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Axler E, Lipner SR. Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes. Infect Drug Resist 2024; 17:819-843. [PMID: 38463386 PMCID: PMC10922011 DOI: 10.2147/idr.s431526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.
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Affiliation(s)
- Eden Axler
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
| | - Shari R Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
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Zhou YB, Xiao YY, Chao JJ, Ma L. A Novel Itraconazole Pulse Therapy Schedule in the Treatment of Tinea Capitis in Children. Clin Cosmet Investig Dermatol 2021; 14:1799-1803. [PMID: 34858043 PMCID: PMC8630426 DOI: 10.2147/ccid.s342203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022]
Abstract
Tinea capitis is a common dermatophytosis predominantly occurring in children, which needs oral antifungal drug therapy. Itraconazole pulse therapy has been widely applicated in the treatment of adult onychomycosis. However, only a few studies are available for the treatment of pediatric tinea capitis with itraconazole pulse therapy. The therapy schedules vary with respect to dose and intermission. Here, we report four cases of tinea capitis that were treated with a novel high-dose itraconazole pulse therapy (6–10 mg/kg/d with 3 weeks off between consecutive pulses). After 2–3 pulses therapy, all the patients were cured and no adverse reactions were observed. We demonstrate the efficacy and safety of this novel itraconazole pulse therapy schedule. It may be a promising therapy in the treatment of tinea capitis in children.
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Affiliation(s)
- Ya Bin Zhou
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, People's Republic of China
| | - Yuan Yuan Xiao
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, People's Republic of China
| | - Jin Jing Chao
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, People's Republic of China
| | - Lin Ma
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, People's Republic of China
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Abstract
PURPOSE OF REVIEW Nail disorders represent an uncommon subset of complaints seen in pediatric dermatology. There is a wide array of disorders that can affect the nail unit in children, including infectious, inflammatory, neoplastic, congenital, and traumatic processes. In order to enhance familiarity with pediatric nail conditions, we review the background and treatment of the more common entities seen in pediatric onychology, including onychomycosis, onychomadesis, nail psoriasis, trachyonychia, longitudinal melanonychia, onychophagia, and onychocryptosis. RECENT FINDINGS Nail involvement in pediatric patients with psoriasis may indicate increased risk for both overall disease severity and the development psoriatic arthritis. In the evaluation of longitudinal melanonychia, the clinical findings that raise concern for subungual melanoma in adults are often found in benign nail unit nevi in children. In the systemic treatment of pediatric onychomycosis, new data raises the possibility that laboratory monitoring may be approached differently. In the approach to onychophagia, emerging pharmacotherapies include N-acetylcysteine. SUMMARY Most nail disorders in pediatric patients have an overall favorable prognosis. However, nail abnormalities can lead to patient and parental anxiety, decreased quality of life, pain, and functional impairment. Clinicians should be aware of these more common diverse entities in order to identify them and apply state of the art management for these issues. Additionally, the reader will learn factors related to these nail disorders, which may require systemic work-up and/or specialist referral.
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Gupta AK, Mays RR, Versteeg SG, Shear NH, Friedlander SF. Onychomycosis in children: Safety and efficacy of antifungal agents. Pediatr Dermatol 2018; 35:552-559. [PMID: 29943838 DOI: 10.1111/pde.13561] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Onychomycosis is an uncommon condition in childhood, but prevalence in children is increasing worldwide.The objective was to review the efficacy and safety of systemic and topical antifungal agents to treat onychomycosis in children. Databases (Pubmed, OVID, Scopus, clinicaltrials.gov, Cochrane Library) were searched. Seven studies were selected for inclusion. Only one was a randomized controlled trial. In total, 208 children were administered antifungal agents for the treatment of onychomycosis. Four reports of mild adverse events were documented (1.9% of treated children), one of which discontinued treatment (0.5%). Limitations of this review are the lack of randomized controlled trials available in pediatric onychomycosis. These findings suggest that antifungal therapies used to treat onychomycosis in children are associated with a low incidence of adverse events. Current dosing regimens for antifungal drugs are effective and appear safe to use in children, notwithstanding that the Food and Drug Administration has not approved any of these agents for the treatment of onychomycosis in children. To our knowledge, this review is the most up-to-date, comprehensive summary of pediatric onychomycosis treatment.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, ON, Canada.,Division of Dermatology, Department of Medicine, School of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Neil H Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Kaul S, Yadav S, Dogra S. Treatment of Dermatophytosis in Elderly, Children, and Pregnant Women. Indian Dermatol Online J 2017; 8:310-318. [PMID: 28979861 PMCID: PMC5621188 DOI: 10.4103/idoj.idoj_169_17] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually straightforward, treatment of dermatophytosis becomes notably challenging in certain population groups - pregnant women, children, and elderly. Treatment with topical azoles/allylamines alone is effective in limited cutaneous disease in all three groups. Terbinafine is the preferred oral agent in elderly population for treatment of extensive cutaneous disease and onychomycosis due to its lack of cardiac complications and lower propensity for drug interactions. If required, additional physical/mechanical modalities can be employed for symptomatic onychomycosis. Data for systemic therapy in children mainly pertains to the treatment of tinea capitis. At present, very little data exists regarding the safety of systemic antifungals in pregnancy and there is an effort to restrict treatment to topical therapies because of their negligible systemic absorption.
