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Gupta AK, Polla Ravi S, Talukder M, Mann A. Effectiveness and safety of oral terbinafine for dermatophyte distal subungual onychomycosis. Expert Opin Pharmacother 2024; 25:15-23. [PMID: 38221907 DOI: 10.1080/14656566.2024.2305304] [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: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Terbinafine has been a cornerstone in dermatophyte infection treatment. Despite its global efficacy, the emergence of terbinafine resistance raises concerns, requiring ongoing vigilance. AREAS COVERED This paper focuses on evaluating the efficacy and safety of terbinafine in treating dermatophyte toenail infections. Continuous and pulse therapies, with a 24-week continuous regimen and a higher dosage of 500 mg/day have demonstrated superior efficacy to the FDA approved regimen of 250 mg/day x 12 weeks. Pulse therapies, though showing comparable effectiveness, present debates with regards to their efficacy as conflicting findings have been reported. Safety concerns encompass hepatotoxicity, gastrointestinal, cutaneous, neurologic, hematologic and immune adverse-effects, and possible drug interactions, suggesting the need for ongoing monitoring. EXPERT OPINION Terbinafine efficacy depends on dosage, duration, and resistance patterns. Continuous therapy for 24 weeks and a dosage of 500 mg/day may enhance outcomes, but safety considerations and resistance necessitate individualized approaches. Alternatives, including topical agents and alternative antifungals, are to be considered for resistant cases. Understanding the interplay between treatment parameters, adverse effects, and resistance mechanisms is critical for optimizing therapeutic efficacy while mitigating resistance risks. Patient education and adherence are vital for early detection and management of adverse effects and resistance, contributing to tailored and effective treatments.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
| | | | - Mesbah Talukder
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | - Avantika Mann
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
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Gupta AK, Venkataraman M, Bamimore MA. Relative impact of traditional vs. newer oral antifungals for dermatophyte toenail onychomycosis: a network meta-analysis study. Br J Dermatol 2023; 189:12-22. [PMID: 37253047 DOI: 10.1093/bjd/ljad070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 02/09/2023] [Accepted: 03/08/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a paucity of evidence regarding the relative therapeutic efficacy of treatments for onychomycosis. OBJECTIVES We determined the relative efficacy of monotherapies for dermatophyte toenail onychomycosis with Bayesian network meta-analyses (NMAs). METHODS We searched PubMed, Scopus, EMBASE (Ovid) and CINAHL to identify studies that investigated the efficacy of monotherapy with oral antifungals for dermatophyte toenail onychomycosis in adults. In this paper, 'regimen' corresponds to a given agent and its dosage. The relative effects and surface under the cumulative ranking curve (SUCRA) values of the various regimens were estimated; evidence quality was assessed at the study level and across networks. RESULTS Data from 21 studies were used. Our two efficacy-related endpoints were: (i) mycological and (ii) complete cure at 1 year; safety--related endpoints were: (i) 1-year count of any adverse event (AE), (ii) 1-year odds of discontinuation due to any AE, (iii) 1-year odds of discontinuation due to liver issues. Thirty-five regimens were identified; the newer agents among these included posaconazole and oteseconazole. We compared the efficacy of newer regimens with traditional ones like 'terbinafine 250 mg daily for 12 weeks' and 'itraconazole 200 mg daily for 12 weeks. We found that an agent's dosage was associated with its efficacy; for example, the 1-year odds of mycological cure with terbinafine 250 mg daily for 24 weeks (SUCRA = 92.4%) were significantly greater than those of terbinafine 250 mg daily for 12 weeks (SUCRA = 66.3%) (odds ratio 2.62, 95% credible interval 1.57-4.54). We also found that booster regimens can increase efficacy. Our results showed that some triazoles could be more effective than terbinafine. CONCLUSIONS This is the first NMA study of monotherapeutic antifungals - and their various dosages - for dermatophyte toenail onychomycosis. Our findings could provide guidance for the selection of the most appropriate antifungal agent, especially amid the growing concerns about terbinafine resistance.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, ON, Canada
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
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Novel and Investigational Treatments for Onychomycosis. J Fungi (Basel) 2022; 8:jof8101079. [PMID: 36294644 PMCID: PMC9604567 DOI: 10.3390/jof8101079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Onychomycosis is a common nail disease caused by fungi. The primary pathogens are dermatophytes; however, yeasts, non-dermatophyte moulds, and mixed fungal populations may also contribute to the development of a recalcitrant condition, usually accompanied by difficulties in everyday life and severe emotional stress. Treatment failure and relapse of the infection are the most frequent problems, though new issues have become the new challenges in the therapeutic approach to onychomycosis. Resistance to antifungals, an increasing number of comorbidities, and polydrug use among the ageing population are imperatives that impose a shift to safer drugs. Topical antifungals are considered less toxic and minimally interact with other drugs. The development of new topical drugs for onychomycosis is driven by the unmet need for effective agents with prolonged post-treatment disease-free time and a lack of systemic impact on the patients’ health. Efinaconazole, Tavaborole, and Luliconazole have been added to physicians’ weaponry during the last decade, though launched on the market of a limited number of countries. The pipeline is either developing new products (e.g., ME-1111 and NP213) with an appealing combination of pharmacokinetic, efficacy, and safety properties or reformulating old, well-known drugs (Terbinafine and Amphotericin B) by using new excipients as penetration enhancers.
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Falotico JM, Lapides R, Lipner SR. Combination Therapy Should Be Reserved as Second-Line Treatment of Onychomycosis: A Systematic Review of Onychomycosis Clinical Trials. J Fungi (Basel) 2022; 8:279. [PMID: 35330281 PMCID: PMC8949799 DOI: 10.3390/jof8030279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/15/2022] Open
Abstract
Onychomycosis is the most common nail disease encountered in clinical practice. Its importance extends well beyond aesthetics, often causing pain, difficulty with ambulation and performing daily activities, and impairing quality of life. Many patients fail to achieve cure with antifungal monotherapy and recurrences are common. Combination therapy has therefore gained considerable interest, given the potential for drug synergy and prevention of antifungal resistance, but it has not been well studied. A systematic review of onychomycosis medication only, as well as medication and procedural (laser, debridement, photodynamic therapy), clinical or randomized controlled trials evaluating combination vs. monotherapies was performed. After exclusions, 30 studies were included in the final analysis. There were conflicting results for medication-only trials, with some showing significant benefit of combination therapy over monotherapy, however, trials were not robustly designed and lacked sufficient follow-up. Procedural studies also lacked long-term follow-up, and failed to demonstrate efficacy in some severe onychomycosis cases. Considering the high cure rates demonstrated in pivotal antifungal monotherapy trials, and conflicting results, costs, and safety concerns associated with combination therapy, we recommend that combination therapy be reserved as second-line treatment options in patients with poor prognostic factors or for those who failed monotherapy for onychomycosis.
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Affiliation(s)
- Julianne M. Falotico
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, USA;
| | - Rebecca Lapides
- Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, VT 05405, USA;
| | - Shari R. Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY 10021, USA
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Chang MJ, Qiu Y, Lipner SR. Race reporting and representation in onychomycosis clinical trials: A systematic review. Mycoses 2021; 64:954-966. [PMID: 33655595 DOI: 10.1111/myc.13262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Onychomycosis is the most common nail disease seen in clinical practice. Inclusion of diverse groups in onychomycosis clinical trials subjects is necessary to generalise efficacy data. OBJECTIVES We aimed to systematically review race and ethnicity reporting and representation, as well as, treatment outcomes in onychomycosis clinical trials. METHODS A PubMed search for onychomycosis clinical trials was performed in August 2020. Primary clinical trial data were included and post hoc analyses were excluded. Categorical variables were compared using chi-squared and Fisher's exact tests. Statistical significance was set at p < .05. Photos in articles were categorised by Fitzpatrick skin type. RESULTS Only 32/182 (17.5%) trials reported on race and/or ethnicity and only one trial compared treatment efficacy in different subgroups. Darker skin colours were infrequently depicted in articles. Topical treatment, location with ≥1 US-based site, industry funding type and publication date after 2000 were significantly associated with reporting of racial/ethnic data (p < .05 for all comparisons). LIMITATIONS Demographics on excluded subjects and methods of recruitment were not available. Assigning Fitzpatrick skin type is inherently subjective. CONCLUSIONS This study highlights a need for consistent reporting of races and ethnicities of onychomycosis clinical trial participants with subgroup analyses of treatment efficacies.
