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Chakraborty S, Sanshita, Singh I. Therapeutic treatment strategies for the management of onychomycosis: a patent perspective. Expert Opin Ther Pat 2023; 33:613-630. [PMID: 37800854 DOI: 10.1080/13543776.2023.2268278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Onychomycosis, a multifactorial fungal infection of the nails, shows a global prevalence of about 5.5% and is responsible for 50% of all nail infections. To develop effective management strategies, it is necessary to understand the etiology, pathophysiology, and risk factors of onychomycosis. Oral route of drug delivery is one of the routes utilized to deliver anti-fungal agents, but, has its own limitations like longer duration of treatment, increased adverse effects, and potential for drug interaction. The ungual route has received greater attention due to its localized, non- invasive action and improved patient compliance. AREAS COVERED This review comprehensively discusses conventional onychomycosis therapies and patented novel drug delivery systems for the management of onychomycosis including chemical permeation enhancers, non-particulate drug delivery systems, penetration enhancing devices etc., Databases such as PubMed, ResearchGate, and Google Patents were searched by using the keywords onychomycosis and trans-ungual drug delivery. EXPERT OPINION Enormous research has been conducted and is still ongoing to find the best possible novel drug delivery system for onychomycosis management. Approaches like incorporation of herbal constituents in nano-formulations, inkjet printing, laser devices, iontophoretic techniques, etc. can be employed to make safe and effective drug delivery systems which are regulatory compliant.
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Affiliation(s)
| | - Sanshita
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Inderbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
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Sobhy N, Talla Eweed H, Omar SS. Fractional CO2 laser - assisted methylene blue photodynamic therapy is a potential alternative therapy for onychomycosis in the era of antifungal resistance. Photodiagnosis Photodyn Ther 2022; 40:103149. [PMID: 36228978 DOI: 10.1016/j.pdpdt.2022.103149] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Treatment of onychomycosis is challenging by virtue of the impact of nail disfigurement, the location of the fungi within the nail and reported antifungal resistance worldwide. Light-based technologies are promising primary or adjunctive therapeutic modalities. We aimed to compare the efficacy of photodynamic therapy and fractional CO2 laser monotherapy either alone or in combination for onychomycosis. PATIENTS AND METHODS This prospective randomized comparative study was conducted on 51 onychomycosis patients divided into three groups. In group A, patients were treated using 6 photodynamic therapy sessions using methylene blue and IPL (560 to 700 nm, fluence 12 J/cm2). Group B patients were treated using 6 bimonthly fractional CO2 laser sessions (10,600 nm, 1.600 mj energy and 0.6 mm density) and group C patients were treated using 6 combined fractional CO2 laser and photodynamic therapy sessions. Patients were evaluated mycologically, dermoscopically and clinically by calculation of proximal nail diameter percentage at baseline, monthly, at the end of treatment and after a 6-month follow-up period post-treatment. RESULTS Candida was the most commonly isolated organismin in 64.7%, 70.6% and 70.6% of the pateints in groups A, B and C, respectively. The dermoscopic findings in the total dystrophic onychomycosis was subungual hyperkeratosis in 6 patients (100%), longitudinal streaks and striae in 1 patient (16.7%). In dorsolateral subungual onychomycosis, jagged proximal edge in 31 patients (70.5%), and pigmentation in 30 patients (68.2%) were noted. In proximal subungual onychomycosis irregular matt patches were seen in 1 patient (100%). Proximal nail diameter percentage showed statistically significant improvement after treatment and 6 months follow up in the 3 studied groups. Mean increase of proximal nail diameter after treatment was highest in group C (52.94 ± 20.24), followed by group B (43.82 ± 21.03) and least in group A (35.29 ± 17.0). This difference was statistically significant (p = 0.044). Reported side effects were mild-moderate pain, discoloration and paronychia. CONCLUSION We conclude that fractional CO2 laser and photodynamic monotherapy, and their combination achieve high success rates, good patient satisfaction and safety profile. Fractional CO2-assisted photodynamic therapy is associated with the highest improvement over either fractional CO2 or photodynamic therapy alone.