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Affiliation(s)
- Subuhi Kaul
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Savita Yadav
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
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Solís-Arias MP, García-Romero MT. Onychomycosis in children. A review. Int J Dermatol 2016; 56:123-130. [DOI: 10.1111/ijd.13392] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 04/04/2016] [Accepted: 05/11/2016] [Indexed: 11/30/2022]
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Gupta AK, Ryder JE, Skinner AR. Treatment of Onychomycosis: Pros and Cons of Antifungal Agents. J Cutan Med Surg 2016. [DOI: 10.1177/120347540400800107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Antifungal agents are beneficial in the treatment of onychomycosis in the general population, as well as in children, the elderly, and immunocompromised individuals. Special patient populations can be more difficult to treat due to such factors as drug interactions with concomitant medications, adverse events, and poor compliance. In addition, there is limited information about the use of antifungal agents in special populations, e.g., children. Objective: The pros and cons of oral and topical antifungal agents are discussed, with focus on special patient populations. Methods: We searched MedLine (1966 to April 2003) for clinical studies evaluating the efficacy of oral and topical antifungal agents to treat onychomycosis. The key words used in conjunction with “onychomycosis” include: “terbinafine,” “itraconazole,” “fluconazole,” “amorolfine nail lacquer,” “ciclopirox nail lacquer,” “HIV,” “transplant patients,” “diabetes,” “children,” and “elderly.” Studies were excluded if published in a language other than English. Results: Studies have shown that antifungal agents can be of benefit in treating the elderly, children, and immunocompromised individuals (e.g., transplant patients, Down's patients, HIV patients, and diabetics) with onychomycosis. Conclusion: The treatment modality of onychomycosis in special patient populations should take into account the clinical presentation of the onychomycosis, the causative organism, patient and physician preference, the concomitant medications that the patient is on, and the potential for adverse events for that patient if antifungal therapy is undertaken.
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Affiliation(s)
- Aditya K. Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook site) and the University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research, London, Ontario, Canada
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Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol 2015; 171:937-58. [PMID: 25409999 DOI: 10.1111/bjd.13358] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/12/2022]
Affiliation(s)
- M Ameen
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, U.K
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Abstract
INTRODUCTION Onychomycosis is a very common fungal infection of the nail apparatus; however, it is very hard to treat, even when the causative agent is identified, and usually requires prolonged systemic antifungal therapy. Until the 1990s, oral treatment options included only griseofulvin and ketoconazole, and the cure rate was very low. New generations of antimycotics, such as fluconazole, itraconazole and terbinafine have improved treatment success. METHODS Literature was identified by performing a PubMed Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) search. Prospective and randomized clinical trials were chosen to be included in this review. Forty-six trials were included. RESULTS Fluconazole, itraconazole and terbinafine are effective in the treatment of onychomycosis and have a good safety profile. When a dermatophyte is the pathogen, terbinafine produces the best results. For Candida and nondermatophyte infections, the azoles, mainly itraconazole, are the recommended therapy. CONCLUSION In the majority of the studies, terbinafine treatment showed a higher cure ratio than the other drugs for dermatophyte onychomycosis.