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Affiliation(s)
| | - Yuqing Qiu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Skin Appendage Disord 2021; 7:351-358. [PMID: 34604322 PMCID: PMC8436613 DOI: 10.1159/000516112] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022] Open
Abstract
There is an increase in the incidence of onychomycosis, especially in at-risk populations. Onychomycosis is difficult to treat, as the efficacy of most antifungal agents is relatively low. Nondermatophyte molds (NDMs) and mixed infection (dermatophyte plus NDM) onychomycosis are contributing to growing antifungal resistance, as they are often underestimated and ignored due to incorrect diagnosis. There is a need for a paradigm shift in the management of onychomycosis to a patient-centered, holistic approach with an emphasis on laboratory diagnosis prior to initiating treatment, which enables the rational choice of the antifungal agent. Additionally, in the case of resistant infections, antifungal susceptibility testing is recommended. Strategies for effective management of onychomycosis include disinfection of fungal reservoirs in shoes and socks and prophylaxis posttreatment using topical antifungal agents. These measures may reduce the recurrence of onychomycosis and improve long-term clinical success.
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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
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil H. Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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Gupta AK, Venkataraman M, Quinlan EM, Bamimore MA. Cure Rates of Control Interventions in Randomized Trials for Onychomycosis Treatments: A Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc 2021; 112:20-226. [PMID: 34121113 DOI: 10.7547/20-226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/16/2020] [Indexed: 02/03/2023]
Abstract
Background: The efficacy of antifungals for onychomycosis has been determined in randomized controlled trials (RCTs); interestingly their control arms have demonstrated some therapeutic effects. These controls constitute either placebos (inert pills) or vehicles (all but the antifungal component of the creams). The objective of this research was to determine (i) whether RCT controls exhibited statistically-relevant efficacy rates (i.e. beyond the "placebo effect"), (ii) whether oral and topical controls differed in their efficacies, and (iii) if the efficacy rates of the controls correlated with those of the active comparator associated with that control. Methods: RCTs of oral and topical monotherapies for dermatophyte toenail onychomycosis were identified through a systematic literature search. For our meta-analyses of cure rates the double arcsine transformation was used. The N-1 chi squared test was used to determine whether the cure rates significantly differed between topical and oral controls. Correlation was investigated using Kendall rank correlation tests. Results: The pooled mycological, complete, and clinical cure rates of all control interventions (n = 19 trials) were 9%, 1%, and 6%, respectively. The pooled efficacy rates for oral and topical controls were: mycological cure rate, 7% and 12% (p=0.0016); complete cure rate, 1% for both; and clinical cure rate, 4% and 8%, respectively (p=0.0033). For oral RCTs, the respective cure rates of the active therapies were not correlated with controls. However, for topical RCTs, as the mycological and clinical cure rates of the active therapy increased, so did those of the topical vehicle associated with the active therapy in question, and vice versa. Conclusions: The topical vehicle cure rates were often higher than the oral placebo cure rates, likely due to the presence of non-antifungal chemicals (e.g. moisturizers, urea) with antifungal and debriding properties, which are not present in oral controls. .
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Siopi M, Efstathiou I, Theodoropoulos K, Pournaras S, Meletiadis J. Molecular Epidemiology and Antifungal Susceptibility of Trichophyton Isolates in Greece: Emergence of Terbinafine-Resistant Trichophytonmentagrophytes Type VIII Locally and Globally. J Fungi (Basel) 2021; 7:jof7060419. [PMID: 34072049 PMCID: PMC8229535 DOI: 10.3390/jof7060419] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023] Open
Abstract
Trichophyton isolates with reduced susceptibility to antifungals are now increasingly reported worldwide. We therefore studied the molecular epidemiology and the in vitro antifungal susceptibility patterns of Greek Trichophyton isolates over the last 10 years with the newly released EUCAST reference method for dermatophytes. Literature was reviewed to assess the global burden of antifungal resistance in Trichophyton spp. The in vitro susceptibility of 112 Trichophyton spp. molecularly identified clinical isolates (70 T. rubrum, 24 T. mentagrophytes, 12 T. interdigitale and 6 T. tonsurans) was tested against terbinafine, itraconazole, voriconazole and amorolfine (EUCAST E.DEF 11.0). Isolates were genotyped based on the internal transcribed spacer (ITS) sequences and the target gene squalene epoxidase (SQLE) was sequenced for isolates with reduced susceptibility to terbinafine. All T. rubrum, T. interdigitale and T. tonsurans isolates were classified as wild-type (WT) to all antifungals, whereas 9/24 (37.5%) T. mentagrophytes strains displayed elevated terbinafine MICs (0.25–8 mg/L) but not to azoles and amorolfine. All T. interdigitale isolates belonged to ITS Type II, while T. mentagrophytes isolates belonged to ITS Type III* (n = 11), VIII (n = 9) and VII (n = 4). All non-WT T. mentagrophytes isolates belonged to Indian Genotype VIII and harbored Leu393Ser (n = 5) and Phe397Leu (n = 4) SQLE mutations. Terbinafine resistance rates ranged globally from 0–44% for T. rubrum and 0–76% for T. interdigitale/T. mentagrophytes with strong endemicity. High incidence (37.5%) of terbinafine non-WT T. mentagrophytes isolates (all belonging to ITS Type VIII) without cross-resistance to other antifungals was found for the first time in Greece. This finding must alarm for susceptibility testing of dermatophytes at a local scale particularly in non-responding dermatophytoses.
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Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Ioanna Efstathiou
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Konstantinos Theodoropoulos
- Second Department of Dermatology & Venereology, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece;
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
- Correspondence: ; Tel.: +30-210-583-1909; Fax: +30-210-532-6421
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Mercer DK, Robertson JC, Miller L, Stewart CS, O'Neil DA. NP213 (Novexatin®): A unique therapy candidate for onychomycosis with a differentiated safety and efficacy profile. Med Mycol 2020; 58:1064-1072. [PMID: 32232410 PMCID: PMC7657096 DOI: 10.1093/mmy/myaa015] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 12/17/2022] Open
Abstract
NP213 (Novexatin®) is a novel antifungal peptide specifically designed for the topical treatment of onychomycosis. NP213 was designed using host defense peptides (HDP), essential components of the innate immune response to infection, as a template. NP213 is a water-soluble cyclic fungicidal peptide that effectively penetrates human nail. NP213 demonstrated a promising preclinical and clinical safety profile, with no evidence of systemic exposure following topical application to the skin and nails. NP213 was efficacious in two phase IIa human trials with 43.3% of patients having no fungi detectable by culture of fragments from NP213-treated nails after 180 days in the first study and likewise 56.5% of patients were culture negative for dermatophytes after 360 days in the second phase IIa study. In both trials, NP213 was applied daily for only 28 days in marked contrast to other topical onychomycosis treatments that require application for up to 52 weeks. Patient reported outcomes from the phase IIa studies were positive with participants recording an improved appearance of their nails after only 14 days of application. All fungi identified in these studies were Trichophyton spp. NP213 (Novexatin®) is a promising, highly differentiated peptide-based candidate for the topical treatment of onychomycosis, addressing the infectious cause and cosmetic issues of this very common condition.