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Affiliation(s)
- Nagat Sobhy
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Elkhartoum Square 21521, Egypt
| | - Heba Talla Eweed
- Bakkous Dermatology Clinic, Ministry of Health, Alexandria, Egypt
| | - Salma Samir Omar
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Elkhartoum Square 21521, Egypt.
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Leung AKC, Lam JM, Leong KF, Hon KL, Barankin B, Leung AAM, Wong AHC. Onychomycosis: An Updated Review. ACTA ACUST UNITED AC 2020; 14:32-45. [PMID: 31738146 PMCID: PMC7509699 DOI: 10.2174/1872213x13666191026090713] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 12/19/2022]
Abstract
Background: Onychomycosis is a common fungal infection of the nail. Objective: The study aimed to provide an update on the evaluation, diagnosis, and treatment of onychomycosis. Methods: A PubMed search was completed in Clinical Queries using the key term “onychomycosis”. The search was conducted in May 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. The search was restricted to English literature. Patents were searched using the key term “onychomycosis” in www.freepatentsonline.com. Results: Onychomycosis is a fungal infection of the nail unit. Approximately 90% of toenail and 75% of fingernail onychomycosis are caused by dermatophytes, notably Trichophyton mentagrophytes and Trichophyton rubrum. Clinical manifestations include discoloration of the nail, subungual hyperkeratosis, onycholysis, and onychauxis. The diagnosis can be confirmed by direct microscopic examination with a potassium hydroxide wet-mount preparation, histopathologic examination of the trimmed affected nail plate with a periodic-acid-Schiff stain, fungal culture, or polymerase chain reaction assays. Laboratory confirmation of onychomycosis before beginning a treatment regimen should be considered. Currently, oral terbinafine is the treatment of choice, followed by oral itraconazole. In general, topical monotherapy can be considered for mild to moderate onychomycosis and is a therapeutic option when oral antifungal agents are contraindicated or cannot be tolerated. Recent patents related to the management of onychomycosis are also discussed. Conclusion: Oral antifungal therapies are effective, but significant adverse effects limit their use.Although topical antifungal therapies have minimal adverse events, they are less effective than oral antifungal therapies, due to poor nail penetration. Therefore, there is a need for exploring more effective and/or alternative treatment modalities for the treatment of onychomycosis which are safer and more effective.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Shatin, Hong Kong
| | | | - Amy A M Leung
- Department of Family Medicine, The University of Alberta, Edmonton, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
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Mochizuki T, Tsuboi R, Iozumi K, Ishizaki S, Ushigami T, Ogawa Y, Kaneko T, Kawai M, Kitami Y, Kusuhara M, Kono T, Sato T, Sato T, Shimoyama H, Takenaka M, Tanabe H, Tsuji G, Tsunemi Y, Hata Y, Harada K, Fukuda T, Matsuda T, Maruyama R. Guidelines for the management of dermatomycosis (2019). J Dermatol 2020; 47:1343-1373. [DOI: 10.1111/1346-8138.15618] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | - Ryoji Tsuboi
- Department of Dermatology Tokyo Medical University TokyoJapan
| | - Ken Iozumi
- Department of Dermatology Tokyo Metropolitan Police Hospital TokyoJapan
| | - Sumiko Ishizaki
