Ciclopirox nail lacquer solution 8% in the 21st century

Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes

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.

Therapeutic treatment strategies for the management of onychomycosis: a patent perspective

INTRODUCTION

Onychomycosis, a multifactorial fungal infection of the nails, shows a global prevalence of about 5.5% and is responsible for 50% of all nail infections. To develop effective management strategies, it is necessary to understand the etiology, pathophysiology, and risk factors of onychomycosis. Oral route of drug delivery is one of the routes utilized to deliver anti-fungal agents, but, has its own limitations like longer duration of treatment, increased adverse effects, and potential for drug interaction. The ungual route has received greater attention due to its localized, non- invasive action and improved patient compliance.

AREAS COVERED

This review comprehensively discusses conventional onychomycosis therapies and patented novel drug delivery systems for the management of onychomycosis including chemical permeation enhancers, non-particulate drug delivery systems, penetration enhancing devices etc., Databases such as PubMed, ResearchGate, and Google Patents were searched by using the keywords onychomycosis and trans-ungual drug delivery.

EXPERT OPINION

Enormous research has been conducted and is still ongoing to find the best possible novel drug delivery system for onychomycosis management. Approaches like incorporation of herbal constituents in nano-formulations, inkjet printing, laser devices, iontophoretic techniques, etc. can be employed to make safe and effective drug delivery systems which are regulatory compliant.

Dermatophytomas: Clinical Overview and Treatment

Dermatophytomas are characterized as a hyperkeratotic fungal mass in the subungual space, showing as dense white or yellow, typically in longitudinal streaks or patches. Masses can be visualized by traditional microscopy or histology. Newer technologies such as dermoscopy and optical coherence tomography also provide visual features for dermatophytoma diagnosis. The density of fungal mass, and lack of adherence to the nail structures, as well as possible biofilm development, may play a role in the reduction in drug penetration and subsequent lack of efficacy with traditional oral therapies such as terbinafine and itraconazole. A combination of drug treatment with mechanical or chemical debridement/avulsion has been recommended to increase efficacy. The topical antifungal solutions such as tavaborole, efinaconazole, and luliconazole may reach the dermatophytoma by both the transungual and subungual routes, due to low affinity for keratin and low surface tension. Current data indicates these topicals may provide efficacy for dermatophytoma treatment without debridement/avulsion. Similarly, fosravuconazole (F-RVCZ) has an improved pharmacological profile versus ravuconazole and may be an improved treatment option versus traditional oral therapies. The availability of improved treatments for dermatophytomas is crucial, as resistance to traditional therapies is on the increase.

One size does not fit all: the need for individualized treatment based on factors that may affect the therapeutic outcome of efinaconazole 10% solution for the treatment of toenail onychomycosis

Successful management of onychomycosis is a challenge because cure rates with most antifungals are relatively low and recurrence rates are high. A drug-based approach by treating the nail alone may not suffice. There are several host-related factors (age, sex, body mass index [BMI], and patient's quality of life), disease-related factors (disease severity, duration, and the number of toenails affected), and comorbidities (tinea pedis and diabetes) that may affect treatment efficacy. Here, we review the post hoc analyses of the phase III trials of efinaconazole 10% solution that have investigated the impact of these factors on topical therapy for toenail onychomycosis. The significant clinical variables that may affect the efficacy of efinaconazole include sex, BMI, disease severity, disease duration, and tinea pedis. As older patients may have slower toenail growth and more severe, longstanding disease compared with younger patients, they may require longer treatment duration, beyond the 48-week standard regimen. Treatment compliance may need to be discussed for an improved health outcome. Therefore, these prognostic factors need to be carefully evaluated, which may aid in formulating individualized therapy to maximize treatment success.

