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Axler E, Lipner SR. Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes. Infect Drug Resist 2024; 17:819-843. [PMID: 38463386 PMCID: PMC10922011 DOI: 10.2147/idr.s431526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.
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Affiliation(s)
- Eden Axler
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
| | - Shari R Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
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2
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Gupta I, Adin SN, Rashid MA, Alhamhoom Y, Aqil M, Mujeeb M. Linalool-Incorporated Synergistically Engineered Modified Liposomal Nanocarriers for Enhanced Transungual Delivery of Terbinafine against Onychomycosis. MATERIALS (BASEL, SWITZERLAND) 2023; 16:4424. [PMID: 37374607 DOI: 10.3390/ma16124424] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 06/29/2023]
Abstract
This work investigates the synthesis of linalool-containing invasomes for terbinafine (TBF-IN) in order to increase the solubility, bioavailability, and nail permeability of terbinafine (TBF) for transungual administration. TBF-IN was created utilising the thin-film hydration technique, and with the Box-Behnken design (BBD), optimisation was carried out. TBF-INopt were investigated for vesicle size, zeta potential, PDI (Polydispersity index), entrapment efficiency (EE) and in vitro TBF release. In addition, nail permeation analysis, TEM (transmission electron microscopy), and CLSM (confocal scanning laser microscopy) were performed for further evaluation. The TBF-INopt exhibited spherical as well as sealed vesicles with a considerably small size of 146.3 nm, an EE of 74.23 per cent, a PDI of 0.1612, and an in vitro release of 85.32 per cent. The CLSM investigation revealed that the new formulation had better TBF nail penetration than the TBF suspension gel. The antifungal investigation demonstrated that the TBF-IN gel has superior antifungal activity against Trichophyton rubrum and Candida albicans compared to the commercially available terbinafine gel. In addition, an investigation of skin irritation using Wistar albino rats indicates that the TBF-IN formulation is safe for topical treatment. This study confirmed that the invasomal vesicle formulation is an effective vehicle for the transungual delivery of TBF for the treatment of onychomycosis.
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Affiliation(s)
- Isha Gupta
- Phytomedicine Laboratory, Department of Pharmacognosy & Phytochemistry, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi 110062, India
| | - Syeda Nashvia Adin
- Phytomedicine Laboratory, Department of Pharmacognosy & Phytochemistry, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi 110062, India
| | - Md Abdur Rashid
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Al Faraa, Abha 62223, Saudi Arabia
| | - Yahya Alhamhoom
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Al Faraa, Abha 62223, Saudi Arabia
| | - Mohd Aqil
- Department of Pharmaceutics, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi 110062, India
| | - Mohd Mujeeb
- Phytomedicine Laboratory, Department of Pharmacognosy & Phytochemistry, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi 110062, India
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3
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Adin SN, Gupta I, Ali A, Aqil M, Mujeeb M, Sultana Y. Investigation on utility of some novel terpenes on transungual delivery of fluconazole for the management of onychomycosis. J Cosmet Dermatol 2022; 21:5103-5110. [PMID: 35390220 DOI: 10.1111/jocd.14978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/08/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Onychomycosis, the most prevailing affliction of the nail, accounts for approximately 90% of the toenail infection worldwide. Owing to this infection, the affected patients experience reduced quality of their life as its awful appearance undermines their daily activities and social interactions. Onychomycosis is notoriously strenuous to cure. Systemic therapy, though effective, possess severe complication of toxicities, contra-indication, and drug-drug interaction. Albeit topical therapy is favorable to its localized effect, its potency relates to the effective concentration of the antifungal drugs achieved at the infection site. An approach to accomplish this goal would be acquiring benefits from the terpenes as penetration enhancers from natural sources. This investigation aimed to study the effectiveness of six terpenes, namely safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, as potential penetration enhancers for improved nail permeation of fluconazole through the human nail. METHODS Ex vivo permeation experiments were carried out by soaking the nail clippings of human volunteers in control and working solutions containing fluconazole (5 mg/ml) per se and fluconazole (5 mg/ml) with 6% of each terpene, including safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, respectively, for 48 hours. The amount of fluconazole in nail clippings was quantified using an HPLC method. RESULTS Statistical analysis showed that fluconazole transungual permeation was influenced by the studied terpenes in the following order: safranal > lavandulol acetate > limonene > rose oxide (P-value > 0.05) while the other terpenes showed no significant difference with the control group and safranal represents as the most effective permeation enhancer for the transungual delivery of fluconazole. CONCLUSION It is concluded that the safranal can be successfully used as a safe and potential permeation enhancer to enhance the transungual delivery of fluconazole for the treatment of onychomycosis.
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Affiliation(s)
- Syeda Nashvia Adin
- Department of Pharmacognosy and Phytochemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
| | - Isha Gupta
- Department of Pharmacognosy and Phytochemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
| | - Asad Ali
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
| | - Mohd Aqil
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
| | - Mohd Mujeeb
- Department of Pharmacognosy and Phytochemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
| | - Yasmin Sultana
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062
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4
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Sajeed M, Wei L, Murdan S. What can GP data tell us about the treatment of onychomycosis in the UK? SKIN HEALTH AND DISEASE 2022; 2:e84. [PMID: 35665209 PMCID: PMC9060066 DOI: 10.1002/ski2.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/29/2021] [Accepted: 12/05/2021] [Indexed: 11/23/2022]
Abstract
Background Treatment of onychomycosis is challenging, and there is much literature on optimal treatment strategies. In contrast, information on how onychomycosis is actually treated in primary care is scarce. Information on practice is important as it can reveal much, such as, to what extent national guidelines are followed and which population groups seek/receive treatment or do not do so. Objectives To describe the pattern of onychomycosis treatment in primary care in the UK, by patient's gender and age. Methods A population‐based retrospective cross‐sectional study was conducted. The Health Improvement Network (THIN) database was used to calculate incidence rates of onychomycosis in the years 2001–2017. The prescription of oral and topical anti‐fungal drugs to patients with onychomycosis was reviewed. Results THIN data showed an onychomycosis incidence rate of about 50 per 100,000. More males than females (52% vs. 48%), and more people aged 50–59 years had received treatment for onychomycosis. Oral terbinafine was the most commonly prescribed drug, followed by topical amorolfine, although terbinafine was used more commonly by men and amorolfine by women. Patients with onychomycosis were also prescribed other antifungals, including itraconazole, griseofulvin, tioconazole, ketoconazole shampoo, fluconazole and clotrimazole. A greater proportion of women, compared to men, were prescribed fluconazole. Conclusions Onychomycosis treatment in primary care in the UK is broadly in concordance with national guidelines.
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Affiliation(s)
- M. Sajeed
- UCL School of Pharmacy University College London London UK
| | - L. Wei
- UCL School of Pharmacy University College London London UK
| | - S. Murdan
- UCL School of Pharmacy University College London London UK
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5
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Printing Drugs onto Nails for Effective Treatment of Onychomycosis. Pharmaceutics 2022; 14:pharmaceutics14020448. [PMID: 35214182 PMCID: PMC8879958 DOI: 10.3390/pharmaceutics14020448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023] Open
Abstract
Inkjet printing (IJP) is an emerging technology for the precision dosing of medicines. We report, for the first time, the printing of the antifungal drug terbinafine hydrochloride directly onto nails for the treatment of onychomycosis. A commercial cosmetic nail printer was modified by removing the ink from the cartridge and replacing it with an in-house prepared drug-loaded ink. The drug-loaded ink was designed so that it was comparable to the commercial ink for key printability properties. Linear drug dosing was shown by changing the lightness of the colour selected for printing (R2 = 0.977) and by printing multiple times (R2 = 0.989). The drug loads were measured for heart (271 µg), world (205 µg) and football (133 µg) shapes. A disc diffusion assay against Trpytophan rubrum showed inhibition of fungal growth with printed-on discs. In vitro testing with human nails showed substantial inhibition with printed-on nails. Hence, this is the first study to demonstrate the ability of a nail printer for drug delivery, thereby confirming its potential for onychomycosis treatment.
