MD, Massachusetts General
`Hospital, Dermatology » BAR 604, 40 Blossom St., Boston, MA
`02114-2696.
`Copyright © 1998 by the American Academy of Dermatology, Inc.
`0190-9622/98/$5.00 + 0
`16/1/89600
`
`educational grant
`
`from Janssen
`
`such as
`cure rates. However, newer agents,
`terbinafine and itraconazole, have been shown to
`be safer and more effective.“ With more effective
`
`treatment options, the impact of onychomycosis
`on patients’ quality of life is worth examining.
`When nails are infected, normal tactile fume-
`
`tions may be impaired or lost, and patients may
`experience pain or discomfort. Toenail dystrophy
`may interfere with walking, standing, exercise. or
`proper shoe fit, and fingernail infection may limit
`activities such as typing or playing a musical
`instrument. Onychomycosis also has psychoses: ial
`effects related to patients’ concerns about the
`appearance of their nails: embarrassment, reduced
`self—esteem, and social withdrawal are commcnly
`
`reported}
`The first study to document the effect of ony-
`chomycosis on quality of life was by Lubeck et al.5
`in 1993. Significantly lower quality—of-life scores
`for almost all measures were found. Our pilot
`study examined quality of life in 20 patients with
`onychomycosis of an average duration of 11
`years‘) Twenty—five percent reported paresthesiflsa
`30% reported loss of fine touch, 35% reported
`
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`]o!73‘l1£tl of the American Academy of Dermatology
`Volume 38, Number 5, Part 1
`
`Drake et al.
`
`703
`
`p.-Iii, and 20% reported problems with retrieval of
`s"T;3I;tll objects. Similar proportions of patients
`described recreational problems caused by diffi-
`culty to perform or embarrassment, fear of injury,
`well as interference with social and profession-
`al relationships. This study extended these find-
`ings by investigating a larger patient population.
`
`PATIENTS AND METHODS
`
`A total of 258 subjects were interviewed by ques-
`tiunnaire: 118 (46%) from Massachusetts General
`
`Hospital, 99 (38%) from Columbia University College
`oi’ Physicians and Surgeons, and 41 (16%) from the
`’t.3.:.'tiversity of Texas Medical Branch at Galveston. The
`subjects were generally healthy, had a median age of
`51.5 years, and were predominantly white and male.
`T3;iirty—seven percent took prescription drugs daily,
`mostly for hypertension or for cardiac or pulmonary
`conditions. About half were employed in white collar or
`§‘:~'.‘-OfeSSlOI1Ell positions; the median household income
`was about $60,000. Seventy percent had attended col-
`lege, and 94% had some form of medical insurance.
`few differences were noted among the three centers,
`although the population from Texas included a higher
`proportion of women (49% vs 39% and 25% at the
`other two sites) and was less affluent (22% with income
`over $60,000 vs 49% and 53% at the other two sites).
`The questionnaire consisted of 57 questions divided
`into patient, physical and functional, psychosocial and
`economic domains. The questions were developed on
`the basis of the authors’ experience, the pilot study at
`Massachusetts General Hospital, and the quality-of—life
`instrument developed by Lubeck et al.5 Interviewers
`presented the questions by telephone. The high and
`complete (95%) response rate indicated favorable
`patient acceptance of the questionnaire. For perceptions
`of general health and impact of onychomycosis, sub-
`iects were asked to respond on a five-point scale (excel-
`lent to poor, and no problem to very severe problem).
`All other physical, functional, and psychosocial ques-
`tions had four possible responses: absent, mild, moder-
`ate, or severe. Quality-of—life scores were determined
`by assigning a weighted average to the responses as fol-
`lows: absent = 100, mild = 66.6, moderate = 33.3,
`severe = 0.
`
`RESULTS
`
`The mean duration of nail fungal disease in the
`study population was 9.5 years. At the time of the
`interview, 227 subjects (88%) had active nail dis-
`ease. More than half with fingernail disease and
`about 35% of those with toenail disease had had
`
`involvement of one to three nails. All 10 digits had
`been affected in 15% of subjects with fingernail
`
`and 28% of those with toenail involvement. Nearly
`40% reported an associated fungal infection on the
`soles during the past 3 years.
`Onychomycosis affected the fingernails alone
`in 23 subjects (9%), the toenails alone in 128
`(50%), and both the fingernails and toenails in 107
`(41%). The group with toenail involvement alone
`included a significantly (p < 0.05) higher propor-
`tion of men (63% vs 43%), white subjects (88% vs
`74%), and subjects employed in white collar or
`professional positions (61% vs 39%) than the
`group with fingernail involvement alone. Seventy
`percent of subjects considered their nails to be at
`least a moderate problem. Subjects with toenail
`involvement alone perceived their problem as
`more serious, with 19% categorizing it as severe or
`very severe as compared with 30% with fingernail
`involvement alone and 46% with both toenail and
`
`fingernail involvement. This difference was also
`significant (p < 0.05).
