Risk Factors and Treatment Trends for Onychomycosis: A Case–Control Study of Onychomycosis Patients in the All of Us Research Program
Authors: Albucker Samantha Jo , Falotico Julianne M. , Choo Zi-Ning , Matushansky Justin T. , Lipner Shari R. 
Published: June 2023

Introda significant: Onychomycosis is the most common nail disorder seen in clinical practice, and it may have significant impact on patient quality of life. Understanding risk factors for onychomycosis may help to devise screening and treatment guidelines for populations that are more susceptible to this infection. Using a national database, we aimed to explore associations between onychomycosis and age, sex, and underlying medical conditions, as well as to examine current onychomycosis treatment trends. Materials and Methods: We performed a nested, matched, case–control study of patients in the All of Us database aged ≥ 18 years (6 May 2018–1 January 2022). Onychomycosis cases were identified using International Classification of Diseases (ICD) and Systematized Nomenclature of Medicine (SNOMED) diagnostic codes (ICD-9 110.1, ICD-10 B35.1, SNOMED 414941008). Demographic information (i.e., age, sex, and race), treatments, and co-diagnoses for onychomycosis patients and case–controls were recorded. Wald’s test applied to multivariate logistic regression was used to calculate odds ratios and p-values between onychomycosis and co-diagnoses. Additionally, 95% confidence intervals were calculated with a proportion test. Results: We included 15,760 onychomycosis patients and 47,280 matched controls. The mean age of onychomycosis patients was 64.9 years, with 54.2% female, 52.8% Non-Hispanic White, 23.0% Black, 17.8% Hispanic, and 6.3% other, which was similar to controls. Patients with onychomycosis vs. controls were more likely to have a co-diagnosis of obesity (46.4%, OR 2.59 [2.49–2.69]), tinea pedis (21.5%, OR 10.9 [10.1–11.6]), peripheral vascular disease (PVD) (14.4%, OR 3.04 [2.86–3.24]), venous insufficiency (13.4%, OR 3.38 [3.15–3.59]), venous varices (5.6%, OR 2.71 [2.47–2.97]), diabetes mellitus (5.6%, OR 3.28 [2.98–3.61]), and human immunodeficiency virus (HIV) (3.5%, OR 1.8 [1.61–2.00]) (p < 0.05, all). The most frequently prescribed oral and topical medications were terbinafine (20.9%) and ciclopirox (12.4%), respectively. The most common therapeutic procedure performed was debridement (19.3%). Over the study period, ciclopirox prescriptions (Spearman correlation 0.182, p = 0.0361) and fluconazole prescriptions increased (Spearman correlation 0.665, p = 2.44 × 10−4), and griseofulvin (Spearman correlation −0.557, p = 0.0131) and itraconazole prescriptions decreased (Spearman correlation −0.681, p = 3.32 × 10−6). Conclusions: Our study demonstrated that age, obesity, tinea pedis, PVD, venous insufficiency, diabetes mellitus, and HIV were significant risk factors for onychomycosis. In addition, the most frequent oral and topical onychomycosis medications prescribed were terbinafine and ciclopirox, likely reflective of efficacy and cost considerations. Identifying and managing these risk factors is essential to preventing onychomycosis’ primary infections and recurrences and improving treatment efficacy.