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Affiliation(s)
- Derry K Mercer
- NovaBiotics Ltd, Bridge of Don, Aberdeen, United Kingdom
| | | | - Lorna Miller
- NovaBiotics Ltd, Bridge of Don, Aberdeen, United Kingdom
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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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Gupta AK, Venkataraman M, Shear NH, Piguet V. Onychomycosis in children - review on treatment and management strategies. J DERMATOL TREAT 2020; 33:1213-1224. [PMID: 32799713 DOI: 10.1080/09546634.2020.1810607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Onychomycosis is an uncommon condition in children with increasing global prevalence. Health practitioners should confirm the diagnosis through mycology examination and examine family members of affected individuals for onychomycosis and tinea pedis. OBJECTIVE To comprehensively summarize the treatment and management strategies for pediatric onychomycosis. METHODS We performed a comprehensive literature search in the PubMed database to identify clinical studies on treatment for mycologically-confirmed dermatophyte onychomycosis in children <18 years. The exclusion criteria were combination therapy, case reports, reviews, systematic reviews and duplicate studies. RESULTS Per-weight dosing regimens of systemic antifungal agents such as terbinafine, itraconazole, and fluconazole are found to be safe in children and are used off-label for the treatment of pediatric onychomycosis with high efficacy. Topical antifungal agents such as ciclopirox, efinaconazole, and tavaborole have established safety and efficacy in children. Children respond better than adults to topical therapy due to their thinner, faster growing nails. There is no data on the efficacy of medical devices for onychomycosis in children. CONCLUSION Efinaconazole topical solution 10% and tavaborole topical solution 5% are FDA approved for the treatment of onychomycosis in children ≥6 years; ciclopirox topical solution 8% nail lacquer is approved in children ≥12 years.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | - Neil H Shear
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Vincent Piguet
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
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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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Fávero MLD, Bonetti AF, Domingos EL, Tonin FS, Pontarolo R. Oral antifungal therapies for toenail onychomycosis: a systematic review with network meta-analysis toenail mycosis: network meta-analysis. J DERMATOL TREAT 2020; 33:121-130. [PMID: 32043906 DOI: 10.1080/09546634.2020.1729336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: Toenail fungal infections account for half of all nail disease cases, and a highly negative impact on patient quality of life. Our aim was to compare the efficacy and safety of commercially available oral antifungals for onychomycosis.Methods: A systematic review was performed in PubMed and Scopus. Randomized controlled trials evaluating the effect of oral antifungals on mycological cure, discontinuation and adverse events were included. Network meta-analyses were built for each outcome. Results were reported as odds ratios (OR) with 95% credibility intervals (CrI). Ranking probabilities were calculated by surface under the cumulative ranking analysis (SUCRA).Results: We included 40 trials (n = 9568). Albaconazole 400 mg (OR 0.02 [95% CrI 0.01-0.07] versus placebo), followed by posaconazole 200-400 mg and terbinafine 250-350 mg were considered the best therapies (SUCRA probabilities over 75%). For the networks of discontinuation and individual adverse events, few significant differences among treatments were observed, but itraconazole 400 mg was considered the safest drug (SUCRA around 25%). Albaconazole 400 mg, posaconazole 200-400 mg, and terbinafine 250-350 mg were the most effective therapies for onychomycosis, while itraconazole 400 mg was the safest.Conclusion: The profile of albaconazole and posaconazole compared to current first-line therapies should be further investigated in well-designed trials.
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Affiliation(s)
- Maria L D Fávero
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Aline F Bonetti
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Eric L Domingos
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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Gupta A, Foley K, Mays R, Shear N, Piguet V. Monotherapy for toenail onychomycosis: a systematic review and network meta‐analysis. Br J Dermatol 2019; 182:287-299. [DOI: 10.1111/bjd.18155] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2019] [Indexed: 01/16/2023]
Affiliation(s)
- A.K. Gupta
- Mediprobe Research Inc. London ON Canada
- Division of Dermatology Department of Medicine University of Toronto School of Medicine Toronto ON Canada
| | - K.A. Foley
- Mediprobe Research Inc. London ON Canada
| | - R.R. Mays
- Mediprobe Research Inc. London ON Canada
| | - N.H. Shear
- Division of Dermatology Department of Medicine University of Toronto School of Medicine Toronto ON Canada
- Division of Dermatology Sunnybrook Health Sciences Centre Toronto ON Canada
| | - V. Piguet
- Division of Dermatology Department of Medicine University of Toronto School of Medicine Toronto ON Canada
- Division of Dermatology Women's College Hospital Toronto ON Canada
- Division of Infection and Immunity Cardiff University School of Medicine Cardiff U.K
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15
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Gupta AK, Versteeg SG, Shear NH. A practical application of onychomycosis cure - combining patient, physician and regulatory body perspectives. J Eur Acad Dermatol Venereol 2018; 33:281-287. [PMID: 30005134 DOI: 10.1111/jdv.15181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
Due to the high relapse rates and the rise of predisposing factors, the need for curing onychomycosis is paramount. To effectively address onychomycosis, the definition of cure used in a clinical setting should be agreed upon and applied homogeneously across therapies (e.g. oral, topical and laser treatments). In order to determine what is or what should be used to define cure in a clinical setting, a literature search was conducted to identify methods used to evaluate treatment success. The limitations, strengths, prevalence and utility of each outcome measure were investigated. Seven ways to measure treatment success were identified; mycological cure, patient/investigator assessments, complete cure, quality of life instruments, severity indexes, clinical cure and temporary clearance. Despite its shortcomings, mycological cure is the most objective and consistent outcome measure used across onychomycosis studies. It is suggested that diagnostic goals of onychomycosis should be used to define cure in a clinical setting. Modifications to outcome measures such as incorporating molecular-based techniques could be a future avenue to explore.
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Affiliation(s)
- A K Gupta
- Divison of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | - N H Shear
- Department of Medicine (Dermatology, Clinical Pharmacology and Toxicology), Department of Pharmacology, Sunnybrook Health Science Centre and the University of Toronto, Toronto, ON, Canada
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16
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Piraccini BM, Tosti A. Ciclopirox Hydroxypropyl Chitosan: Efficacy in Mild-to-Moderate Onychomycosis. Skin Appendage Disord 2018; 5:13-19. [PMID: 30643775 DOI: 10.1159/000488606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/19/2018] [Indexed: 11/19/2022] Open
Abstract
The severity and percentage of nail involvement are usually considered the main prognostic factors for the treatment of onychomycosis. This study investigated the efficacy of P-3051 (ciclopirox [CPX] 8% nail lacquer in hydroxypropyl chitosan technology) in a population subset of the pivotal study, selected according to the criteria used in recent onychomycosis pivotal studies. The original study was a multicenter, randomized, three-arm, placebo-controlled, parallel groups, evaluator-blinded study comparing P-3051 with reference CPX (standard, insoluble 8% CPX nail lacquer) and placebo (P-3051 vehicle) in a 2: 2: 1 ratio, applied once daily for 48 weeks to 467 patients with onychomycosis, followed by a 12-week follow up. The primary endpoint was complete cure (negative mycology and 100% clear nail) at the end of treatment. Among the secondary endpoints, response rate (negative mycology and ≥90% clear nail) and negative culture were chosen as most representative for a clinical setting. A population subset (modified intention-to-treat population, 302 patients) was selected, excluding those with more severe disease (> 50% nail involvement), in line with recent onychomycosis pivotal trials. P-3051 was superior to placebo in all parameters but culture at week 60 and was superior to reference CPX in cure and response rates at week 60. Compared to the overall patient population, efficacy rates in the P-3051 group were higher in the subset excluding patients with nail involvement > 50%. Results increased by 33% (from 5.7 to 7.6%) at week 48 and by 19.0% (from 12.7 to 15.1%) at week 60 for cure rate, by 33% (from 24.0 to 31.9%) and 20% (from 28.7 to 34.5%) for response rate, and by 3% (from 89.1 to 91.6%) and 4.0% (from 79.0 to 82.4%) for culture conversion to negative. This post hoc analysis confirms that the severity of onychomycosis is a prognostic factor for responsiveness to antifungal treatments and that this can significantly affect reported efficacy data. The different inclusion criteria should be taken into account when reviewing the efficacy of antifungal agents from different studies.