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Ghaemi B, Hashemi SJ, Kharrazi S, Moshiri A, Kargar Jahromi H, Amani A. Photodynamic therapy-mediated extirpation of cutaneous resistant dermatophytosis with Ag@ZnO nanoparticles: an efficient therapeutic approach for onychomycosis. Nanomedicine (Lond) 2022; 17:219-236. [PMID: 35118874 DOI: 10.2217/nnm-2021-0138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim: The aim of this study was to determine whether photodynamic therapy of resistant onychomycosis with Ag@ZnO nanoparticles can promote the treatment procedure and extirpates the recurrence of fungal infection. Methods: Ag@ZnO nanoparticles (NPs) under UVB-radiation were applied to treat T. rubrum and T. mentagrophytes in vitro through photodynamic therapy. In vivo therapeutic efficacy, biocompatibility and biodistribution of Ag@ZnO NPs were studied. Results: 40 μg/ml of UVB-activated Ag@ZnO NPs showed 100% antifungal activity against dermatophytosis in vitro and in vivo followed by complete growth prevention by degeneration of spores and mycelium after 180 days, while posed biocompatibility. Conclusion: This study showed the superiority of photodynamic therapy with Ag@ZnO NPs followed by proper regeneration of the skin with Zinc ion of the shell.
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Affiliation(s)
- Behnaz Ghaemi
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, 1417755469, Iran
| | - Seyed Jamal Hashemi
- Department of Medical Mycology & Parasitology, School of Public Health, Tehran University of Medical Sciences,Tehran, 1417755469, Iran.,Food Microbiology Research Centre, Tehran University of Medical Sciences, Tehran, 1417755469, Iran
| | - Sharmin Kharrazi
- Department of Medical Nanotechnology, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, 1417755469, Iran
| | - Arfa Moshiri
- Microbiology Research Centre, Pasteur Institute of Iran, Tehran, 1417755469, Iran.,Laboratory of Experimental Therapies in Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Hossein Kargar Jahromi
- Research Centre for Non-Communicable Disease, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Amani
- Natural Products & Medicinal Plants Research Centre, North Khorasan University of Medical Sciences, Bojnurd, Iran.,Medical Biomaterial Research Centre, Tehran University of Medical Sciences, Tehran, 1417755469, Iran
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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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Firooz A, Daneshpazhooh M, Lotfali E, Sharzad Kavkani M, Ghasemi Z, Khamesipoor A, Nassiri Kashani M, Miramin Mohammadi A, Skandari SE, Ahmad Nasrollahi S, Fattahi A. Drug Sensitivity Profile of Fungi Isolated from Onychomycosis Patients and Evaluation of Squalene Epoxidase Mutation in One Terbinafine-Resistant Trichophyton mentagrophytes Species. Microb Drug Resist 2021; 27:1658-1663. [PMID: 34297623 DOI: 10.1089/mdr.2020.0572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The resistance to treatment of onychomycosis is increasingly reported. The present study aimed to assess the antifungal activity of itraconazole, terbinafine, luliconazole, and efinaconazole against dermatophytes, molds, and also yeast isolated from patients with onychomycosis. Furthermore, the mechanism of resistance to terbinafine in resistant Trichophyton mentagrophytes species was evaluated using the squalene epoxidase (SQLE) gene sequence. Methods: A total of 71 fungal isolates were collected from 97 patients with suspected onychomycosis. The identification of fungal species was performed using conventional and molecular approaches. In vitro drug susceptibility for itraconazole, terbinafine, luliconazole, and efinaconazole was carried out using the broth microdilution method according to the CLSI-M60 and CLSI-M38 3rd ed., respectively. The SQLE gene of one terbinafine-resistant T. mentagrophytes was amplified using the specific primers. Results: Efinaconazole and luliconazole demonstrated higher effectiveness against all isolates in the study. One mismatch was detected at position 1177, which showed A → C change associated with Phe397Leu amino acid substitution of the SQLE protein in terbinafine-resistant T. mentagrophytes. Conclusion: The occurrence of resistant strains of organisms causing onychomycosis should be considered and evaluated. Furthermore, the identification of amino acid changes responsible for resistance to antifungals is a useful consideration in drug-target interaction.
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Affiliation(s)
- Alireza Firooz
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Razi Dermatology Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Lotfali
- Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zeinab Ghasemi
- Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Khamesipoor
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Nassiri Kashani
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Miramin Mohammadi
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ebrahim Skandari
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Saman Ahmad Nasrollahi
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Fattahi
- Center for Research and Training in Skin Disease and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Ahmad Nasrollahi S, Fattahi A, Naeimifar A, Lotfali E, Firooz A, Khamesipoor A, Skandari SE, Miramin Mohammadi A. The in vitro effect of nanoliposomal amphotericin B against two clinically important dermatophytes. Int J Dermatol 2021; 61:383-389. [PMID: 34176127 DOI: 10.1111/ijd.15609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/23/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
AIMS The present study aimed to investigate the antifungal activity of amphotericin B-loaded nanoliposomes against Trichophyton interdigitale and Trichophyton rubrum. Moreover, it was attempted to assess the obtained resistance in vitro. METHODS In total, 29 archived clinical strains, namely, T. interdigitale (n = 16) and T. rubrum (n = 13), were included in this study. These strains were determined using a previous ITS1-ITS2 region sequence. Moreover, a liposomal formulation of amphotericin B was formulated by a thin-film hydration method. Particle size, polydispersity index (PdI), and zeta potential (ZP) were measured by a Zetasizer. Furthermore, physicochemical properties, such as appearance, aggregation of particles, particle size, PdI, and ZP, were determined at 0-, 1-, and 3-month intervals. A scanning electron microscope (SEM) was also used to examine nanoparticles structure. The minimum inhibitory concentration (MIC) of amphotericin B-loaded nanoliposomes, itraconazole, efinaconazole, terbinafine, and ciclopirox was determined according to the protocol of the broth microdilution method of CLSI M38-A2. The morphological changes of T. interdigitale and T. rubrum strains exposed to the amphotericin B-loaded nanoliposomes were observed using SEM. RESULTS The amphotericin B-loaded nanoliposomes displayed a lower MIC compared to those of the amphotericin B and liposomes when used separately. Based on the results, amphotericin B-loaded nanoliposomes induced no drug resistance in any of the tested strains. CONCLUSION Accordingly, amphotericin B-loaded nanoliposomes can be a potent antifungal for the topical treatment of onychomycosis. There was no in vitro evidence regarding the resistance of the tested strains to amphotericin B-loaded nanoliposomes. This reflects that amphotericin B-loaded nanoliposomes have a low probability to induce drug resistance in dermatophyte species.
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Affiliation(s)
- Saman Ahmad Nasrollahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Fattahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Naeimifar
- Pharmaceutical Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Lotfali
- Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Firooz
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Khamesipoor
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ebrahim Skandari
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Miramin Mohammadi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Valkov A, Zinigrad M, Nisnevitch M. Photodynamic Eradication of Trichophyton rubrum and Candida albicans. Pathogens 2021; 10:pathogens10030263. [PMID: 33668866 PMCID: PMC7996248 DOI: 10.3390/pathogens10030263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 01/10/2023] Open
Abstract
Conventional methods of onychomycosis treatment are ineffective in some cases because the cure of onychomycosis very often depends on the patient’s individual response to the treatment; therefore, there is a crucial need to research and develop new methods of onychomycosis therapy. One of the most innovative treatments is photodynamic therapy (PDT) using photosensitizers (PSs). However, effective treatment depends on the correct choice of photosensitizer and substances that improve the characteristics of the final formulation. The aim of our work was to find an effective formulation for the treatment of onychomycosis. To achieve this goal, we tested the effect of three types of PSs, rose Bengal (RB), malachite green oxalate (MGO), and methylene blue (MB), on Candida albicans. The most effective PS was RB, and so the study was continued with Trichophyton rubrum. Additional comparative studies were carried out on substances included in the formulation (urea and thiourea), focusing on their antifungal activity, which can improve penetration through the nail plate. The composition of the formulation that achieved 100% eradication of Trichophyton rubrum under our conditions consisted of 150 μM RB, 5% urea, and 0.5% thiourea in glycerol/water (70/30%, w/w) solution. A white luminescent lamp was used as a light source (1.9 ± 0.1 mW cm−2). Stability of the formulation was checked. The selected formulation shows potential for future simplification and acceleration of PDT treatment of onychomycosis.
