{"doi":"10.1016/j.jaad.2022.06.1201","title":"Opportunities to improve guideline adherence for the diagnosis and treatment of onychomycosis: Analysis of commercial insurance claims data, United States","abstract":"To the Editor: Onychomycosis, a fungal nail infection most frequently caused by dermatophytes, is an underrecognized public health problem, particularly given the global emergence of terbinafine resistance.1Gu D. Hatch M. Ghannoum M. Elewski B.E. Treatment-resistant dermatophytosis: a representative case highlighting an emerging public health threat.JAAD Case Rep. 2020; 6: 1153-1155Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar,2Singh S. Chandra U. Anchan V.N. Verma P. Tilak R. Limited effectiveness of four oral antifungal drugs (fluconazole, griseofulvin, itraconazole and terbinafine) in the current epidemic of altered dermatophytosis in India: results of a randomized pragmatic trial.Br J Dermatol. 2020; 183: 840-846Crossref PubMed Scopus (30) Google Scholar We estimated onychomycosis prevalence, described risk factors, and assessed adherence to American Academy of Dermatology (AAD) guidelines that recommend confirmatory testing (eg, direct microscopy, histopathology, fungal culture) before prescribing oral antifungal therapy.3Guidelines of care for superficial mycotic infections of the skin: onychomycosis. Guidelines/Outcomes Committee. American Academy of Dermatology.J Am Acad Dermatol. 1996; 34: 116-121Abstract Full Text PDF PubMed Scopus (53) Google Scholar We analyzed IBM MarketScan Commercial and Medicare Supplemental databases. We used International Classification of Diseases, 10th Revision, codes to identify onychomycosis patients and underlying conditions; we used Current Procedural Terminology codes to identify onychomycosis-related tests and procedures (Supplementary Table I, available via Mendeley at https://doi.org/10.17632/33j7s646j7.1). We calculated disease prevalence among all outpatients seen during 2018. We assessed underlying conditions and diagnostic and treatment practices in an analytic cohort; this cohort included outpatients diagnosed with onychomycosis during 2018 who had continuous insurance enrollment 365 days before and after incident diagnosis date and no onychomycosis diagnosis during the 365 days before their 2018 incident diagnosis. During 2018, among 21,298,716 outpatients, onychomycosis prevalence was 1.6% overall and 12.7% among patients aged ≥65 years. In the analytic cohort (n = 121,386), male gender (age-adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI]: 1.02-1.04) and nonrural residence (aOR = 1.34, 95% CI: 1.31-1.37) were associated with onychomycosis (Table I). Common underlying conditions included diabetes (23.0%), immunosuppressive conditions (21.8%), and non-unguium tinea (12.6%).Table IDemographic features and underlying medical conditions associated with onychomycosis patients (n = 121,386) in a large, commercially insured population—United States, 2018Characteristicn%aOR (95% CI)∗Age-adjusted odds ratios were calculated by comparing patients diagnosed with onychomycosis versus patients not diagnosed with onychomycosis during 2018. Among the 121,386 patients diagnosed with onychomycosis, 2.6% were aged <18 years, 8.8% were aged 18-34 years, 12.6% were aged 35-44 years, 22.2% were aged 45-54 years, 31.2% were aged 55-64 years, and 22.6% were aged ≥65 years. Among the 10,732,239 patients without onychomycosis, 23.6% were aged <18 years, 19.8% were aged 18-34 years, 15.1% were aged 35-44 years, 19.0% were aged 45-54 years, 18.4% were aged 55-64 years, and 4.1% were aged ≥65 years.Age (years), median (IQR)56 (45-63)NAGender Male56,23146.31.03 (1.02-1.04) Female65,15553.7ReferentUrban-rural classification Nonrural110,37190.91.34 (1.31-1.37) Rural10,8478.9Referent Unknown/missing†These missing data were excluded from aOR calculations.1680.1NAUS census region of primary beneficiary's residence Northeast37,09130.61.47 (1.45-1.50) South47,59339.21.04 (1.02-1.05) West13,93311.51.01 (0.99-1.03) Midwest22,52918.6Referent Unknown/missing†These missing data were excluded from aOR calculations.2400.2NAUnderlying conditions Tinea (non-unguium)15,23712.613.46 (13.","journal":"Journal of the American Academy of Dermatology","year":2022,"id":249424,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":28,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9555,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2022-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":889678,"name":"Karen Wu","orcid":"0000-0003-4294-6278","position":1,"is_corresponding":false},{"id":271206,"name":"Brendan R. Jackson","orcid":"0000-0002-3369-2408","position":2,"is_corresponding":false},{"id":468308,"name":"Kaitlin Benedict","orcid":"0000-0003-0458-2493","position":3,"is_corresponding":false},{"id":712810,"name":"Jeremy A.W. Gold","orcid":"0000-0002-5054-7616","position":0,"is_corresponding":true}],"reference_count":5,"raw_metadata":null,"created_at":"2026-07-19T00:24:19.356023Z","pmid":"35809801","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}