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Affiliation(s)
- Bianca Maria Piraccini
- Division of Dermatology, Department of Specialized, Diagnostic, and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Gupta AK, Versteeg SG, Shear NH. Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective. J Cutan Med Surg 2017; 22:129-141. [DOI: 10.1177/1203475417733461] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Onychomycosis can be investigated by sampling. Information gleaned includes nail bed involvement, nail plate penetration, fungal viability, and species identification. Testing samples can confirm a diagnosis. While diagnostic testing is considered useful in directing therapy, a substantial number of clinicians do not confirm diagnosis prior to treatment. Objectives: The aim of this study is to quantify the benefit of confirmatory testing prior to treating toenail onychomycosis. Methods: The cost of mycological cure (negative potassium hydroxide and negative culture) and the cost-effectiveness of confirmatory testing were determined using the average cost of potassium hydroxide (KOH), culture, periodic acid–Schiff (PAS), efinaconazole, ciclopirox, terbinafine, and itraconazole. Costs were obtained through literature searches, public domain websites, and telephone surveys to local pharmacies and laboratories. To represent the potential risks of prescribing onychomycosis treatment, the costs associated with liver monitoring, potential life-threatening adverse events, and drug-drug interactions were obtained through public domain websites, published studies, and product inserts. Results: PAS was determined to be the most sensitive confirmatory test and KOH the least expensive. The overall cost of an incorrect diagnosis (no confirmatory test used) ranged between $350 and $1175 CAD per patient for treatment of 3 infected toenails. Comparatively, performing confirmatory testing prior to treatment decreases the overall cost to $320 to $930, depending on the therapy, physician, and test. Conclusions: It is preferred to diagnose onychomycosis prior to treatment. Furthermore, there are cost savings when confirmatory testing is performed before initiating treatment with both topical and oral antifungals in Canada.
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Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Mediprobe Research, London, ON, Canada
| | | | - Neil H. Shear
- Department of Medicine (Dermatology, Clinical Pharmacology and Toxicology) and Department of Pharmacology, Sunnybrook and Women’s College Health Science Centre and the University of Toronto, Toronto, ON, Canada
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Ishii M, Matsumoto Y, Yamada T, Abe S, Sekimizu K. An invertebrate infection model for evaluating anti-fungal agents against dermatophytosis. Sci Rep 2017; 7:12289. [PMID: 28947778 PMCID: PMC5612966 DOI: 10.1038/s41598-017-12523-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/30/2017] [Indexed: 01/06/2023] Open
Abstract
Animal models of pathogenic infection are needed to evaluate candidate compounds for the development of anti-infectious drugs. Dermatophytes are pathogenic fungi that cause several infectious diseases. We established a silkworm dermatophyte infection model to evaluate anti-fungal drugs. Injection of conidia of the dermatophyte Arthroderma vanbreuseghemii into silkworms was lethal. A. vanbreuseghemii conidia germinated in liquid culture were more potent against silkworms than non-germinated conidia. Germinated conidia of other dermatophytes, Arthroderma benhamiae, Trichophyton rubrum, and Microsporum canis, also killed silkworms. Injection of heat-treated germinated A. vanbreuseghemii conidia did not kill silkworms, suggesting that only viable fungi are virulent. Injecting terbinafine or itraconazole, oral drugs used clinically to treat dermatophytosis, into the silkworm midgut had therapeutic effects against infection with germinated A. vanbreuseghemii conidia. When silkworms were injected with A. vanbreuseghemii expressing enhanced green fluorescent protein (eGFP), mycelial growth of the fungus was observed in the fat body and midgut. Injection of terbinafine into the silkworm midgut, which corresponds to oral administration in humans, inhibited the growth of A. vanbreuseghemii expressing eGFP in the fat body. These findings suggest that the silkworm infection model with eGFP-expressing dermatophytes is useful for evaluating the therapeutic activity of orally administered anti-fungal agents against dermatophytes.
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Affiliation(s)
- Masaki Ishii
- Genome Pharmaceuticals Institute Co. Ltd., 102 Next Building, 3-24-17 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yasuhiko Matsumoto
- Teikyo University Institute of Medical Mycology, 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Tsuyoshi Yamada
- Teikyo University Institute of Medical Mycology, 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Shigeru Abe
- Teikyo University Institute of Medical Mycology, 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Kazuhisa Sekimizu
- Genome Pharmaceuticals Institute Co. Ltd., 102 Next Building, 3-24-17 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Teikyo University Institute of Medical Mycology, 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan.
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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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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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Gupta AK, Lynde CW, Barber K. Pharmacoeconomic Assessment of Ciclopirox Topical Solution, 8%, Oral Terbinafine, and Oral Itraconazole for Onychomycosis. J Cutan Med Surg 2016. [DOI: 10.2310/7750.2006.00057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most pharmacoeconomic data available for antifungal agents are based on US or European cost parameters. Similar data have not been reported in a Canadian health care system. A pharmacoeconomic analysis was performed considering the costs of drug acquisition and medical management, which were representative of the Canadian health care system, for each of the therapies approved for use in toenail onychomycosis in Canada: continuous oral terbinafine, oral pulse itraconazole, and topical ciclopirox 8% nail lacquer. A survey of provincial fee schedules was conducted to determine the representative costs of parameters relating to onychomycosis treatment, such as consultation visit cost, return visit cost, mycology testing, liver function testing, and complete blood count analysis. Manufacturers' costs were used to calculate representative drug acquisition costs. Meta-analysis was used to determine the average mycologic cure rates of each therapy, and the medical literature was consulted to determine the relapse rates for each therapy. Ciclopirox nail lacquer had the lowest drug acquisition costs compared with continuous terbinafine and pulse itraconazole ($197.89 vs $311.39 and $323.40, respectively). Using the pharmacoeconomic model with three 1-year treatment phases, in which failures or relapses were re-treated with the primary drug, the expected cost per patient was $601.52 with ciclopirox nail lacquer, $746.72 with oral terbinafine, and $938.42 with itraconazole. The main analysis assumed that two bottles of ciclopirox nail lacquer were required per treatment. The cost for the ciclopirox lacquer exceeded continuous terbinafine but remained lower than pulse itraconazole when three bottles of ciclopirox nail lacquer were considered in the calculation of cost per mycological cure. A variety of relapse rates were tested, and ciclopirox using two or fewer bottles remained cost-effective compared with continuous terbinafine or pulse itraconazole, regardless of the relapse rate. Where three bottles are required, the cost-effectiveness of ciclopirox nail lacquer is less than that of continuous terbinafine but more cost-effective than that of pulse itraconazole.