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Gupta AK, Paquet M. Systemic antifungals to treat onychomycosis in children: a systematic review. Pediatr Dermatol 2013; 30:294-302. [PMID: 23278514 DOI: 10.1111/pde.12048] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Because of the low prevalence of onychomycosis in children, little is known about the efficacy and safety of systemic antifungals in this population. PubMed and Embase databases and the references of related publications were searched in March 2012 for clinical trials (CTs), retrospective analyses (RAs), and case reports (CRs) on the use of systemic antifungals for onychomycosis in children (<18 years). Twenty-six studies (5 CTs, 3 RAs, and 18 CRs) were published between 1976 and 2011. Most of these studies reported the use of systemic terbinafine and itraconazole for the treatment of onychomycosis in children. Therapy with systemic antifungals alone in children ages 1 to 17 years resulted in a complete cure rate of 70.8% (n = 151), whereas combined systemic and topical antifungal therapy in one infant and 19 children age 8 and older resulted in a complete cure rate of 80.0% (n = 20). The efficacy and safety profiles of terbinafine, itraconazole, griseofulvin, and fluconazole in children were similar to those previously reported for adults. In conclusion, based on the little information available on onychomycosis in children, systemic antifungal therapies in children are safe and cure rates are similar to the rates achieved in adults.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada; Clinical Research, Mediprobe Research Inc, London, Ontario, Canada.
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Arroll B, Oakley A. Preventing long term relapsing tinea unguium with topical anti-fungal cream: a case report. CASES JOURNAL 2009; 2:70. [PMID: 19154619 PMCID: PMC2647914 DOI: 10.1186/1757-1626-2-70] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Accepted: 01/21/2009] [Indexed: 11/18/2022]
Abstract
Background The patient was aged 34 when he consulted a dermatologist in Vancouver BC with onychomycosis affecting the right great toenail. Case presentation Trichophyton rubrum was cultured from nail clippings. Griseofulvin was taken for 6 months, resulting in clinical and mycological cure. Over the next 27 years there were multiple relapses. Each course of treatment with oral terbinafine (for up to 18 months) or itraconazole resulted in clinical and mycological cure. A dermatological colleague suggested the reason for relapse was likely to be self re-infection. Conclusion No clinical relapse has occurred with once-weekly miconazole cream applied to the toenail and webspaces of the right foot over the last four years.
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Affiliation(s)
- Bruce Arroll
- University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Ginter-Hanselmayer G, Weger W, Smolle J. Onychomycosis: a new emerging infectious disease in childhood population and adolescents. Report on treatment experience with terbinafine and itraconazole in 36 patients. J Eur Acad Dermatol Venereol 2008; 22:470-5. [DOI: 10.1111/j.1468-3083.2007.02498.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Aisha Sethi
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
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Abstract
This is a retrospective study of the agents, clinical aspects, sources of infection and therapy of onychomycosis in children. In the period 1989-2000, we observed 46 consecutive children, until 16 years of age with onychomycosis (29 boys, 17 girls, mean age 10.8 years). Dermatophytes were isolated in 30 cases (Trichophyton rubrum in 22 cases, Trichophyton mentagrophytes in five, Epidermophyton floccosum in two and Trichophyton violaceum in one) and Candida spp. in 16, associated with Trichophyton rubrum in two. Moulds were isolated in three children (Fusarium oxysporum in one, Scopulariopsis brevicaulis in another and Aspergillus fumigatus associated with Trichophyton rubrum in a third). The commonest features were distal and distolateral subungual hyperkeratosis in dermatophyte infections (93%) and onychodystrophy and paronychia in Candida infections (56% and 50% respectively). Forty patients achieved clinical and mycological recovery. It is appropriate to suspect onychomycosis in children, perform microbiological diagnosis and undertake early treatment. An approach of this kind may help to prevent nail dystrophy and the spread of infection.
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Affiliation(s)
- C Romano
- Department of Dermatology, University of Siena, Italy.