`involve-
`Of the 130 subjects with fingernail
`ment, 54 (42%) reported tingling, burning, numb-
`ness, pressure, or discomfort. These feelings were
`reported by all 235 subjects with toenail involve-
`
`ment. A total of 193 (75%) of the 258 subjects
`were embarrassed about their nails. The extent of
`
`embarrassment was described as mild by 56
`(29%), moderate by 74 (38%), and severe by 63
`(33%). Embarrassment was reported significantly
`less frequently (p < 0.05) by subjects with toenail
`involvement alone (66%) than by those with fin-
`gernail involvement alone (74%) or involvement
`of
`both
`fingernails
`and
`toenails
`(85%).
`Onychomycosis was more likely to cause embar-
`rassment for women (83%) than for men (71%).
`
`Moreover, women were more likely than men to
`feel severe embarrassment (44% vs 26%). Thirty-
`two subjects (12%) reported that their infection
`had interfered with social relationships and 38
`(15%) had avoided social situations because of
`their condition.
`
`More than 58 days of sick time were reported as
`a result of onychomycosis, and 468 medical visits
`(1.8 per subject) were made for nail—related rea-
`sons during a 6-month period. Subjects with toe-
`nail involvement sought medical care significantly
`more often than those with fingernail involvement
`(p < 0.001). A total of 249 subjects (97%) stated
`that they would be willing to pay for a nail fungus
`medication with an 80% cure rate, even if their
`insurance would not cover the cost. However,
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`
`704 Drake et al.
`
`Journal of the American Academy of D€I‘11'lat010gf’
`May 1998
`
`although women were more embarrassed about
`their disease, men were more willing to pay for
`treatment. Regression analysis showed a relation
`between the willingness to pay more than $100 for
`a treatment with an 80% cure rate and male sex
`
`(1.5—fold), household income, and a greater level
`of embarrassment
`(3.7—fo1d). The number of
`
`patients willing to pay for treatment not covered
`by insurance decreased to 148 (57%) when the
`theoretic cure rate was reduced to 35%.
`
`DISCUSSION
`
`Our subjects all volunteered for clinical trials on
`onyehomyeosis and were therefore a self—selected
`population likely to perceive their disease as sig-
`nificant. In addition, in our study, nail disease
`severity was judged by patients without reference
`to anything external (i.e., they could say their nails
`were severely affected, then separately and subse-
`quently deny physical pain and discomfort and
`even functional and psychosocial problems). For
`these reasons, quality—of—life scores often do not
`correlate with self—reported “global” severity rat-
`ings. In other words, severity and quality of life are
`two separate and different measurements that often
`do not overlap.
`There is strong support for the physical and psy-
`chosocial value of treating non—1ife—threatening but
`
`disfiguring skin conditions. Toenail infection can
`contribute to social isolation; in the elderly, for
`
`example, the ability to walk is crucial to remaining
`active in society.73 Our results indicate that ony-
`chomycosis should be included among the cuta~
`neous disorders with social, psychologic, and
`occupational effects, as well as possibly predis-
`posing persons to more serious medical disorders.
`
`REFERENCES
`
`l. Scher RK. Onyehomycosis is more than a cosmetic pro};-
`lem. Br J Dermatol l944;130(Suppl 43):l5.
`. Piérard GE, Arrese—Estrada J, Pierard—Franchimont L.
`Treatment of onychomycosis: traditional approaches. J
`Am Acad Dermatol l993;29(Suppl):S4l—5.
`. Roberts DT. Oral therapeutic agents in fungal nail dis»
`ease. J Am Acad Dermatol l994;3l(Suppl):S78—81.
`. Arenas R, Dominguez-Cherit J, Fernandez LM. Op: 1
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`. Lubeck DP, Patrick DL, McNulty P, et al. Quality of lire‘-
`of persons with onyehornycosis. Quality of Life
`Research l993;2:341—8.
`. Hong JJ, Stiller M.l, Menn E, et al. A pilot study to deter»
`mine the biopsychosoeial effects of onychomycosis on a
`northeastern American subpopulation [Abstract]. J 11]V’C"’/E
`Dermatol 1995;104:668.
`. Helfand AE. Onychomycosis in the aged: an administ::.:-—
`tive perspective. J Am Podiatr Med Assoc 1986;76:142-
`5.
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`. Kligman AM. Psychological aspects of skin disorders in
`the elderly. Cutis 1989;43:498-501.
`
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