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Affiliation(s)
- Aditya K. Gupta
- From the Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; Mediprobe Research Inc., London, ON, Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; The Dermatology Centre, Calgary, AB
| | - Charles W. Lynde
- From the Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; Mediprobe Research Inc., London, ON, Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; The Dermatology Centre, Calgary, AB
| | - Kirk Barber
- From the Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; Mediprobe Research Inc., London, ON, Lynderm Research Inc., Markham, ON; University of Toronto, Toronto, ON; The Dermatology Centre, Calgary, AB
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22
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Gupta AK, Studholme C. How do we measure efficacy of therapy in onychomycosis: Patient, physician, and regulatory perspectives. J DERMATOL TREAT 2016; 27:498-504. [DOI: 10.3109/09546634.2016.1161156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Andrade Cerquera E. Eficacia y seguridad de la terbinafina oral en pauta intermitente o pulsátil versus pauta continua para el tratamiento de la onicomicosis en mayores de 18 años. REVISTA DE LA FACULTAD DE MEDICINA 2016. [DOI: 10.15446/revfacmed.v64n1.47890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
<p>La onicomicosis es una enfermedad que compromete las uñas y afecta el 5% de la población mundial. Objetivo. Determinar la efectividad y seguridad de la terbinafina oral en pauta intermitente versus continua para la onicomicosis en mayores de 18 años. Materiales y métodos. A través de una búsqueda sistemática electrónica en Cochrane, Medline, Embase, LILACS y Opengrey se identificaron ensayos clínicos aleatorizados paralelos, excluyendo cruzados, conglomerados o clúster. Se aplicó el RevMan 5.3 para revisiones sistemáticas de ensayos clínicos. Mediante búsqueda sistemática se identificaron ensayos clínicos aleatorizados paralelos en pacientes mayores de 18 años, de sexo masculino o femenino, humanos, en idioma inglés y español, sin límite de tiempo de publicación y cuyo desenlace fue la curación clínica y micológica, incluyendo efectos adversos leves. Se valoró el riesgo de sesgo; se utilizó RR como medida del efecto, IC95% para variables dicotómicas; la unidad de análisis fue el paciente y la estimación agrupada se calculó usando un modelo de efectos aleatorios para variables dicotómicas —método de Mantel-Haenszel en RevMan 5.3—. Resultados. El RR agrupado fue de 1.13 (IC95%: 1.06-1.2) indicando que la falla del tratamiento con terbinafina intermitente es 1.1 veces más probable que con terbinafina continua. Su RR agrupado dio 0.923 (IC95%: 0.77-1.09) indicando 7.7% de mayor probabilidad de desarrollar eventos adversos con terbinafina continua que con intermitente. Conclusiones. La terbinafina intermitente tiene menor éxito de cura clínica y micológica que la continua; su RR corregido demuestra que la pauta intermitente es 13% menos eficiente que la continua. Clínicamente los hallazgos son significativos pero estadísticamente falta poder en los estudios y un mayor tamaño de muestra agrupado para mejorar la evidencia.</p>
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Lipner SR, Scher RK. Efinaconazole 10% topical solution for the topical treatment of onychomycosis of the toenail. Expert Rev Clin Pharmacol 2015; 8:719-31. [PMID: 26325488 DOI: 10.1586/17512433.2015.1083418] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Efinaconazole 10% topical solution is a new antifungal therapy for the topical treatment of mild to moderate toenail onychomycosis. In vitro and in vivo data have shown significant antifungal activity against dermatophytes, Candida spp. and nondermatophyte molds, and its mechanism of action is through inhibition of fungal lanosterol 14α-demethylase. In two parallel, double-blind, randomized, controlled, Phase III trials, complete cure rates were 17.8 and 15.2%, respectively, and mycological cure rates were 55.2 and 53.4%, respectively, for efinaconazole 10% topical solution, which were superior to vehicle, with minimal adverse events. This drug profile reviews the most recent basic science and clinical data for efinaconazole in the treatment of toenail onychomycosis.
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Affiliation(s)
| | - Richard K Scher
- a Department of Dermatology, Weill Cornell Medical College , NY, USA
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Gupta AK, Daigle D, Paquet M. Therapies for onychomycosis a systematic review and network meta-analysis of mycological cure. J Am Podiatr Med Assoc 2015; 105:357-66. [PMID: 25032982 DOI: 10.7547/13-110.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
New therapies for onychomycosis continue to be developed, yet treatments are seldom directly compared in randomized controlled trials. The objective of this study was to compare the rates of mycological cure for oral and topical onychomycosis treatments using network meta-analysis. A systematic review of the literature on onychomycosis treatments published before March 25, 2013, was performed, and data were analyzed using network meta-analysis. Terbinafine, 250 mg, therapy was significantly superior to all treatments except itraconazole, 400 mg, pulse therapy; itraconazole, 200 mg, therapy was significantly superior to fluconazole and the topical treatments; and fluconazole, efinaconazole, ciclopirox, terbinafine nail solution, and amorolfine treatments were significantly superior to only placebo. These results support the superiority of 12-week continuous terbinafine, 250 mg, therapy and itraconazole, 400 mg, pulse therapy (1 week per month for 3 months) while suggesting the equivalence of topical therapies. These results reflect findings from the literature and treatment efficacy observed in clinical practice.
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Gupta AK, Daigle D, Foley KA. Network Meta-Analysis of Onychomycosis Treatments. Skin Appendage Disord 2015; 1:74-81. [PMID: 27170937 DOI: 10.1159/000433473] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 05/19/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many onychomycosis treatments have not been directly compared in head-to-head clinical trials. OBJECTIVE To determine the relative efficacy of onychomycosis treatments using network meta-analysis (NMA). METHODS We conducted a systematic review and NMA of mycological cure rates. RESULTS Nineteen trials were included in the network. Terbinafine 250 mg was significantly superior to all treatments except itraconazole 400 mg pulse therapy. The itraconazole 400 mg pulse regimen was significantly superior to all topicals except efinaconazole 10% nail solution. Itraconazole 200 mg was significantly superior to all topical treatments, while fluconazole 150-450 mg, efinaconazole 10% nail solution, tavaborole 5% nail solution, ciclopirox nail lacquer 8%, terbinafine nail solution, and amorolfine 5% nail lacquer were significantly superior to placebo. CONCLUSIONS Newly developed topicals have improved the odds ratios (ORs) of mycological cure, yet these ORs were not significantly greater than preexisting topical treatments. Further experience with these agents will reveal their clinical significance, and head-to-head trials are warranted. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, University of Toronto, Toronto, Ont., Canada; Mediprobe Research Inc., London, Ont., Canada
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Abstract
Efinaconazole 10% topical solution is a new triazole recently approved for the treatment of onychomycosis. It inhibits fungal lanosterol 14α-demethylase in the ergosterol biosynthesis pathway, has potent antifungal activity against dermatophytes, as well as activity against Candida spp. and non-dermatophyte molds, and showed promising results in clinical trials. This review summarizes the mechanism of action, in vitro and in vivo data, clinical trials, safety, and quality-of-life data of efinaconazole as it applies to the treatment of onychomycosis.
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Affiliation(s)
- Shari R Lipner
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
| | - Richard K Scher
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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Abstract
Background Onychomycosis has several clinical presentations and is caused by various infectious organisms. Objective To provide guidance for selection of appropriate treatment. Methods The literature on onychomycosis management was reviewed to generate an evidence-based decision tree. Results and Conclusion Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.