Superior efficacy of the antifungal agent ciclopirox olamine over gemcitabine in pancreatic cancer models

Ciclopirox olamine (CPX) is an antifungal agent that has recently demonstrated promising anti-neoplastic activity against hematologic and solid tumors. Here, we evaluated CPX compared with gemcitabine alone as well as their combination in human pancreatic cancer cell lines; BxPC-3, Panc-1, and MIA PaCa-2 and in humanized xenograft mouse models. We also examined the preclinical pharmacodynamic activity of CPX. CPX caused a pronounced decrease in cell proliferation and clonogenic growth potential. These inhibitory effects were accompanied by induction of reactive oxygen species (ROS), which were strongly associated with reduced Bcl-xL and survivin levels and activation of a panel of caspases, especially caspase-3, and finally resulted in apoptotic death. CPX-induced apoptosis was associated with reduced pEGFR (Y1068) and pAkt (Ser473) protein levels. Additionally, decreased proliferation was observed in CPX-treated xenografts tumors, demonstrating unique tumor regression and a profound survival benefit. Finally, we showed that CPX significantly abrogated gemcitabine-induced ROS levels in pancreatic tissues. These pre-clinical results have verified the superior antitumor efficacy of CPX over gemcitabine alone, while their combination is even more effective, providing the rationale for further clinical testing of CPX plus gemcitabine in pancreatic cancer patients.

Combined analysis of gene expression and genome binding profiles identified potential therapeutic targets of ciclopirox in Ewing sarcoma

Ciclopirox (CPX) is a synthetic antifungal drug that is mainly used to treat dermatomycoses. The aim of the present study was to determine whether CPX could influence Ewing sarcoma progression. The present study suggested that CPX treatment may inhibit Ewing sarcoma (ES) progression through Ewing sarcoma breakpoint region 1-Friend leukemia integration 1 (EWS-FLI1), a common fusion transcript structure in patients with ES. To determine the underlying mechanisms of ES progression, cross analysis was conducted on three high-throughput genome or transcript me datasets from the Gene Expression Omnibus. The results indicated that CPX may inhibit ES growth by affecting vasculature development and DNA replication. A combination of genome-wide expression and binding profiles revealed several potential targets for CPX in ES, including collagen type I α2 chain, N-myc proto-oncogene and transforming growth factor β1, which contained significantly enriched binding peaks of FLI1. In addition, network analysis, including a protein-protein interaction network and a transcription regulatory network, provided further detailed information about the roles of CPX in ES. This study may provide a novel solution for ES treatment and may also aid in improving its prognosis.

Tavaborole - a treatment for onychomycosis of the toenails

INTRODUCTION

Onychomycosis is a fungal nail infection that accounts for half of all nail diseases. Oral drugs on the market have adverse effects, while it is difficult for traditional topical drugs to penetrate the nail plate to reach the diseased nail bed. Tavaborole is a new drug that addresses the unmet needs of currently available treatments. Tavaborole (5%) is FDA approved for treating toenail onychomycosis and has shown antifungal activities against yeast, moulds and dermatophytes.

AREAS COVERED

The objective of this article is to review the efficacy, pharmacokinetics, pharmacodynamics, and safety of tavaborole for treatment of toenail onychomycosis. Expert commentary: Tavaborole, with its unique mechanism, may be a good candidate for use in treating children with fungal infections, diabetic individuals, and treating mixed infections. Tavaborole may be paired with other therapies to potentially increase cure rates.

Improving Cure Rates in Onychomycosis

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.

Comparative clinical evaluation of efficacy and safety of a formulation containing ciclopirox 8% in the form of a therapeutic nail lacquer in two different posologies for the treatment of onychomycosis of the toes

BACKGROUND: The use of topical antifungal agents in the treatment of onychomycosis is of great value in clinical practice as there are different limitations regarding the use of systemic treatment. OBJECTIVE: To evaluate the efficacy and safety of a nail lacquer formulation containing ciclopirox 8% in two different posologies: the traditional regimen (3/2/1) and a regimen of weekly use. METHODS: A blind, randomized, comparative trial which included 41 patients divided into 02 groups, with Group I using the nail lacquer once weekly and Group II using the traditional regimen (3/2/1). Both groups applied the medication for 06 months. RESULTS: The species most frequently found in groups I and II were Trichophyton rubrum (55% and 61.9%) and Trichophyton mentagrophytes (30% and 19%). There was a tendency to a higher level of treatment resistance by T. mentagrophytes infection in both groups, without any predilection for sex, age, proportion of the nail affected at the beginning of the study, duration of the clinical disease and quantity of nails affected per person. Both groups had significant levels of mycological cure, clinical response and therapeutic success and there was no statistically significant difference between groups I and II (p >0.05). CONCLUSION: The nail lacquer containing ciclopirox 8% was equally effective at a weekly dose when compared to the traditional dosing (3/2/1), allowing a more comfortable regimen.