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11
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1064-nm Nd:YAG laser treatment for onychomycosis: is it worthwhile? Lasers Med Sci 2020; 36:463-467. [PMID: 32607712 DOI: 10.1007/s10103-020-03085-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/22/2020] [Indexed: 10/24/2022]
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12
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Alberdi E, Gómez C. Methylene blue vs methyl aminolevulinate photodynamic therapy in combination with oral terbinafine in the treatment of severe dermatophytic toenail onychomycosis: Short- and long-term effects. Mycoses 2020; 63:859-868. [PMID: 32506733 DOI: 10.1111/myc.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 05/31/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Photodynamic therapy (PDT) kills target microorganisms via reactive oxygen species (ROS) production. PDT seems to be a good alternative treatment option for onychomycosis. OBJECTIVE To compare the efficacy of combined therapies based on oral terbinafine (TN) plus adjunctive PDT mediated by methylene blue (MB) (TN + MB/PDT) or methyl aminolevulinate (MAL) (TN + MAL/PDT) in the treatment of onychomycosis. METHODS Twenty patients affected by severe dermatophyte onychomycosis in the nails of the big toe (>60% disease involvement of target nail) received oral TN for 12 weeks and concomitantly were randomly allocated to receive nine sessions, separated by 2-week intervals, of urea (40%) plus a PDT protocol mediated by MB (TN + MB/PDT: group I) or mediated by MAL (TN + MAL/PDT: group II). Clinical and mycological efficacy was evaluated at 16-, 40- and 52-week follow-up. RESULTS Both protocols showed a significant decrease in Onychomycosis Severity Index (OSI) scores (P < .05), from 24.2 ± 4.6 to 0.7 ± 0.6 (group I)) and from 18.5 ± 10.1 to 2.1 ± 2.0 (group II). No side effects or complications were reported in any of the combinations used. Mycological cure rates were significantly higher during the last third of the evaluated period of time, reaching 100% and 90% in group I and group II, respectively, at the 52-week follow-up. In both modalities, complete cure was achieved in 70% of the patients at the 52-week follow-up. CONCLUSIONS TN + MB/PDT and TN + MAL/PDT show similar outcomes in the treatment of toenails with severe onychomycosis. PDT is an effective method to accelerate the TN-mediated healing process.
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Affiliation(s)
| | - Clara Gómez
- Institute of Physical Chemistry Rocasolano, CSIC, Madrid, Spain
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13
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Kracht T, Müller-Goymann CC. Antifungal efficacy of liquid poloxamer 407-based emulsions loaded with sertaconazole nitrate. Int J Pharm 2020; 585:119400. [PMID: 32512222 DOI: 10.1016/j.ijpharm.2020.119400] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 12/31/2022]
Abstract
Drug delivery into the human nail plate for the treatment of onychomycosis is difficult due to limited permeability of the nail plate. Semisolid poloxamer 407-based formulations have recently shown promising results for drug delivery into and through the nail plate. In this study, liquid poloxamer 407-based emulsions loaded with sertaconazole nitrate have been developed and the permeation behavior was determined in vitro using modified Franz diffusion cells. The antifungal efficacy was evaluated in an infected nail plate model, where the growth inhibition of Trichophyton rubrum was observed. Bovine hoof plates and keratin films made from human hair were used as models for the human nail plate. In both cases, formulations with low viscosity and high water content showed best results despite a lower solubility of sertaconazole nitrate, suggesting that the composition of the vehicle plays a major role in permeation through the membrane. In addition, an API content close to saturation solubility had a positive effect on permeation.
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Affiliation(s)
- Tobias Kracht
- Institut für Pharmazeutische Technologie TU Braunschweig, Mendelssohnstr. 1, D-38106 Braunschweig, Germany.
| | - Christel C Müller-Goymann
- Institut für Pharmazeutische Technologie TU Braunschweig, Mendelssohnstr. 1, D-38106 Braunschweig, Germany.
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Idris NFB, Huang G, Jia Q, Yuan L, Li Y, Tu Z. Mixed Infection of Toe Nail Caused by Trichosporon asahii and Rhodotorula mucilaginosa. Mycopathologia 2019; 185:373-376. [PMID: 31760556 DOI: 10.1007/s11046-019-00406-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/11/2019] [Indexed: 12/27/2022]
Abstract
Trichosporon asahii and Rhodotorula mucilaginosa are important fungal species causing disseminated disease in immunocompromised patients. Onychomycosis prevalence rate ranges from 2 to 30%, which were 50% of nail diseases and 30% of superficial mycosis, respectively. Although important, little is known about the co-habitation of T. asahii and R. mucilaginosa in the causation of onychomycosis. Here, we present the co-habitation of T. asahii and R. mucilaginosa as causative agents of onychomycosis in a healthy 41-year-old male in China. Direct microscopic examination, fungal culture and MALDI-TOF MS were employed in isolated pathogens; hence, antifungal susceptibility test was evaluated. T. asahii was sensitive to posaconazole, voriconazole and itraconazole, whereas R. mucilaginosa was sensitive to both 5-flucytosine and amphotericin B. This report highlights the co-habitation of T. asahii and R. mucilaginosa in the causation of onychomycosis and to raise the awareness of this infection among dermatologists.
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Affiliation(s)
- Nur Fazleen Binti Idris
- Department of Microbiology, College of Basic Medical Sciences, Chongqing Medical University, Chongqing, 400016, China
| | - Guowang Huang
- Department of Microbiology, College of Basic Medical Sciences, Chongqing Medical University, Chongqing, 400016, China
| | - Qianying Jia
- Department of Infectious Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lin Yuan
- Department of Microbiology, College of Basic Medical Sciences, Chongqing Medical University, Chongqing, 400016, China
| | - Yimin Li
- Department of Microbiology, College of Basic Medical Sciences, Chongqing Medical University, Chongqing, 400016, China
| | - Zeng Tu
- Department of Microbiology, College of Basic Medical Sciences, Chongqing Medical University, Chongqing, 400016, China.
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15
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Chen B, Sun Y, Zhang J, Chen R, Zhong X, Wu X, Zheng L, Zhao J. In vitro Evaluation of Photodynamic Effects Against Biofilms of Dermatophytes Involved in Onychomycosis. Front Microbiol 2019; 10:1228. [PMID: 31231330 PMCID: PMC6568038 DOI: 10.3389/fmicb.2019.01228] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/16/2019] [Indexed: 02/01/2023] Open
Abstract
Dermatophytes are the most common cause of onychomycosis, counting for 90% fungal nail infection. Although dermatophyte pathogens are normally susceptible to antifungal agents, onychomycosis often results in refractory chronic disease, and the formation of biofilms frequently underlines the inadequate responses and resistance to standard antifungal treatment. Numerous in vitro and in vivo antimicrobial photodynamic therapy (aPDT) studies have shown biofilm eradication or substantial reduction, however, such investigation has not yet been expanded to the biofilms of dermatophytes involved in onychomycosis. To shed a light on the potential application of aPDT in the clinic management of onychomycosis, in particular with the manifestation of dermatophytoma, we investigated photodynamic effects on the viabilities and the drug susceptibilities of the biofilm of dermatophytes in vitro. Here, methylene blue at the concentration of 8, 16, and 32 μg/ml applied as photosensitizing agent and LED (635 ± 10 nm, 60 J/cm2) as light source were employed against six strains of Trichophyton rubrum, ten strains of Trichophyton mentagrophytes and three strains of Microsporum gypseum isolated from clinical specimens. Our results indicated highly efficient photodynamic inhibition, exhibiting CFU (colony forming unit) reduction up to 4.6 log10, 4.3 log10, and 4.7 log10 against the biofilms formed by T. rubrum, T. mentagrophytes, and M. gypseum, respectively. Subjected biofilms displayed considerable decreases in SMICs (sessile minimum inhibitory concentrations) to multiple antifungal agents when compared with untreated groups, indicating the biofilms of dermatophytes became more susceptible to conventional antifungal drugs after aPDT. Additionally, the obliteration of biofilm after aPDT could be observed as shattered and ruptured structures being evident in SEM (Scanning Electron Microscopy) images. These findings suggest that aPDT is an attractive alternative treatment holding great promise for combating recalcitrant onychomycosis associated with the biofilm formation.