- Department of Dermatology Tokyo Women’s Medical University Medical Center East TokyoJapan
| | | | - Yumi Ogawa
- Department of Dermatology Juntendo University TokyoJapan
| | - Takehiko Kaneko
- Graduate School of Human Ecology Wayo Women’s University IchikawaJapan
| | - Masaaki Kawai
- Department of Dermatology Juntendo University Koshigaya Hospital KoshigayaJapan
| | - Yuki Kitami
- Department of Dermatology Showa University TokyoJapan
| | | | - Takeshi Kono
- Department of Dermatology Nippon Medical School Chibahokusoh Hospital InzaiJapan
| | | | - Tomotaka Sato
- Department of Dermatology Teikyo University Medical Center IchiharaJapan
| | - Harunari Shimoyama
- Department of Dermatology Teikyo University Mizonokuchi Hospital KawasakiJapan
| | - Motoi Takenaka
- Department of Dermatology Nagasaki University NagasakiJapan
| | | | - Gaku Tsuji
- Department of Dermatology Kyushu UniversityGraduate School of Medical Sciences FukuokaJapan
| | - Yuichiro Tsunemi
- Department of Dermatology Saitama Medical University MoroyamaJapan
| | - Yasuki Hata
- Kanagawa Hata Dermatology Clinic YokohamaJapan
| | | | - Tomoo Fukuda
- Department of Dermatology Saitama Medical Center KawagoeJapan
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Photodynamic therapy treatment of superficial fungal infections: A systematic review. Photodiagnosis Photodyn Ther 2020; 31:101774. [DOI: 10.1016/j.pdpdt.2020.101774] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 01/31/2023]
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Gupta AK, Surprenant MS, Kempers SE, Pariser DM, Rensfeldt K, Tavakkol A. Efficacy and safety of topical terbinafine 10% solution (MOB-015) in the treatment of mild to moderate distal subungual onychomycosis: A randomized, multicenter, double-blind, vehicle-controlled phase 3 study. J Am Acad Dermatol 2020; 85:95-104. [PMID: 32585278 DOI: 10.1016/j.jaad.2020.06.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Onychomycosis is a recalcitrant fungal nail infection. Topical antifungal agents may be preferred over systemic agents due to lack of systemic adverse effects. OBJECTIVE To investigate the efficacy and safety of topical terbinafine 10% solution (MOB-015) for the treatment of distal and lateral subungual onychomycosis. METHODS In a multicenter, double-blind, phase III, North American study, patients with mild to moderate distal and lateral subungual onychomycosis involving 20% to 60% of at least 1 great toenail were randomized to once daily application of MOB-015 or matching vehicle for 48 weeks. The primary efficacy variable was complete cure, while the secondary efficacy variables were mycological cure and treatment success. Safety evaluations were also performed. RESULTS At week 52, the mycological cure (negative culture and potassium hydroxide microscopy) rate in the MOB-015 and vehicle groups was 69.9% and 27.7%, respectively (P < .001), and complete cure (0% clinical disease involvement and mycological cure) was achieved in 4.5% and 0% of patients, respectively (P = .0195). At least 1 adverse event leading to discontinuation of treatment occurred in 2.8% of patients in the MOB-015 group and in 4.2% in the vehicle group. LIMITATION The follow-up period after end of treatment may not be sufficient to accurately reflect cure in distal and lateral subungual onychomycosis. CONCLUSIONS MOB-015 is a treatment option for onychomycosis with an adverse event profile similar to vehicle.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Mediprobe Research Inc, London, Ontario, Canada.