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Arenas R, Ruiz-Esmenjaud J. Onicomicose na infância: uma perspectiva atual com ênfase na revisão do tratamento. An Bras Dermatol 2004. [DOI: 10.1590/s0365-05962004000200011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A prevalência da onicomicose na infância, principalmente quando provocada por dermatófitos e Candida sp, tem aumentado. Tais infecções em crianças parecem infreqüentes em países desenvolvidos, mas não são excepcionais na América Latina. O objetivo principal deste trabalho foi analisar a literatura médica atual. Foi observada a onicomicose por dermatófitos em crianças com idade a partir de dois anos. A faixa entre 12-16 anos é a mais afetada (66,4%), provavelmente devido aos fatores de risco aumentado, como a prática de esportes e os hormônios da puberdade. Os pais foram a fonte de infecção em 46,2% dos casos, e 65% dos parentes de pacientes apresentavam onicomicose ou tinea pedis. As unhas dos dedos dos pés são afetadas por dermatófitos, sendo mais freqüente a onicomicose distal subungueal (88,5%); contudo, também se observam as formas superficial branca e branca subungueal proximal. A suspeita de diagnóstico é obtida com o exame clínico, mas a confirmação micológica é necessária. Os principais agentes dermatófitos são: T. rubrum (69%-92,7%), T. tonsurans (8,8%), T. mentagrophytes var interdigitale (5,4%) e M. canis (2,9%). A griseofulvina constitui o tratamento de primeira linha, mas itraconazol, fluconazol e terbinafina também são recomendados para o tratamento sistêmico. O tratamento tópico com ciclopirox a 8%, amorolfina a 5% e uréia a 40% associada a bifonazol a 1% pode ser considerado alternativa terapêutica. Dada a escassez de relatos de onicomicose em crianças, não foi possível uma conclusão sobre a melhor abordagem terapêutica. Mais dados clínicos são necessários para estabelecer o perfil de segurança dos novos agentes antimicóticos a fim de determinar a conduta ideal na onicomicose infantil.
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Abstract
Onychomycosis in children is uncommon. In those children that are affected, a family history of onychomycosis is not uncommon, giving importance to the examination of the entire family for fungal nail infections. In the United States, the newer oral antifungal agents itraconazole, fluconazole, and terbinafine, and the topical nail lacquers ciclopirox and amorolfine are not approved for this indication. More data are needed on the use of these antifungal agents for the treatment of onychomycosis in children.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Center and University of Toronto, Toronto, Ontario, Canada.
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Lateur N, Mortaki A, André J. Two hundred ninety-six cases of onychomycosis in children and teenagers: a 10-year laboratory survey. Pediatr Dermatol 2003; 20:385-8. [PMID: 14521552 DOI: 10.1046/j.1525-1470.2003.20502.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is still little data available about the epidemiology of childhood onychomycosis. Looking at our laboratory figures over a 10-year period provided us with some useful information. Nail keratin samples were taken by dermatologists from 21,557 patients with nail conditions, mainly in the Brussels region. The specimens were examined by direct microscopy and/or histology, and cultured on Sabouraud medium agar. Only patients less than 17 years of age were considered as children. Clinical information was gathered about age, sex, and the location of the infected nail. Nine hundred sixty-three of the samples were from children, and 296 of those children had proven onychomycosis. More than three-fourths of the cases were found in children more than 6 years old, and boys were more frequently affected than girls. Toenails were the predominant location of infection. Trichophyton rubrum was the main pathogen, followed by Candida spp. and Trichophyton interdigitale. One case was caused by Scopulariopsis spp. As in adults, onychomycosis is probably the main nail disease in children. After the age of 6 years, the presentation is very similar to that in adults: toenails are mostly involved, and T. rubrum, the main pathogen, is responsible for distal and lateral subungual onychomycosis.
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Affiliation(s)
- N Lateur
- Department of Dermatology, CHU Saint Pierre, Brugmann, Belgium.
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Abstract
Terbinafine, itraconazole, and fluconazole are effective and well tolerated for treating onychomycosis in children. Dosage depends on body weight. Duration of treatment is the same for adults.
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Affiliation(s)
- Antonella Tosti
- Department of Dermatology, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy.
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Abstract
Current dosing regimens for itraconazole are effective, safe, and versatile for use in superficial fungal infections in children, particularly tinea capitis. Good efficacy rates have been noted in both Trichophyton and Microsporum tinea capitis infections. Itraconazole has a high affinity for keratin, and accumulates to high levels at the site of superficial fungal infections. A pulse regimen may be chosen over continuous dosing, because the accumulation persists after dosing of itraconazole has been stopped. An oral solution of itraconazole is available, and may be more convenient for children who cannot swallow capsules. The oral solution also produces good rates of efficacy, but may be associated with a somewhat higher potential for gastrointestinal adverse events than the capsules. The range of adverse events noted with itraconazole capsules or oral solution use in children is similar to the range in adults. Events are generally mild and transient. Attention must be taken to note any medications that the child is using, because itraconazole is associated with a range of potential drug interactions. This safety of use, in combination with itraconazole's wide antifungal spectrum and pharmacokinetic properties, which allow for shorter dosing regimens, may make itraconazole a suitable alternative to griseofulvin for pediatric superficial fungal infections.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook Site), University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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