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Affiliation(s)
- Borui Chen
- Department of Dermatology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Dermatology Hospital of Fuzhou, Fuzhou, China
| | - Yi Sun
- Department of Dermatology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, China
| | | | - Ruijun Chen
- Dermatology Hospital of Fuzhou, Fuzhou, China
| | - Xiurong Zhong
- Electron Microscopy Laboratory, Fujian Medical University, Fuzhou, China
| | - Xiaomo Wu
- Dermatology Hospital of Fuzhou, Fuzhou, China
| | - Libao Zheng
- Dermatology Hospital of Fuzhou, Fuzhou, China
| | - Jingjun Zhao
- Department of Dermatology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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16
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Yue X, Wang A, Sun Y, Li Q. Ultrastructural changes of Trichophyton rubrum in tinea unguium after itraconazole therapy in vivo observed using scanning electron microscopy. Clin Exp Dermatol 2018; 43:883-889. [PMID: 30387190 DOI: 10.1111/ced.13641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tinea unguium is a dermatophyte infection of the nails. Itraconazole is a broad-spectrum antifungal drug used to treat this disease. It works by interfering with the synthesis of ergosterol in the cell membrane, thus causing changes that can be seen under scanning electron microscopy (SEM). AIM To observe under SEM the in vivo ultrastructural changes of tinea unguium caused by Trichophyton rubrum before and after itraconazole (ICZ) therapy, and to explore the in vivo antifungal effect of ICZ. METHODS Ten outpatients diagnosed by mycology and SEM as having with tinea unguium caused by T. rubrum were recruited. They received ICZ pulse therapy (200 mg twice/day for 1 week, stop for 3 weeks, repeated for 3-4 months). Clinical change, mycology and SEM results were obtained after therapy. RESULTS After ICZ therapy, 3 of the 10 cases were positive by both mycology and SEM; the latter showed completely dry, shrivelled, curved and folded hyphae with a relatively smooth surface or local destruction. Several hyphae remained intact with only some local bumps or crimps. The other cases were negative by SEM, but two were positive by mycology. CONCLUSION In vivo ultrastructural changes of hyphae of T. rubrum in tinea unguium after ICZ treatment could be seen under SEM, demonstrating that ICZ fungistasis was effective and that SEM is a good tool for evaluating the effectiveness of ICZ in vivo. To our knowledge, this study is the first to show by SEM ICZ permeates the affected nail plate via the nail bed capillaries.
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Affiliation(s)
- X Yue
- Department of Dermatology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - A Wang
- Department of Dermatology and Venereology, Peking University First Hospital and Research Center for Medical Mycology, Peking University, Beijing, China
| | - Y Sun
- Department of Ultrastructural Pathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Q Li
- Department of Dermatology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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17
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Weber GC, Firouzi P, Baran AM, Bölke E, Schrumpf H, Buhren BA, Homey B, Gerber PA. Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients. Eur J Med Res 2018; 23:53. [PMID: 30355363 PMCID: PMC6199788 DOI: 10.1186/s40001-018-0340-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser. Methods We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013–December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2–6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy. Results Clinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed. Conclusions The 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.
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Affiliation(s)
- G C Weber
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - P Firouzi
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - A M Baran
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - E Bölke
- Department of Radiation Oncology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - H Schrumpf
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - B A Buhren
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - B Homey
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - P A Gerber
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany.
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18
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Hay R. Therapy of Skin, Hair and Nail Fungal Infections. J Fungi (Basel) 2018; 4:E99. [PMID: 30127244 PMCID: PMC6162762 DOI: 10.3390/jof4030099] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/28/2022] Open
Abstract
Treatment of superficial fungal infections has come a long way. This has, in part, been through the development and evaluation of new drugs. However, utilising new strategies, such as identifying variation between different species in responsiveness, e.g., in tinea capitis, as well as seeking better ways of ensuring adequate concentrations of drug in the skin or nail, and combining different treatment methods, have played equally important roles in ensuring steady improvements in the results of treatment. Yet there are still areas where we look for improvement, such as better remission and cure rates in fungal nail disease, and the development of effective community treatment programmes to address endemic scalp ringworm.
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19
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Zhang L, Xu H, Shi Y, Yu J, Tao Y, Li X. An exploration of the optimum dosage and number of cycles of itraconazole pulse therapy for severe onychomycosis. Mycoses 2018; 61:736-742. [PMID: 29893422 DOI: 10.1111/myc.12799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/14/2018] [Accepted: 06/05/2018] [Indexed: 12/27/2022]
Abstract
Although standard itraconazole pulse therapy is a well-established regimen for toenail onychomycosis, the cure rate for onychomycosis remains low. To evaluate the efficacy and safety of different cycles of itraconazole pulse therapy, determine the optimal dosage and number of cycles for onychomycosis. A total of 90 outpatients of our hospital with onychomycosis were randomised into three treatment groups: (1) standard itraconazole pulse therapy (200 mg twice per day, 1 week each month for three pulses); (2) long-term pulse therapy (200 mg twice per day, 1 week each month for six pulses); (3) low-dose and long-term pulse therapy (200 mg/d, 1 week per month for six pulses) and were followed up for 15 months. Of the initial patients, the trial was completed by 81 patients. The complete cure rates were 32.43% for three cycles and 75% for six cycles (P < .001). For six cycles, despite the administration of half-dose for patients weighing no more than 55 kg, there was no statistical difference in the complete cure rate (P = .862). Long-term therapy is effective and safe for the treatment of toenail onychomycosis. For patients weighing no more than 55 kg, long-term half-dose itraconazole pulse therapy is recommended .
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Affiliation(s)
- Li Zhang
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Hui Xu
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Yuling Shi
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Jing Yu
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
| | - Yunjiao Tao
- Dermatology, Zhangjiagang second people's hospital, Suzhou, China
| | - Xiuli Li
- Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, P.R.China
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20
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Angelo T, Borgheti-Cardoso LN, Gelfuso GM, Taveira SF, Gratieri T. Chemical and physical strategies in onychomycosis topical treatment: A review. Med Mycol 2018; 55:461-475. [PMID: 27703019 DOI: 10.1093/mmy/myw084] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/30/2016] [Indexed: 12/13/2022] Open
Abstract
Onychomycosis is a fungal infection of the fingernails or toenails caused by dermatophytes, nondermatophytes, moulds, and yeasts. This condition affects around 10-30% people worldwide, negatively influencing patients' quality of life, with severe outcomes in some cases. Since the nail unit acts as a barrier to exogenous substances, its physiological features hampers drug penetration, turning the onychomycosis treatment a challenge. Currently, there are several oral and topical therapies available; nevertheless, cure rates are still low and relapse rates achieves 10-53%. Also, serious side effects may be developed due to long-term treatment. In light of these facts, researchers have focused on improving topical treatments, either by modifying the vehicle or by using some physical technique to improve drug delivery trough the nail plate, hence increasing therapy effectiveness. Therefore, the aim of this paper is to explain these novel alternative approaches. First, the challenges for drug ungual penetration are presented. Then, the chemical and physical strategies developed for overcoming the barriers for drug penetration are discussed. We hope that the information gathered may be useful for the development of safer and more effective treatments for onychomycosis.