| | | | | | - David M Pariser
- Department of Dermatology, Eastern Virginia Medical School and Virginia Clinical Research, Inc, Norfolk, Virginia
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Gupta A, Stec N, Summerbell R, Shear N, Piguet V, Tosti A, Piraccini B. Onychomycosis: a review. J Eur Acad Dermatol Venereol 2020; 34:1972-1990. [DOI: 10.1111/jdv.16394] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 01/25/2023]
Affiliation(s)
- A.K. Gupta
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Mediprobe Research Inc. London ON Canada
| | - N. Stec
- Mediprobe Research Inc. London ON Canada
| | - R.C. Summerbell
- Sporometrics Toronto ON Canada
- Dalla Lana School of Public Health University of Toronto Toronto ON Canada
| | - N.H. Shear
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Division of Dermatology Sunnybrook Health Sciences Centre Toronto ON Canada
| | - V. Piguet
- Division of Dermatology Department of Medicine University of Toronto Toronto ON Canada
- Division of Dermatology Women's College Hospital Toronto ON Canada
| | - A. Tosti
- Department of Dermatology and Cutaneous Surgery Leonard Miller School of Medicine University of Miami Miami FL USA
| | - B.M. Piraccini
- Dermatology Unit Department of Experimental, Diagnostic and Specialty Medicine University of Bologna Bologna Italy
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Aggarwal R, Targhotra M, Sahoo P, Chauhan MK. Onychomycosis: Novel strategies for treatment. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Different Numbers of Long-Pulse 1064-nm Nd-YAG Laser Treatments for Onychomycosis: A Pilot Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1216907. [PMID: 32051822 PMCID: PMC6995308 DOI: 10.1155/2020/1216907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 11/17/2022]
Abstract
Purpose To examine the benefits of different numbers of 1064-nm Nd-YAG laser treatments in patients with onychomycosis. Methods This was a pilot study of patients with onychomycosis who were divided into three groups: four treatment sessions (group A), eight sessions (group B), and 12 sessions (group C). Only infected nails of degrees II–III (Scoring Clinical Index for Onychomycosis) were included. Treatment was given once a week using a long-pulse Nd-YAG 1064-nm laser. Patients were followed at 8, 16, and 24 weeks after the first treatment. Side effects were recorded. Results Treatments were completed for 442 nails in 102 patients. The efficacy rates at 8, 16, and 24 weeks were 35.5%, 38.7%, and 37.4% for group A; 31.4%, 41.7%, and 44.0% for group B; and 27.7%, 50.0%, and 55.4% for group C, respectively. There was a significant difference in the efficacy rate at 24 weeks (P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all Conclusions The 1064-nm Nd-YAG laser had clinical benefits against onychomycosis. Higher numbers of treatments provided better long-term (24-week) benefits, but had no impact on the short-term outcomes. The efficacy of laser treatment on degree II onychomycosis was better than for degree III.
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Abstract
BACKGROUND Onychomycosis is one of the most common nail diseases with an increasing number of cases. There is always a need for therapy because fungal nail infection never shows a tendency to spontaneous self-healing. Thus, the disease belongs to core competency of dermatologists. CONCLUSION Successful treatment requires a correct diagnosis based on meticulous anamnesis, the clinical findings as well as the identification of the pathogen fungus. Dermatoscopy and histological examination play an important role in this context. The algorithm as presented gives a concise overview of treatment.
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Affiliation(s)
- E G Hasche
- Hautklinik, Klinikum Darmstadt, Heidelberger Landstr. 379, 64297, Darmstadt, Deutschland.
| | - M Podda
- Hautklinik, Klinikum Darmstadt, Heidelberger Landstr. 379, 64297, Darmstadt, Deutschland
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Hay R. Therapy of Skin, Hair and Nail Fungal Infections. J Fungi (Basel) 2018; 4:E99. [PMID: 30127244 PMCID: PMC6162762 DOI: 10.3390/jof4030099] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/28/2022] Open
Abstract
Treatment of superficial fungal infections has come a long way. This has, in part, been through the development and evaluation of new drugs. However, utilising new strategies, such as identifying variation between different species in responsiveness, e.g., in tinea capitis, as well as seeking better ways of ensuring adequate concentrations of drug in the skin or nail, and combining different treatment methods, have played equally important roles in ensuring steady improvements in the results of treatment. Yet there are still areas where we look for improvement, such as better remission and cure rates in fungal nail disease, and the development of effective community treatment programmes to address endemic scalp ringworm.