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Affiliation(s)
- Aditya K. Gupta
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
| | - Maryse Paquet
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
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Shemer A, Sakka N, Baran R, Scher R, Amichai B, Norman L, Farhi R, Magun R, Brazilai A, Daniel R. Clinical comparison and complete cure rates of terbinafine efficacy in affected onychomycotic toenails. J Eur Acad Dermatol Venereol 2014; 29:521-6. [DOI: 10.1111/jdv.12609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A. Shemer
- Department of Dermatology; Chaim Sheba Medical Center; Sackler School of Medicine; Tel-Aviv University; Tel Aviv Israel
| | - N. Sakka
- Department of Dermatology; Chaim Sheba Medical Center; Sackler School of Medicine; Tel-Aviv University; Tel Aviv Israel
| | - R. Baran
- Department of Dermatology; Nail Disease Centre; University of Franche-Comté; Cannes France
| | - R. Scher
- Department of Dermatology; College of Physicians and Surgeons Columbia University; New York NY USA
| | - B. Amichai
- Department of Dermatology; Meir Medical Center Kfar Saba; Tel Aviv University; Tel Aviv Israel
| | - L. Norman
- Tel Aviv University; Tel Aviv Israel
| | - R. Farhi
- Department of Dermatology; Faculdade Tecnico Educacional Souza Marques; Santa Casa da Misericordia do Rio de Janeiro; Rio de Janeiro Brazil
| | - R. Magun
- Department of Dermatology and Venereology; Faculty of Health Sciences; Soroka Medical Center; Ben-Gurion University of the Negev; Beer-Sheva Israel
| | - A. Brazilai
- Department of Dermatology; Chaim Sheba Medical Center; Sackler School of Medicine; Tel-Aviv University; Tel Aviv Israel
| | - R. Daniel
- Department of Medicine (Dermatology); University of Mississippi; Oxford USA
- Department of Dermatology; University of Alabama Birmingham; Birmingham USA
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Abstract
Placebo cure rates vary among randomized clinical trials for onychomycosis, but the factors influencing these cure rates have not been systematically investigated. The PubMed database and reference sections of relevant publications were searched for randomized controlled trials of dermatophyte toenail onychomycosis that included a placebo control and that assessed cure rates. From 21 studies, the pooled mean ± SD placebo cure rates regarding mycological, clinical, and complete cure were 8.7% ± 3.7%, 3.4% ± 2.2%, and 1.2% ± 1.4%, respectively. There was no statistically significant difference between oral and topical treatments. None of the cure rates significantly correlated with any of the participant or study design characteristics analyzed. Placebo cure rates in randomized controlled trials of toenail onychomycosis are relatively low and are independent of the study characteristics.
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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
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, Cooper EA, Paquet M. Recurrences of Dermatophyte Toenail Onychomycosis during Long-Term Follow-up after Successful Treatments with Mono- and Combined Therapy of Terbinafine and Itraconazole. J Cutan Med Surg 2013; 17:201-6. [DOI: 10.2310/7750.2013.12088] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The influence of dosing regimens on the recurrence rates of onychomycosis has not been investigated. Objective: To compare recurrence rates for toenail dermatophyte onychomycosis between four dosing regimens. Methods: A prospective, investigator-blinded, long-term follow-up (1.25 to 7 years postenrolment) study of the following regimens was undertaken with or without booster therapy at week 36: overlapping continuous itraconazole and terbinafine (COMBO), continuous terbinafine (CTERB), intermittent terbinafine (TOT), and pulsed itraconazole (III). Results: One hundred six mycologically and 43 completely cured participants at week 48 were included. Recurrence rates (RR) for mycologically and completely cured participants were respectively termed mycologic recurrence (MRR) and complete cure recurrence (CRR) rates. No statistically significant difference was detected between the four regimens for the two rates. However, lower MRRs were obtained for CTERB (32%) and TOT (36%) compared to III (59%) and COMBO (57%). When participants who received booster therapy were excluded from the analysis, the MRR was lower for CTERB (21%) compared to TOT (39%). Conclusions: Itraconazole therapy was associated with higher RRs than terbinafine therapy. Combined therapy did not reduce the RRs compared to monotherapies. A difference might exist between continuous and intermittent antifungal regimens, but additional randomized clinical trials are needed for confirmation.
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Affiliation(s)
- Aditya K. Gupta
- From the Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
| | - Elizabeth A. Cooper
- From the Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
| | - Maryse Paquet
- From the Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
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Emtestam L, Kaaman T, Rensfeldt K. Treatment of distal subungual onychomycosis with a topical preparation of urea, propylene glycol and lactic acid: results of a 24-week, double-blind, placebo-controlled study. Mycoses 2012; 55:532-40. [DOI: 10.1111/j.1439-0507.2012.02215.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Van Duyn Graham L, Elewski BE. Recent updates in oral terbinafine: its use in onychomycosis and tinea capitis in the US. Mycoses 2011; 54:e679-85. [PMID: 21668517 DOI: 10.1111/j.1439-0507.2011.02038.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Onychomycosis and tinea capitis are prevalent fungal diseases that are difficult to cure and usually require systemic treatment. Onychomycosis has high recurrence rates and can significantly affect a patient's quality of life. Oral terbinafine has been approved for onychomycosis for 20 years in Europe and 15 years in the United States. Over these past 20 years, numerous studies show that oral terbinafine is a safe and efficacious treatment for onychomycosis. More recently, oral terbinafine also has been approved for tinea capitis. Once difficult to treat, terbinafine has revolutionised treatment of these fungal diseases. It has minimal side effects and its limited drug interactions make it an excellent treatment option for patients with co-morbidities. This review discusses oral terbinafine and new insights into the treatment of onychomycosis and tinea capitis. Recent publications have enhanced our knowledge of the mechanisms of oral terbinafine and its efficacy in treating onychomycosis. Oral terbinafine vs. other antifungal therapeutic options are reviewed. Overall, terbinafine remains a superior treatment for dermatophyte infections because of its safety, fungicidal profile, once daily dosing, and its ability to penetrate the stratum corneum.
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Özcan D, Seçkin D, Demirbilek M. In vitro antifungal susceptibility of dermatophyte strains causing tinea pedis and onychomycosis in patients with non-insulin-dependent diabetes mellitus: a case-control study. J Eur Acad Dermatol Venereol 2010; 24:1442-6. [DOI: 10.1111/j.1468-3083.2010.03666.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. REVIEW ARTICLE: Toenail onychomycosis: an important global disease burden. J Clin Pharm Ther 2010; 35:497-519. [DOI: 10.1111/j.1365-2710.2009.01107.x] [Citation(s) in RCA: 204] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Sigurgeirsson B, Elewski BE, Rich PA, Opper C, Cai B, Nyirady J, Bakshi R. Intermittent versus continuous terbinafine in the treatment of toenail onychomycosis: A randomized, double‐blind comparison. J DERMATOL TREAT 2009; 17:38-44. [PMID: 16467022 DOI: 10.1080/09546630500504713] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Terbinafine is an established drug for the treatment of toenail onychomycosis. Minimizing the total dose of terbinafine and giving it intermittently could improve tolerability as well as compliance, provided efficacy is not compromised. OBJECTIVE Two identical trials were conducted to compare the efficacy, safety and tolerability of the current standard regimen of terbinafine 250 mg daily with a new formulation of terbinafine given intermittently for three cycles of 2 weeks of treatment (350 mg daily) followed by 2 weeks off treatment. METHODS A total of 2005 patients with a clinical diagnosis of subungual onychomycosis of the large toenail confirmed by microscopy and culture for a dermatophyte were recruited into the two trials and treated for 12 weeks. RESULTS Patients with onychomycosis of prolonged duration (mean 9 years) and a median nail involvement of 63% with or without spikes, lateral involvement and white superficial onychomycosis (WSO) were included in the trial. The studies found a significant difference (p<0.05) in favour of standard daily dosing with terbinafine. Response rates for the primary variable complete cure (mycological and clinical cure) were lower with the new formulation in both Trial I (-5.8%; 95% CI -11.8, 0.07) and Trial II (difference -5.9%; 95% CI -12, 0.1). Both treatments were equally well tolerated, with approximately 11% of patients in both groups reporting at least one treatment-related adverse event. CONCLUSIONS Pulsed dosing with terbinafine did not provide any clear safety advantages and was significantly less effective. Consequently, continuous treatment with terbinafine tablets remains the optimal therapy for onychomycosis.