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Affiliation(s)
- Tamara Angelo
- Laboratory of Food, Drugs and Cosmetics (LTMAC). School of Health Sciences, University of Brasília. Campus Universitário Darcy Ribeiro, s/n, 70910-900, Brasília, DF, Brazil
| | - Lívia Neves Borgheti-Cardoso
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo. Avenida do Café, s/n, 14040903, Ribeirão Preto, SP, Brazil
| | - Guilherme Martins Gelfuso
- Laboratory of Food, Drugs and Cosmetics (LTMAC). School of Health Sciences, University of Brasília. Campus Universitário Darcy Ribeiro, s/n, 70910-900, Brasília, DF, Brazil
| | - Stephânia Fleury Taveira
- School of Pharmacy, Federal University of Goiás. Rua 240 c/5ª. Avenida, s/n, Setor Leste Universitário, 74.605-170, Goiânia, GO, Brazil
| | - Tais Gratieri
- Laboratory of Food, Drugs and Cosmetics (LTMAC). School of Health Sciences, University of Brasília. Campus Universitário Darcy Ribeiro, s/n, 70910-900, Brasília, DF, Brazil
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21
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Houang J, Perrone G, Mawad D, Boughton PC, Ruys AJ, Lauto A. Light treatments of nail fungal infections. JOURNAL OF BIOPHOTONICS 2018; 11:e201700350. [PMID: 29227574 DOI: 10.1002/jbio.201700350] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/07/2017] [Indexed: 06/07/2023]
Abstract
Nail fungal infections are notoriously persistent and difficult to treat which can lead to severe health impacts, particularly in the immunocompromized. Current antifungal treatments, including systemic and topical drugs, are prolonged and do not effectively provide a complete cure. Severe side effects are also associated with systemic antifungals, such as hepatotoxicity. Light treatments of onychomycosis are an emerging therapy that has localized photodynamic, photothermal or photoablative action. These treatments have shown to be an effective alternative to traditional antifungal remedies with comparable or better cure rates achieved in shorter times and without systemic side effects. This report reviews significant clinical and experimental studies in the field, highlighting mechanisms of action and major effects related to light therapy; in particular, the impact of light on fungal genetics.
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Affiliation(s)
- Jessica Houang
- Biomedical Engineering, School of Aerospace, Mechanical and Mechatronic Engineering, University of Sydney, Sydney, NSW, Australia
| | - Gabriel Perrone
- School of Science and Health, Western Sydney University, Penrith, NSW, Australia
| | - Damia Mawad
- School of Materials Science and Engineering, University of New South Wales, Kensington, NSW, Australia
- Australian Centre for NanoMedicine and ARC Centre of Excellence in Convergent BioNano Science and Technology, University of New South Wales, Sydney, NSW, Australia
- Centre for Advanced Macromolecular Design, University of New South Wales, Sydney, NSW, Australia
| | - Philip C Boughton
- Biomedical Engineering, School of Aerospace, Mechanical and Mechatronic Engineering, University of Sydney, Sydney, NSW, Australia
| | - Andrew J Ruys
- Biomedical Engineering, School of Aerospace, Mechanical and Mechatronic Engineering, University of Sydney, Sydney, NSW, Australia
| | - Antonio Lauto
- School of Science and Health, Western Sydney University, Penrith, NSW, Australia
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Biomedical Engineering & Neuroscience Research Group, The MARCS Institute, Western Sydney University, Penrith, NSW, Australia
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22
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Park KY, Suh JH, Kim BJ, Kim MN, Hong CK. Randomized Clinical Trial to Evaluate the Efficacy and Safety of Combination Therapy with Short-Pulsed 1,064-nm Neodymium-Doped Yttrium Aluminium Garnet Laser and Amorolfine Nail Lacquer for Onychomycosis. Ann Dermatol 2017; 29:699-705. [PMID: 29200757 PMCID: PMC5705350 DOI: 10.5021/ad.2017.29.6.699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/25/2017] [Accepted: 02/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background Onychomycosis is one of the most prevalent fungal diseases in the general population. However, treatment is of limited effectiveness and must be administered for long periods of time. Systemic antifungal agents are associated with adverse effects. Objective We evaluated the clinical efficacy and safety of a 1,064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser with amorolfine nail lacquer to treat onychomycosis. Methods The 128 patients were randomly divided to 2 groups: 64 in the experimental group were treated with 1,064-nm Nd:YAG laser therapy and amorolfine nail lacquer; the other 64 were in a control group treated with topical amorolfine lacquer monotherapy. The laser treatment was 4 sessions at 4-week intervals and amorolfine lacquer was applied once a week for 16 weeks. Efficacy was assessed as response rate from standardized photographs with ImagePro®Plus (Media Cybernetics, Inc., USA) analysis, microscopic examination, and subjective evaluation. Results At 16 weeks, the experimental group showed a significantly higher cumulative cure rate than the control group (71.88% vs. 20.31%, p<0.0001). Clinical therapeutic effects were linked to patient satisfaction. The percent of “very satisfied” or “satisfied” responses was higher in the test group than the control group (81.25% vs. 23.44%). The treatment regimen was well tolerated, with transient discomfort observed in the test group. Conclusion The 1,064-nm Nd:YAG laser with amorolfine nail lacquer was effective and safe for treating onychomycosis. This therapy should be considered an alternative treatment, especially for patients with contraindications to systemic antifungal agents.
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Affiliation(s)
- Kui Young Park
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Joon Hyuk Suh
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Beom Joon Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Myeung Nam Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chang Kwun Hong
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
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23
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Shemer A, Daniel R, Rigopoulos D, Farhi R, Babaev M. Variability in Systemic Treatment Efficacy for Onychomycosis: Information That Clinical Studies Do Not Impart to the Office Dermatologist. Skin Appendage Disord 2017; 4:141-144. [PMID: 30197889 DOI: 10.1159/000481693] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/06/2017] [Indexed: 01/21/2023] Open
Abstract
Wide differences in the cure rates of onychomycosis in various clinical studies can be avoided if we bear in mind some insights that will help us make study results more consistent. We suggest less rigid criteria in defining the cure rate, the inclusion of all toenails in studies, and the exclusion of nails with a history of trauma. Rather than address patients as a homogenous group, regardless of age, we suggest dividing them into age groups. Researchers should not forget inflammatory diseases that can imply changes on the nails and should take into account the duration of onychomycosis, nail changes caused by asymmetry, and the possibility of dermatophytoma.
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Affiliation(s)
- Avner Shemer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel.,Department of Dermatology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Ralph Daniel
- University of Mississippi Medical Center and University of Alabama, Birmingham, AL, USA
| | - Dimitris Rigopoulos
- 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens Medical School, "Attikon" General University Hospital, Athens, Greece
| | - Renata Farhi
- Hospital Nossa Senhora da Saúde, University Fundação Tecnico Educacional Souza Marques, Rio de Janeiro, Brazil
| | - Meir Babaev
- Division of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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24
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The Efficacy and Safety of Systemic Antifungals in Children’s Onychomycosis. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0280-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Yamaguchi H. Potential of Ravuconazole and its Prodrugs as the New OralTherapeutics for Onychomycosis. Med Mycol J 2017; 57:E93-E110. [PMID: 27904057 DOI: 10.3314/mmj.16-00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Onychomycosis is a fungal infection of the nail apparatus caused by dermatophytes, Candida and non-dermatophytic molds. It is highly prevalent in the general population worldwide and also responsible for significant morbidity and complications and does not usually cure itself. Thus, the condition needs to be treated in view of physical and psychological problems produced. Currently, oral medications using terbinafine are the most effective therapy, but it has relatively limited therapeutic success, particularly for long-term management. Such existing oral therapies are associated with high recurrence rates and treatment failure, as well as with potential adverse events and drug-drug interactions. In the light of these issues, development of more efficacious and safer alternatives for the treatment of onychomycosis is warranted.Ravuconazole and its prodrugs are promising new drug candidates for oral therapy of onychomycosis, among which a water-soluble prodrug, mono-lysine phosphoester derivative (E1224 or BFE1224) is in the most advanced stage of clinical development; a Phase II dose-finding study has been successfully completed and Phase III comparative studies are in progress in Japan.This review aims to summarize our current status of knowledge and information on ravuconazole and its prodrugs, particularly BFE1224, as the potential oral treatment option for onychomycosis. It also summarize the clinical features of onychomycosis with particular stress on its etiology, epidemiology, and current therapeutic options and their limitations. Given its clinical usefulness, BFE1224 may become a valuable addition to the current armamentarium for the treatment of onychomycosis.