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Zhang L, Xu H, Shi Y, Yu J, Tao Y, Li X. An exploration of the optimum dosage and number of cycles of itraconazole pulse therapy for severe onychomycosis. Mycoses 2018; 61:736-742. [PMID: 29893422 DOI: 10.1111/myc.12799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/14/2018] [Accepted: 06/05/2018] [Indexed: 12/27/2022]
Abstract
Although standard itraconazole pulse therapy is a well-established regimen for toenail onychomycosis, the cure rate for onychomycosis remains low. To evaluate the efficacy and safety of different cycles of itraconazole pulse therapy, determine the optimal dosage and number of cycles for onychomycosis. A total of 90 outpatients of our hospital with onychomycosis were randomised into three treatment groups: (1) standard itraconazole pulse therapy (200 mg twice per day, 1 week each month for three pulses); (2) long-term pulse therapy (200 mg twice per day, 1 week each month for six pulses); (3) low-dose and long-term pulse therapy (200 mg/d, 1 week per month for six pulses) and were followed up for 15 months. Of the initial patients, the trial was completed by 81 patients. The complete cure rates were 32.43% for three cycles and 75% for six cycles (P < .001). For six cycles, despite the administration of half-dose for patients weighing no more than 55 kg, there was no statistical difference in the complete cure rate (P = .862). Long-term therapy is effective and safe for the treatment of toenail onychomycosis. For patients weighing no more than 55 kg, long-term half-dose itraconazole pulse therapy is recommended .
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Affiliation(s)
- Li Zhang
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Hui Xu
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Yuling Shi
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Jing Yu
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Yunjiao Tao
- Dermatology, Zhangjiagang second people's hospital, Suzhou, China
| | - Xiuli Li
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
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Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol 2018; 80:853-867. [PMID: 29959962 DOI: 10.1016/j.jaad.2018.05.1260] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 11/16/2022]
Abstract
Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.
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Affiliation(s)
- Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York.
| | - Richard K Scher
- Department of Dermatology, Weill Cornell Medicine, New York, New York
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Yamaguchi H. Potential of Ravuconazole and its Prodrugs as the New OralTherapeutics for Onychomycosis. Med Mycol J 2017; 57:E93-E110. [PMID: 27904057 DOI: 10.3314/mmj.16-00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Onychomycosis is a fungal infection of the nail apparatus caused by dermatophytes, Candida and non-dermatophytic molds. It is highly prevalent in the general population worldwide and also responsible for significant morbidity and complications and does not usually cure itself. Thus, the condition needs to be treated in view of physical and psychological problems produced. Currently, oral medications using terbinafine are the most effective therapy, but it has relatively limited therapeutic success, particularly for long-term management. Such existing oral therapies are associated with high recurrence rates and treatment failure, as well as with potential adverse events and drug-drug interactions. In the light of these issues, development of more efficacious and safer alternatives for the treatment of onychomycosis is warranted.Ravuconazole and its prodrugs are promising new drug candidates for oral therapy of onychomycosis, among which a water-soluble prodrug, mono-lysine phosphoester derivative (E1224 or BFE1224) is in the most advanced stage of clinical development; a Phase II dose-finding study has been successfully completed and Phase III comparative studies are in progress in Japan.This review aims to summarize our current status of knowledge and information on ravuconazole and its prodrugs, particularly BFE1224, as the potential oral treatment option for onychomycosis. It also summarize the clinical features of onychomycosis with particular stress on its etiology, epidemiology, and current therapeutic options and their limitations. Given its clinical usefulness, BFE1224 may become a valuable addition to the current armamentarium for the treatment of onychomycosis.
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Kreijkamp‐Kaspers S, Hawke K, Guo L, Kerin G, Bell‐Syer SEM, Magin P, Bell‐Syer SV, van Driel ML. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017; 7:CD010031. [PMID: 28707751 PMCID: PMC6483327 DOI: 10.1002/14651858.cd010031.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence-based choice for treatment. OBJECTIVES To assess the effects of oral antifungal treatments for toenail onychomycosis. SEARCH METHODS We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. SELECTION CRITERIA RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years.We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high-risk domain was 'blinding of personnel and participants'.We found high-quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine-treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate-quality evidence).There was high-quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu-like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate-quality evidence).Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low-quality evidence).There is moderate-quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate-quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low-quality evidence). Common adverse events in both groups included headache, viral infection, and nausea.Moderate-quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate-quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin-treated participants) along with nausea and vomiting (in azole-treated participants). Very low-quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants).There is low-quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low-quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin-treated participants) as well as taste loss and nausea (in terbinafine-treated participants). No studies addressed recurrence rate for this comparison.No study addressed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate-quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate-quality evidence).Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate-quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low-quality evidence).Only four comparisons assessed recurrence rate: low-quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them.Only a limited number of studies reported adverse events, and the severity of the events was not taken into account.Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding.