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Newland JG, Abdel-Rahman SM. Update on terbinafine with a focus on dermatophytoses. Clin Cosmet Investig Dermatol 2009; 2:49-63. [PMID: 21436968 PMCID: PMC3047923 DOI: 10.2147/ccid.s3690] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since terbinafine was introduced on the world market 17 years ago, it has become the leading antifungal for the treatment of superficial fungal infections, aided by unique pharmacologic and microbiologic profiles. This article reviews mode of action, antimycotic spectrum and disposition profile of terbinafine. It examines the data, accumulated over 15 years, on the comparative efficacy of terbinafine (vs griseofulvin, itraconazole, fluconazole) in the management of the infections for which it is primarily indicated (eg, dermatophytoses) and provides a brief discussion on its use for the treatment of non-dermatophyte infections. Finally, the available data on the newest topical and systemic formulations are introduced.
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Affiliation(s)
- Jason G Newland
- Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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Ghannoum MA, Long L, Pfister WR. Determination of the efficacy of terbinafine hydrochloride nail solution in the topical treatment of dermatophytosis in a guinea pig model. Mycoses 2009; 52:35-43. [DOI: 10.1111/j.1439-0507.2008.01540.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cribier B, Paul C. Long-term efficacy of antifungals in toenail onychomycosis: a critical review. Br J Dermatol 2008. [DOI: 10.1111/j.1365-2133.2001.04378.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chang CH, Young-Xu Y, Kurth T, Orav JE, Chan AK. The safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. Am J Med 2007; 120:791-8. [PMID: 17765049 DOI: 10.1016/j.amjmed.2007.03.021] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 03/10/2007] [Accepted: 03/13/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE We estimated the absolute risks of treatment termination and incidence of adverse liver outcomes among all commonly used oral antifungal treatments for superficial dermatophytosis and onychomycosis. METHODS MEDLINE, EMBASE, and Cochrane Library were searched to identify randomized and nonrandomized controlled trials, case series, and cohort studies published before December 31, 2005. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. Treatment arms with the same regimen in terms of drug, type (continuous or intermittent), and dosage were combined to estimate the risk of an outcome of interest. RESULTS We identified 122 studies with approximately 20,000 enrolled patients for planned comparison. The pooled risks (95% confidence intervals) of treatment discontinuation resulting from adverse reactions for continuous therapy were 3.44% (95% confidence interval [CI], 2.28%-4.61%) for terbinafine 250 mg/day; 1.96% (95% CI, 0.35%-3.57%) for itraconazole 100 mg/day; 4.21% (95% CI, 2.33%-6.09%) for itraconazole 200 mg/day; and 1.51% (95% CI, 0%-4.01%) for fluconazole 50 mg/day. For intermittent therapy, the pooled risks were as follows: pulse terbinafine: 2.09% (95% CI, 0%-4.42%); pulse itraconazole: 2.58% (95% CI, 1.15%-4.01%); intermittent fluconazole 150 mg/week: 1.98% (95% CI, 0.05%-3.92%); and intermittent fluconazole 300 to 450 mg/week: 5.76% (95% CI, 2.42%-9.10%). The risk of liver injury requiring termination of treatment ranged from 0.11% (continuous itraconazole 100 mg/day) to 1.22% (continuous fluconazole 50 mg/day). The risk of having asymptomatic elevation of serum transaminase but not requiring treatment discontinuation was less than 2.0% for all treatment regimens evaluated. CONCLUSION Oral antifungal therapy against superficial dermatophytosis and onychomycosis, including intermittent and continuous terbinafine, itraconazole, and fluconazole, was associated with a low incidence of adverse events in an immunocompetent population.
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Affiliation(s)
- Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
Onychomycosis is a common disease affecting as much as 8% of the general population. Treatment of onychomycosis is challenging, complicated by low cure rates and relatively high relapse rates. This paper reviews the efficacy of current oral, topical, and surgical treatment options. Currently, the treatment of choice for toenail onychomycosis is oral terbinafine because of its high efficacy, low relapse rates, and cost-effectiveness. Oral itraconazole or fluconazole could be considered for infections caused by Candida. Topical therapies may be a useful adjunct to these systemic therapies, but are less effective when used alone. More research is needed to determine the best measures for preventing reinfection.
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Affiliation(s)
- Justin J Finch
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
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Lilly KK, Koshnick RL, Grill JP, Khalil ZM, Nelson DB, Warshaw EM. Cost-effectiveness of diagnostic tests for toenail onychomycosis: A repeated-measure, single-blinded, cross-sectional evaluation of 7 diagnostic tests. J Am Acad Dermatol 2006; 55:620-6. [PMID: 17010741 DOI: 10.1016/j.jaad.2006.03.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 02/27/2006] [Accepted: 03/24/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Our purpose was to estimate and compare the cost-effectiveness of the most commonly used diagnostic tests for onychomycosis: potassium hydroxide preparation (KOH), interpreted both by a dermatologist (KOH-CLINIC) and a laboratory technician (KOH-LAB); KOH with dimethyl sulfoxide (KOH-DMSO) and with chlorazol black E (KOH-CBE), interpreted by a dermatologist; culture using dermatophyte test medium, culture with Mycobiotic and Inhibitory Mold Agar (Cx); and histopathologic analysis using periodic acid-Schiff stain (PAS). METHODS This was a repeated-measure, blinded, cross-sectional study conducted at the Minneapolis Veterans Affairs Medical Center. Inclusion criteria included: at least one toenail with 25% or more clinical disease, which was defined as subungual debris with onycholysis and/or onychauxis. Exclusion criteria included other nail dystrophies, use of oral antifungal medication for 2 months or longer within the past year, or topical ciclopirox lacquer within 6 weeks of enrollment. The main outcome measure was the cost-effectiveness (Medicare and non-Medicare costs) of 7 diagnostic tests. Sensitivity (at least 3 positive tests) was the unit of effectiveness. RESULTS Two hundred four participants were enrolled; their average age was 69.5 years and 95.5% were male. PAS was the most sensitive test (98.8%); it was statistically significantly more sensitive than all other diagnostic tests except KOH-CBE (94.3%). Dermatophye test medium was the least sensitive test (57.3%). KOH-CBE was statistically significantly more cost effective than any other test, with the exception of KOH-CLINIC and KOH-LAB. PAS was the least cost effective. LIMITATIONS Test specificities were not evaluated. CONCLUSION KOH-CBE should be the test of choice for practitioners confident in interpreting KOH preparations because of its combination of high sensitivity and cost-effectiveness.
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Affiliation(s)
- Kia K Lilly
- University of Minnesota, Minneapolis, Minnesota, USA
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Kaçar N, Ergin S, Ergin C, Erdogan BS, Kaleli I. The prevalence, aetiological agents and therapy of onychomycosis in patients with psoriasis: a prospective controlled trial. Clin Exp Dermatol 2006; 32:1-5. [PMID: 16824053 DOI: 10.1111/j.1365-2230.2006.02215.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nail involvement morphologically resembling onychomycosis frequently accompanies psoriatic lesions. The role of psoriasis as a predisposing factor for onychomycosis and the possible influence of psoriasis on responsiveness of onychomycosis to treatment are controversial. AIM To investigate the frequency of onychomycosis, the aetiological agents responsible for it, and the efficacy of terbinafine 250 mg/day in patients with psoriasis compared with controls in order to reveal the role of psoriatic process on fungal growth. METHODS Over a 1-year period, 168 patients with psoriasis and 164 nonpsoriatic controls were recruited. In the case of clinically suspected of fungal infection, further mycological investigations were performed. Systemic terbinafine therapy 250 mg daily for 12 weeks was administered to the patients with onychomycosis. Patients were followed up clinically and mycologically for 24 weeks. RESULTS Onychomycosis was diagnosed in 22 patients with psoriasis (13.1% of the psoriasis group, which constituted 28.6% of patients with suspicion of onychomycosis) and 13 controls (7.9% of control group; 40.6% of controls with suspicion of onychomycosis). The prevalence rates of onychomycosis were similar in both groups. The most commonly isolated fungi were dermatophytes in the psoriasis group and nondermatophytic moulds in controls. Dermatophytes were more common in psoriatic than control nails (P = 0.02). All patients in each group were cured at the end of the therapy. CONCLUSION It seems that nail psoriasis constitutes a risk factor not for onychomycosis, but specifically for dermatophytic nail infections. Because of the similar therapeutic results in each group, different antifungal treatment protocols may not be needed in psoriasis. However, to confirm this, new comprehensive studies are necessary.