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26
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Kerai LV, Hilton S, Maugueret M, Kazi BB, Faull J, Bhakta S, Murdan S. UV-curable gels as topical nail medicines:In vivo residence, anti-fungal efficacy and influence of gel components on their properties. Int J Pharm 2016; 514:244-254. [PMID: 27863669 DOI: 10.1016/j.ijpharm.2016.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 11/29/2022]
Abstract
UV-curable gels, used as nail cosmetics for their in vivo durability, were reported to be promising as topical nail medicines. Our first aim was thus to investigate whether such durability applies to drug-loaded formulations. This was found to be true. However, ethanol inclusion in the pharmaceutical formulation (to enable drug loading) reduced the in vivo residence. The second aim was therefore to determine any other effects of ethanol, and if ethanol could be avoided by the choice of monomers. Thus, three methacrylate monomers, ethyl methacrylate, isobornyl methacrylate and 2-hydroxyethyl methacrylate (HEMA) were selected, and their influence on the formulation properties were determined. Ethanol and the methacrylate monomer influenced some (but not all) of the formulation properties. The most significant was that HEMA could dissolve drug and enable the preparation of ethanol-free, drug-loaded formulations, which would benefit in vivo residence. The absence of ethanol reduced drug loading, release and ungual flux, but had no negative impact on the in vitro anti-fungal efficacy. Thus, judicious selection of gel components enabled the exclusion of ethanol. The long in vivo residence, little residual monomers, sufficient ungual permeation and in vitro anti-fungal activity of the gels indicates their potential as anti-onychomycotic topical medicines.
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Affiliation(s)
- L V Kerai
- UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - S Hilton
- UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - M Maugueret
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, Malet Street, London, WC1E 7HX, UK
| | - B B Kazi
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, Malet Street, London, WC1E 7HX, UK
| | - J Faull
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, Malet Street, London, WC1E 7HX, UK
| | - S Bhakta
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, Malet Street, London, WC1E 7HX, UK
| | - S Murdan
- UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK.
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Asz-Sigall D, Tosti A, Arenas R. Tinea Unguium: Diagnosis and Treatment in Practice. Mycopathologia 2016; 182:95-100. [PMID: 27787643 DOI: 10.1007/s11046-016-0078-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/03/2016] [Indexed: 11/26/2022]
Abstract
Onychomycosis is caused by dermatophytes, yeasts or non-dermatophyte molds; when caused by dermatophytes, it is called tinea unguium. The main etiological agents are Trichophyton rubrum and Trichophyton interdigitale. The most frequent types are distal and lateral subungual onychomycosis. Diagnosis usually requires mycological laboratory confirmation. Dermoscopy can be helpful and also biopsy is an excellent diagnostic method in uncommon cases or when mycological test is negative. Treatment must be chosen according to clinical type, number of affected nails and severity. The goal for antifungal therapy is the clearing of clinical signs or mycological cure.
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Affiliation(s)
- Daniel Asz-Sigall
- Mycology Section, "Dr. Manuel Gea Gonzalez" General Hospital, Av. Calzada de Tlalpan 4800, Tlalpan, Sección XVI, 14080, Cuidad de Mexico, D.F., Mexico.
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, University of Miami Hospital, 1295 NW 14th St, South Bldg, Stes K, L & M, Miami, FL, 33136, USA
| | - Roberto Arenas
- Mycology Section, "Dr. Manuel Gea Gonzalez" General Hospital, Av. Calzada de Tlalpan 4800, Tlalpan, Sección XVI, 14080, Cuidad de Mexico, D.F., Mexico
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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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30
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Abstract
New medications and new formulations have provided an increase in the cure rates for onychomycosis. Many cases of infection, however, are still not cured. It is not always obvious which factors are most relevant to reduction of cure, and factors may vary with each patient. For these reasons, a multitherapy approach to onychomycosis may be needed to individualize treatment to each patient's specific condition. Different presentations and severity levels of onychomycosis may respond differently to treatment modalities and require varying amounts of intervention. Nail débridement may be used to lessen the burden of infection in cases in which drug penetration may not occur adequately otherwise, such as dermatophytoma, onycholysis, or lateral infection. Ciclopirox nail lacquer has been approved for use in conjunction with regular débridement and represents the first approved multitherapy approach. Topical antifungals may be combined with oral antifungals to provide dual fronts of drug penetration. Similarly, two oral medications may be combined to provide a wider spectrum of antifungal activity and differential mode of action against the organisms, which may increase fungistatic or fungicidal action. There is a nonclinical component of therapy, represented by patient education on onychomycosis infection and treatment, which should be used to ensure that patient expectations are realistic and to encourage patient compliance with the chosen regimens.
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Affiliation(s)
- Joël Claveau
- From the Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ, Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; and Mediprobe Research Inc., London, ON
| | - Ronald B. Vender
- From the Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ, Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; and Mediprobe Research Inc., London, ON
| | - Aditya K. Gupta
- From the Dermatology Division, Laval University, Quebec City, PQ; Centre Hospitalier Universitaire de Quebec, Hotel Dieu de Quebec, Quebec City, PQ, Dermatrials Research, Hamilton, ON; McMaster University, Hamilton, ON; Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Sunnybrook site) and the University of Toronto, Toronto, ON; and Mediprobe Research Inc., London, ON
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31
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Lu S, Zhang J, Liang Y, Li X, Cai W, Xi L. The Efficacy and Prognostic Factors for Long Pulse Neodymium: Yttrium-Aluminum-Garnet Laser Treatment on Onychomycosis: A Pilot Study. Ann Dermatol 2016; 28:406-8. [PMID: 27274650 PMCID: PMC4884728 DOI: 10.5021/ad.2016.28.3.406] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/02/2015] [Accepted: 06/25/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Sha Lu
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Zhang
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuheng Liang
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.; Institute of Pathogenic Microbiology, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Xiqing Li
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenying Cai
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liyan Xi
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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32
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Imperiale JC, Sosnik AD. Cyclodextrin complexes for treatment improvement in infectious diseases. Nanomedicine (Lond) 2016; 10:1621-41. [PMID: 26008196 DOI: 10.2217/nnm.15.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Infectious diseases are a heterogeneous group of maladies that represent a serious burden to healthcare systems worldwide. Most of the available antimicrobial drugs display poor biopharmaceutical properties that compromise their effectiveness. Cyclodextrins (CDs) are cyclic oligosaccharides of glucopyranose formed by a variable number of repeating units that combine a hydrophilic surface with a hydrophobic cavity. The production of drug/CD complexes has become one of the most extensively investigated technology approaches to improve the stability, solubility, dissolution rate and bioavailability of drugs. The present work overviews the applications of CDs for the formulation of anti-infective agents along with the most relevant administration routes. Finally, an update on the complexes with CDs available on the market to treat infectious diseases is presented.
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Otašević S, Barac A, Pekmezovic M, Tasic S, Ignjatović A, Momčilović S, Stojanović P, Arsic Arsenijevic V, Hay R. The prevalence of Candida onychomycosis in Southeastern Serbia from 2011 to 2015. Mycoses 2015; 59:167-72. [PMID: 26710983 DOI: 10.1111/myc.12448] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 10/22/2015] [Accepted: 11/18/2015] [Indexed: 12/01/2022]
Abstract
Despite the increasing of onychomycosis caused by Candida spp., in referent literature, there is still data insufficiency about this nail infection. The objectives of this retrospective study were to determine epidemiological characteristics of Candida onychomycosis, the antifungal susceptibility of isolated species in vitro, and to compare the results of antifungal susceptibility testing with conducted treatment in period from 2011 to the end of March 2015. Out of 761 patients who were underwent clinical and mycological examinations, 137 had Candida species isolated from nails. The dominant species was Candida albicans (C. albicans) (36.59%) followed by C. parapsilosis (23.78%), C. krusei (9.76%), and C. guilliermondii (6.71%). Antifungal susceptibility in vitro testing showed good susceptibility to antimycotics, except C. krusei, which was resistance to fluconazole (FCZ) and isolates of C. tropicalis and C. glabrata which were dose dependent to itraconazole (ITZ) and fluconazole. Evaluation of medical histories determined that combined therapy, which included pulsed systemic regimen of ITZ with topical application of clotrimazole, had better clinical outcomes regarding the proscribed only topical application of clotrimazole. Multidisciplinary approach of dermatologists and mycologists is required in solving the problem of onychomycosis, which is the dominant nail disease.