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Affiliation(s)
- Sanne Kreijkamp‐Kaspers
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Kate Hawke
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Linda Guo
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - George Kerin
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Sally EM Bell‐Syer
- CochraneCochrane Editorial UnitSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Parker Magin
- The University of NewcastleDiscipline of General Practice, School of Medicine and Public HealthNewbolds Buiding, University of Newcastle,University DriveNewcastleAustralia2308
| | | | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
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Cutaneous fungal infections in solid organ transplant recipients. Transplant Rev (Orlando) 2017; 31:158-165. [DOI: 10.1016/j.trre.2017.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 12/29/2022]
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17
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Lipner SR, Friedman G, Scher RK. Pilot study to evaluate a plasma device for the treatment of onychomycosis. Clin Exp Dermatol 2017; 42:295-298. [PMID: 28188648 DOI: 10.1111/ced.12973] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2016] [Indexed: 11/29/2022]
Abstract
Onychomycosis is a fungal infection of the nail unit, and is the most common of the nail disorders. Current therapies for onychomycosis have less than ideal efficacy and have the potential for adverse effects. As previous studies have shown that nonthermal plasma inhibits the in vitro growth of Trichophyton rubrum, we conducted a pilot study on 19 participants with toenail onychomycosis. The primary endpoint was safety of the device, and secondary outcome measures were clinical efficacy and mycological cure. Patient satisfaction was measured using questionnaires at the completion of the study. All but one patient met the primary endpoint of safety and there were no long-term sequelae. The overall clinical cure was 53.8% and the mycological cure was 15.4%. The majority of patients were satisfied with the treatment. Our conclusions are that nonthermal plasma is a safe treatment and may have a beneficial effect on toenail onychomycosis.
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Affiliation(s)
- S R Lipner
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
| | - G Friedman
- Department of Electrical and Computer Engineering, Drexel University, Philadelphia, PA, USA
| | - R K Scher
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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18
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Clinical trials of lasers for toenail onychomycosis: The implications of new regulatory guidance. J DERMATOL TREAT 2016; 28:264-270. [DOI: 10.1080/09546634.2016.1214670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gupta AK, Foley KA, Versteeg SG. New Antifungal Agents and New Formulations Against Dermatophytes. Mycopathologia 2016; 182:127-141. [PMID: 27502503 DOI: 10.1007/s11046-016-0045-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 11/24/2022]
Abstract
A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353-67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, University of Toronto, Toronto, Canada. .,Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada.
| | - Kelly A Foley
- Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada
| | - Sarah G Versteeg
- Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada
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20
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Abstract
Background: Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management. Objective: To identify ways to improve cure rates for onychomycosis. Method: The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates. Results and Conclusion: To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.
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Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Mediprobe Research, Inc, London, ON, Canada
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Abstract
Nail disorders are a common presenting complaint for both the primary care physician and the dermatologist. Nail diagnoses are broad in scope and include infectious, inflammatory, and neoplastic conditions. Onychomycosis is an especially common nail condition, and treatment should always be preceded by appropriate fungal studies for confirmation of diagnosis. Inflammatory conditions of the nail unit can mimic onychomycosis, and a dermatologist can assist with diagnosis and treatment recommendations. Likewise, subungual tumors often require biopsy, and should be evaluated by a dermatologist who is experienced in nail evaluation and treatment.