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Affiliation(s)
- N Kaçar
- Department of Dermatology, Faculty of Medicine, Pamukkale University, Denizli, Turkey.
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Tavakkol A, Fellman S, Kianifard F. Safety and efficacy of oral terbinafine in the treatment of onychomycosis: Analysis of the elderly subgroup in improving results in ONychomycosis-concomitant lamisil® and debridement (IRON-CLAD), an open-label, randomized trial. ACTA ACUST UNITED AC 2006; 4:1-13. [PMID: 16730616 DOI: 10.1016/j.amjopharm.2005.12.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary objective of this subanalysis was to examine the safety, tolerability, and efficacy of terbinafine in the treatment of toenail onychomycosis in the patients aged > or = 65 years in the Improving Results in Onychomycosis Concomitant Lamisil And Debridement (IRON-CLAD) trial. (Lamisil and IRON-CLAD are trademarks of Novartis Pharmaceuticals Corporation, East Hanover, New Jersey.) The secondary objective was to determine if toenail debridement would provide additional efficacy benefits in this subgroup. METHODS The IRON-CLAD trial was an open-label, randomized, multicenter study of adults who underwent 4 weeks of screening and received terbinafine 250 mg/d for 12 weeks with or without aggressive toenail debridement (at baseline and weeks 6, 12, and 24). Clinic visits occurred at weeks 6, 12, 24, and 48. Safety and tolerability were assessed by adverse event (AE) rates based on changes in laboratory values, patient-volunteered information, answers to investigator questions, and physical examinations. Efficacy was evaluated by mycologic cure (negative microscopy of potassium hydroxide samples and negative culture), clinical cure (> or = 87.5% nail clearing), and complete cure (mycologic cure and complete toenail clearing) at week 48. The present subanalysis of IRON-CLAD results assessed participants aged > or = 65 years (older subgroup). RESULTS A total of 504 patients were randomized, of whom 75 were aged > or = 65 years. In the older subgroup, the mean (SD) age was 68.9 (3.04), 86.7% (65/75) were white, and 66.7% (50/75) were male. Incidence of AEs reported during the treatment period or within 30 days after treatment discontinuation (treatment-emergent AEs [TEAEs]) was 28.0% in the older subgroup and 23.0% in the overall study population. Most TEAEs were mild (73.7%) to moderate (23.7%) in severity, and most (86.8%) were not suspected by the investigators to be related to study treatment. The most frequently occurring TEAEs in the older subgroup were nausea (4.0%), sinusitis (4.0%) arthralgia (2.7%), and hypercholesterolemia (2.7%). The proportion of participants who withdrew from the trial due to TEAEs was 4.0% (3/75) in the older group and 2.8% (14/504) in the overall population. Only 3 of 11 discontinuations in the older subgroup were due to a TEAE suspected by the investigator to be related to study treatment. Sixty-four percent of the older subgroup took antihypertensive medications, 25% took antidiabetics, and 47% took antilipemic medications. There were no clinical signs of drug interactions in the older subgroup. Clinical efficacy outcomes in the older subgroup were generally good and appeared to be comparable with those in the younger subgroup. At week 48, mycologic cure had occurred in 64.0% (95% CI, 53.1%-74.9%) of the older subgroup, clinical cure in 41.3% (95% CI, 30.2%-52.5%), and complete cure in 28.0% (95% CI, 17.8%-38.2%). Debridement did not appear to affect mycologic outcomes or clinical effectiveness, but rates of clinical and complete cure appeared to be higher among older patients who underwent adjuvant debridement. CONCLUSIONS The results of this subanalysis suggest that terbinafine was well tolerated and efficacious in these patients aged > or = 65 years with moderate to severe toenail onychomycosis, many of whom were taking antihypertensives, antidiabetics, or lipid-lowering agents concomitantly. There were no reported clinical signs of drug interactions.
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Affiliation(s)
- Amir Tavakkol
- US Clinical Development & Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey 07936-1080, USA.
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Warshaw EM, St Clair KR. Prevention of onychomycosis reinfection for patients with complete cure of all 10 toenails: Results of a double-blind, placebo-controlled, pilot study of prophylactic miconazole powder 2%. J Am Acad Dermatol 2005; 53:717-20. [PMID: 16198805 DOI: 10.1016/j.jaad.2005.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Revised: 06/03/2005] [Accepted: 06/20/2005] [Indexed: 11/21/2022]
Abstract
The objective of this 2-year, double-blind, placebo-controlled, randomized trial involving 48 participants was to determine if biweekly miconazole powder prevents onychomycosis recurrence. Intent-to-treat analysis found no significant differences in mycologic, clinical, or complete onychomycosis reinfection rates or time to reinfection. Limitations include small sample size and dosing regimen.
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Affiliation(s)
- Erin M Warshaw
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
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Warshaw EM, Fett DD, Bloomfield HE, Grill JP, Nelson DB, Quintero V, Carver SM, Zielke GR, Lederle FA. Pulse versus continuous terbinafine for onychomycosis: A randomized, double-blind, controlled trial. J Am Acad Dermatol 2005; 53:578-84. [PMID: 16198776 DOI: 10.1016/j.jaad.2005.04.055] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 04/11/2005] [Accepted: 04/19/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Effective treatments for onychomycosis are expensive. Previous studies suggest that less costly, pulsed doses of antifungal medications may be as effective as standard, continuous doses. Terbinafine is the current treatment of choice for toenail onychomycosis. OBJECTIVE Our purpose was to determine whether pulse-dose terbinafine is as effective as standard continuous-dose terbinafine for treatment of toenail onychomycosis. METHODS We conducted a double-blind, randomized, noninferiority, clinical intervention trial in the Minneapolis Veterans Affairs Medical Center. The main inclusion criteria for participants were a positive dermatophyte culture and at least 25% distal subungual clinical involvement. Six hundred eighteen volunteers were screened; 306 were randomized. Terbinafine, 250 mg daily for 3 months (continuous) or terbinafine, 500 mg daily for 1 week per month for 3 months (pulse) was administered. The primary outcome measure was mycological cure of the target toenail at 18 months. Secondary outcome measures included clinical cure and complete (clinical plus mycological) cure of the target toenail and complete cure of all 10 toenails. RESULTS Results of an intent-to-treat analysis did not meet the prespecified criterion for noninferiority but did demonstrate the superiority of continuous-dose terbinafine for: mycological cure of the target toenail (70.9% [105/148] vs 58.7% [84/143]; P =.03, relative risk [RR] of 1.21 [95% confidence interval (CI), 1.02-1.43]); clinical cure of the target toenail (44.6% [66/148] vs 29.3% [42/143]; P =.007, RR =1.52 [95% CI, 1.11-2.07); complete cure of the target toenail (40.5% [60/148] vs 28.0% [40/143]; P =.02, RR=1.45 [95% CI, 1.04-2.01); and complete cure of all 10 toenails (25.2% [36/143] vs 14.7% [21/143]; P =.03, RR =1.71 [95% CI, 1.05-2.79). Tolerability of the regimens did not differ significantly between the groups (chi2 =1.63; P =.65). LIMITATIONS The study population primarily consisted of older men with severe onychomycosis. CONCLUSIONS This study demonstrated the superiority of continuous- over pulse-dose terbinafine. We also found this expensive therapy to be much less effective than previously believed, particularly for achieving complete cure of all 10 toenails.
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Affiliation(s)
- Erin M Warshaw
- Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA.
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