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Affiliation(s)
- Suzana Otašević
- Center of Microbiology and Parasitology, Public Health Institute Niš, Niš, Serbia.,Department of Microbiology and Immunology, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Aleksandra Barac
- Department of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marina Pekmezovic
- Department of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sinisa Tasic
- Clinic for skin and veneral diseases, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Aleksandra Ignjatović
- Center of Microbiology and Parasitology, Public Health Institute Niš, Niš, Serbia.,Department of Medical Statistics, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Stefan Momčilović
- Department of Microbiology and Immunology, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Predrag Stojanović
- Center of Microbiology and Parasitology, Public Health Institute Niš, Niš, Serbia.,Department of Microbiology and Immunology, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Valentina Arsic Arsenijevic
- Department of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,National Medical Mycology Reference Laboratory, Department of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Roderick Hay
- Department of Dermatology, Skin Infection Clinic, Kings College Hospital NHS Trust, London, UK
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34
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Helou J, Maatouk I, Hajjar MA, Moutran R. Evaluation of Nd:YAG laser device efficacy on onychomycosis: a case series of 30 patients. Mycoses 2015; 59:7-11. [DOI: 10.1111/myc.12425] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 10/22/2022]
Affiliation(s)
- J. Helou
- Dermatology; Hotel-Dieu de France; Faculty of medicine; Saint Joseph University; Beirut Lebanon
| | | | | | - R. Moutran
- Dermatology; Mount Lebanon hospital; Beirut Lebanon
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35
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Snell M, Klebert M, Önen NF, Hubert S. A Novel Treatment for Onychomycosis in People Living With HIV Infection: Vicks VapoRub™ is Effective and Safe. J Assoc Nurses AIDS Care 2015; 27:109-13. [PMID: 26585031 DOI: 10.1016/j.jana.2015.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
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36
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Auvinen T, Tiihonen R, Soini M, Wangel M, Sipponen A, Jokinen J. Efficacy of topical resin lacquer, amorolfine and oral terbinafine for treating toenail onychomycosis: a prospective, randomized, controlled, investigator-blinded, parallel-group clinical trial. Br J Dermatol 2015; 173:940-8. [DOI: 10.1111/bjd.13934] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 11/28/2022]
Affiliation(s)
- T. Auvinen
- Department of Vascular Surgery, Heart Centre; Kuopio University Hospital; FI-70029 Kuopio Finland
| | - R. Tiihonen
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - M. Soini
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - M. Wangel
- Vääksy Medical Centre; FI-17200 Vääksy Finland
| | - A. Sipponen
- Department of Orthopaedics and Traumatology; Päijät-Häme Central Hospital; FI-15850 Lahti Finland
| | - J.J. Jokinen
- Department of Cardiac Surgery, Heart and Lung Centre; Helsinki University Hospital; FI-00029 Helsinki Finland
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37
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Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol 2015; 171:937-58. [PMID: 25409999 DOI: 10.1111/bjd.13358] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/12/2022]
Affiliation(s)
- M Ameen
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, U.K
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38
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Nematollahi AR, Badiee P, Nournia E. The Efficacy of Ultraviolet Irradiation on Trichophyton Species Isolated From Nails. Jundishapur J Microbiol 2015; 8:e18158. [PMID: 26322201 PMCID: PMC4548401 DOI: 10.5812/jjm.18158v2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 06/07/2014] [Accepted: 06/08/2014] [Indexed: 01/24/2023] Open
Abstract
Background: The treatment of onychomycosis is a challenge and infections are typically more severe and difficult to treat in toenails than in fingernails. Objectives: The current study aimed to investigate the fungicidal effect of ultraviolet radiation on the growth of dermatophytes isolated from nails. Patients and Methods: Samples from patients with clinical manifestations of onychomycosis were inoculated onto Sabouraud dextrose agar and incubated at 30°C for 14 days. Isolated species were identified by specific laboratory examinations; UV-A, UV-B, and UV-C light were used to irradiate two strains of Trichophyton mentagrophytes and T. rubrum. Colony count, size and growth rate of the isolated fungi were evaluated under laboratory conditions. Results: Trichophyton rubrum type 1 was less sensitive to UV-A and UV-C, and more sensitive to UV-B than type 2. T. mentagrophytes type 2 was slightly responsive to UV-A therapy, although no decrease in colony count was observed. Increased doses of UV-B and UV-C irradiation decreased the counts. The effect of radiation on colony size was dependent on the dose and type of irradiation. Conclusions: UV-A, UV-B, and UV-C light seem to be effective in decreasing colony growth of the most prevalent fungi, which caused onychomycosis in the current study samples. Further studies are needed to determine the efficacy of ultraviolet light therapy, identify possible side effects, and establish appropriate dosages for the antifungal effect of this therapy.
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Affiliation(s)
- Ahmad Reza Nematollahi
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Parisa Badiee
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Parisa Badiee, Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-7136474292, Fax: +98-7136474303, E-mail:
| | - Ensieh Nournia
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, IR Iran
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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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40
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Simmons B, Griffith R, Falto-Aizpurua L, Nouri K. An update on photodynamic therapies in the treatment of onychomycosis. J Eur Acad Dermatol Venereol 2015; 29:1275-9. [DOI: 10.1111/jdv.12950] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/04/2014] [Indexed: 11/28/2022]
Affiliation(s)
- B.J. Simmons
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - R.D. Griffith
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - L.A. Falto-Aizpurua
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - K. Nouri
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
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41
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LaSenna CE, Tosti A. Patient considerations in the management of toe onychomycosis - role of efinaconazole. Patient Prefer Adherence 2015; 9:887-91. [PMID: 26170638 PMCID: PMC4494615 DOI: 10.2147/ppa.s72701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Onychomycosis is a difficult diagnosis to manage and treatment is sometimes avoided, as this diagnosis is often wrongly perceived as a cosmetic problem. However, onychomycosis has a negative impact on patients' quality of life, affecting social interaction, psychological well-being, and physical activities. Onychomycosis is also a risk factor for patients with diabetes, with proven increased rates of cellulitis, gangrene, and foot ulcers. Treatments are only mild to moderately effective, and rates of relapse and reinfection are high. Oral treatments require laboratory monitoring due to risk of hepatotoxicity and may be contraindicated in some patients due to risk of drug-drug interactions. Topical treatments require prolonged application and are not very effective. Efinaconazole 10% solution is a new topical triazole treatment for mild to moderate distal subungual onychomycosis, with good efficacy and without the need for debridement of nails. In onychomycosis of the toenails, efinaconazole 10% solution is documented to have a statistically significant, positive impact on patient satisfaction and quality of life.
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Affiliation(s)
- Charlotte E LaSenna
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Correspondence: Charlotte LaSenna, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, 1600 Northwest, 10th Avenue, RMSB Building, Room 2023C, Miami, FL 33136, USA, Tel +1 305 243 5523, Fax +1 305 243 5810, Email
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
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Abstract
Onychomycosis is a chronic infection of the nail unit, and its prevalence increases with age. Treatment options for children are similar to those for adults and include both oral and topical therapies. Oral agents, such as terbinafine, itraconazole, and fluconazole have been reported to have good efficacy and a low rate of side effects in children. Topical therapies, such as amorolfine and ciclopirox, can also be used as monotherapy or combined with oral agents to treat onychomycosis. Due to their thinner, faster-growing nails, children are more likely to respond to topical monotherapy than adults. There is currently insufficient data comparing emerging medical devices, such as laser therapy, with standard therapeutic options to recommend their use in children.