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Affiliation(s)
- Lauren K Biesbroeck
- Division of Dermatology, University of Washington School of Medicine, 1959 Northeast Pacific Street, BB-1353, Box 356524, Seattle, WA 98195-6524, USA.
| | - Philip Fleckman
- Division of Dermatology, University of Washington School of Medicine, 1959 Northeast Pacific Street, BB-1353, Box 356524, Seattle, WA 98195-6524, USA
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22
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Abstract
Onychomycosis is the most common nail infective disorder. It is caused mainly by anthropophilic dermatophytes, in particular by Trichophyton rubrum and T. mentagrophytes var. interdigitale. Yeasts, like Candida albicans and C. parapsilosis, and molds, like Aspergillus spp., represent the second cause of onychomycosis. The clinical suspect of onychomycosis should be confirmed my mycology. Onychoscopy is a new method that can help the physician, as in onychomycosis, it shows a typical fringed proximal margin. Treatment is chosen depending on the modality of nail invasion, fungus species and the number of affected nails. Oral treatments are often limited by drug interactions, while topical antifungal lacquers have less efficacy. A combination of both oral and systemic treatment is often the best choice.
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LaSenna CE, Tosti A. Patient considerations in the management of toe onychomycosis - role of efinaconazole. Patient Prefer Adherence 2015; 9:887-91. [PMID: 26170638 PMCID: PMC4494615 DOI: 10.2147/ppa.s72701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Onychomycosis is a difficult diagnosis to manage and treatment is sometimes avoided, as this diagnosis is often wrongly perceived as a cosmetic problem. However, onychomycosis has a negative impact on patients' quality of life, affecting social interaction, psychological well-being, and physical activities. Onychomycosis is also a risk factor for patients with diabetes, with proven increased rates of cellulitis, gangrene, and foot ulcers. Treatments are only mild to moderately effective, and rates of relapse and reinfection are high. Oral treatments require laboratory monitoring due to risk of hepatotoxicity and may be contraindicated in some patients due to risk of drug-drug interactions. Topical treatments require prolonged application and are not very effective. Efinaconazole 10% solution is a new topical triazole treatment for mild to moderate distal subungual onychomycosis, with good efficacy and without the need for debridement of nails. In onychomycosis of the toenails, efinaconazole 10% solution is documented to have a statistically significant, positive impact on patient satisfaction and quality of life.
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Affiliation(s)
- Charlotte E LaSenna
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Correspondence: Charlotte LaSenna, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, 1600 Northwest, 10th Avenue, RMSB Building, Room 2023C, Miami, FL 33136, USA, Tel +1 305 243 5523, Fax +1 305 243 5810, Email
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
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Abstract
BACKGROUND Managing toenail onychomycosis with topical treatments is challenging. It is difficult for topical medication to penetrate the nail plate, and this is reflected in lower cure rates with topical treatment than with oral treatment. However, oral medications may not be suitable for some patients, because of drug interactions; therefore, topical treatments are critical in managing the disease in certain patient populations. OBJECTIVE This paper reviews the quality and content of the scientific literature on topical treatments for toenail onychomycosis. METHODS PubMed, Ovid (Medline and Embase), Scopus, Cochrane library, and clinicaltrials.gov databases were searched for original clinical reports of topical monotherapy for microscopy and/or culture-confirmed toenail onychomycosis in adults. Studies were evaluated using an onychomycosis study quality scale, which was based on the CONSORT guidelines. RESULTS Twenty-five publications (28 studies) were identified and met the inclusion criteria. Thirteen studies scored high ratings on the quality scale. These were randomized controlled trials or randomized comparative trials. Low-quality studies were nonrandomized, open studies that prevented statistical analysis. Most studies reported clinical and mycological cure. The most variation was observed with reporting outcomes of clinical improvement. Amorolfine, ciclopirox, tavaborole, and efinaconazole produced clinical and mycological cure in patients with mild to moderate toenail onychomycosis (<50-65 % nail involvement), with efinaconazole showing the highest rates. Treatments were generally applied daily for 24-48 weeks, with longer treatment and follow-up showing better outcomes. CONCLUSION Topical treatment with amorolfine, ciclopirox, tavaborole, or efinaconazole is appropriate for cases of mild to moderate toenail onychomycosis due to dermatophyte or mixed dermatophyte/Candida infection.
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