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Affiliation(s)
- Stephanie Feldstein
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital-San Diego and University of California, San Diego School of Medicine, 8010 Frost St. Suite 602, San Diego, CA 92123
| | - Christine Totri
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital-San Diego and University of California, San Diego School of Medicine, 8010 Frost St. Suite 602, San Diego, CA 92123
| | - Sheila Fallon Friedlander
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital-San Diego and University of California, San Diego School of Medicine, 8010 Frost St. Suite 602, San Diego, CA 92123.
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44
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Eldridge ML, Chambers CJ, Sharon VR, Thompson GR. Fungal infections of the skin and nail: new treatment options. Expert Rev Anti Infect Ther 2014; 12:1389-405. [DOI: 10.1586/14787210.2014.960849] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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45
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Clarke M, Brice A, Chalmers I. Accumulating research: a systematic account of how cumulative meta-analyses would have provided knowledge, improved health, reduced harm and saved resources. PLoS One 2014; 9:e102670. [PMID: 25068257 PMCID: PMC4113310 DOI: 10.1371/journal.pone.0102670] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/20/2014] [Indexed: 12/17/2022] Open
Abstract
Background “Cumulative meta-analysis” describes a statistical procedure to calculate, retrospectively, summary estimates from the results of similar trials every time the results of a further trial in the series had become available. In the early 1990s, comparisons of cumulative meta-analyses of treatments for myocardial infarction with advice promulgated through medical textbooks showed that research had continued long after robust estimates of treatment effects had accumulated, and that medical textbooks had overlooked strong, existing evidence from trials. Cumulative meta-analyses have subsequently been used to assess what could have been known had new studies been informed by systematic reviews of relevant existing evidence and how waste might have been reduced. Methods and Findings We used a systematic approach to identify and summarise the findings of cumulative meta-analyses of studies of the effects of clinical interventions, published from 1992 to 2012. Searches were done of PubMed, MEDLINE, EMBASE, the Cochrane Methodology Register and Science Citation Index. A total of 50 eligible reports were identified, including more than 1,500 cumulative meta-analyses. A variety of themes are illustrated with specific examples. The studies showed that initially positive results became null or negative in meta-analyses as more trials were done; that early null or negative results were over-turned; that stable results (beneficial, harmful and neutral) would have been seen had a meta-analysis been done before the new trial; and that additional trials had been much too small to resolve the remaining uncertainties. Conclusions This large, unique collection of cumulative meta-analyses highlights how a review of the existing evidence might have helped researchers, practitioners, patients and funders make more informed decisions and choices about new trials over decades of research. This would have led to earlier uptake of effective interventions in practice, less exposure of trial participants to less effective treatments, and reduced waste resulting from unjustified research.
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Affiliation(s)
- Mike Clarke
- All-Ireland Hub for Trials Methodology Research, Queen's University Belfast, Belfast, United Kingdom
- * E-mail:
| | - Anne Brice
- James Lind Initiative, Oxford, United Kingdom
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Systematic review of severe acute liver injury caused by terbinafine. Int J Clin Pharm 2014; 58:5609-12. [PMID: 24986266 DOI: 10.1128/aac.02875-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Terbinafine is an effective antimicrobial agent against dermatophytes, cryptococcus and other fungi. It is the preferred drug to treat onychomycosis. However, severe acute hepatitis from oral terbinafine administration has been recently reported. AIM To describe a representative case, and review the literature regarding the best evidence on treatment and prognosis of severe acute hepatitis caused by oral terbinafine. METHODS The literature was searched for publications on severe hepatitis caused by terbinafine using MEDLINE, China Biology Medicine Disc, and the VIP Medical Information Resource System. Related references were searched manually. RESULTS Seventeen English and three Chinese references of case reports were included after eliminating duplicate publications. No randomized control studies were found. Liver enzyme levels were found to have been increased significantly. Abdominal ultrasound demonstrated cholestasis. CONCLUSIONS Severe acute liver injury is a known, but unusual complication of terbinafine exposure. The prognosis is often good with appropriate treatment. Liver function assessment before treatment and periodic monitoring 4-6 weeks after initiation of treatment is recommended.
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Yan J, Wang X, Chen S. Systematic review of severe acute liver injury caused by terbinafine. Int J Clin Pharm 2014; 36:679-83. [PMID: 24986266 DOI: 10.1007/s11096-014-9969-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 06/04/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Terbinafine is an effective antimicrobial agent against dermatophytes, cryptococcus and other fungi. It is the preferred drug to treat onychomycosis. However, severe acute hepatitis from oral terbinafine administration has been recently reported. AIM To describe a representative case, and review the literature regarding the best evidence on treatment and prognosis of severe acute hepatitis caused by oral terbinafine. METHODS The literature was searched for publications on severe hepatitis caused by terbinafine using MEDLINE, China Biology Medicine Disc, and the VIP Medical Information Resource System. Related references were searched manually. RESULTS Seventeen English and three Chinese references of case reports were included after eliminating duplicate publications. No randomized control studies were found. Liver enzyme levels were found to have been increased significantly. Abdominal ultrasound demonstrated cholestasis. CONCLUSIONS Severe acute liver injury is a known, but unusual complication of terbinafine exposure. The prognosis is often good with appropriate treatment. Liver function assessment before treatment and periodic monitoring 4-6 weeks after initiation of treatment is recommended.
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Affiliation(s)
- Jun Yan
- Jinan City Hospital for Skin Diseases Prevention and Treatment, Jinan, 250001, China
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48
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Cronin L, Moffitt M, Mawad D, Morton OC, Lauto A, Stack C. An in vitro study of the photodynamic effect of rose bengal on Trichophyton rubrum. JOURNAL OF BIOPHOTONICS 2014; 7:410-417. [PMID: 23125143 DOI: 10.1002/jbio.201200168] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 06/01/2023]
Abstract
Onychomycosis, a fungal infection of the finger or toenails, is predominantly caused by Trichophyton rubrum. Treatment is difficult due to high recurrence rates and problems with treatment compliance. For these reasons, alternative therapies are needed. Here we describe the photoactivation of Rose Bengal (RB) using a green laser (λ = 532 nm) at fluences of 68, 133 and 228 J/cm(2) , and assess its fungicidal activity on T. rubrum spore suspensions. A 140 µM RB solution was able to induce a fungicidal effect on T. rubrum when photosensitized with the fluence of 228 J/cm(2) . RB photosensitization using a green laser provides a potential novel treatment for T. rubrum infections.
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Affiliation(s)
- Leah Cronin
- School of Science and Health, University of Western Sydney, Campbelltown NSW 2560, Australia
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49
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Hollmig ST, Rahman Z, Henderson MT, Rotatori RM, Gladstone H, Tang JY. Lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet laser for the treatment of onychomycosis: A randomized, controlled trial. J Am Acad Dermatol 2014; 70:911-7. [DOI: 10.1016/j.jaad.2013.12.024] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/14/2013] [Accepted: 12/17/2013] [Indexed: 11/26/2022]
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50
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Abstract
Disorders of the dermis and the nails on the feet are common. Despite the simplicity of the skin and nail disorders of the foot, they can be debilitating and impact the patient's ability to ambulate and perform activities of daily living. Diagnosis in most cases is confirmed on physical examination alone. Diligent care of skin and nail disorders can prevent further pathology involving the deeper structures of the foot and allow the patient to fully participate in their usual activities.
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Affiliation(s)
- Wesley W Flint
- Department of Orthopaedics, Penn State Hershey Medical Center, Penn State Bone and Joint Institute, 30 Hope Drive, Hershey, PA 17033, USA
| | - Jarrett D Cain
- Department of Orthopaedics, Penn State Hershey Medical Center, Penn State Bone and Joint Institute, 30 Hope Drive, Hershey, PA 17033, USA.
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