Efficacy, safety and tolerability of topical terbinafine nail solution in patients with mild-to-moderate toenail onychomycosis: results from three randomized studies using double-blind vehicle-controlled and open-label active-controlled designs

BACKGROUND

Terbinafine nail solution (TNS) was developed for the treatment of onychomycosis.

OBJECTIVE

To assess the efficacy of TNS vs. vehicle and amorolfine 5% nail lacquer.

METHODS

Subjects with mild-to-moderate toe onychomycosis (25% to ≤75% nail-involvement, matrix uninvolved) were randomized to receive either TNS or vehicle in two double-blind studies, and to TNS or amorolfine in an active-controlled, open-label study. Primary endpoint was complete cure (no residual clinical involvement and negative mycology) at week 52. Secondary endpoints were mycological cure (negative mycology defined as negative KOH microscopy and negative culture) and clinical effectiveness (≤10% residual-involvement and negative mycology) at week 52.

RESULTS

Complete cure was not different between TNS vs. vehicle and amorolfine. Mycological cure was higher with TNS vs. vehicle, as was clinical effectiveness with TNS vs. vehicle, and TNS and amorolfine were not different for secondary efficacy endpoints. Patients achieving mycological cure had a better clinical outcome, and efficacy was improved in subjects with milder disease. Post hoc analysis suggests that nail thickness is an important prognostic factor. Moreover, mycological cure may require 6 months of treatment regimen while complete cure and clinical effectiveness may be achievable only after 10 months. A simulation study suggests that longer treatment duration would have resulted in higher complete cure with TNS vs. vehicle. Study treatments were well-tolerated.

CONCLUSION

Primary efficacy objectives were not met in the studies reported herein. Possible reasons for failure to achieve significant outcomes include insufficient length of treatment; stringency of primary endpoint and severity of nail involvement of study population.

Effect of a novel penetration enhancer on the ungual permeation of two antifungal agents

OBJECTIVES

The aim of this study was to demonstrate the effect of a novel permeation enhancer system using two existing marketed nail lacquers and the delivery of terbinafine through human nail samples in vitro.

METHODS

Initially a modified Franz cell was used, where sections of human nail serve as the barrier through which drug penetrates into an agar-filled chamber infected with dermatophytes. A second study was performed using a novel infected nail model where dermatophytes are incubated with and grow into human nail and ATP levels are used as biological marker for antimicrobial activity.

KEY FINDINGS

The novel permeation enhancing system increased the permeation of both existing drugs formulated in nail lacquers and terbinafine through human nail sections mounted in a modified Franz cell. Furthermore the ATP assay confirmed that the system also enhanced the permeation of terbinafine through infected cadaver nail resulting in a decrease in ATP levels equivalent to those of uninfected negative control samples.

CONCLUSIONS

This study has clearly demonstrated that the use of a novel permeation enhancing system, which fundamentally alters the chemical structure of the nail, not only enhances the efficacy of the existing topical formulations but also enables the delivery and efficacy of terbinafine when applied ungually. Such a topically applied system has the possibility of overcoming the systemic side effects when terbinafine is delivered orally.

[Antifungal agents for onychomycoses]

Nail fungal infections are considered one of the major dermatological problems due to their high rate of therapeutic failure, management and treatment difficulties. Long-term treatments, inadequate therapies, mycological misdiagnosis and follow-up, secondary alterations of the nail, and resistant microorganisms, are some of the causes of these complications. Although the discovery of new antifungal agents has provided some effective molecules, none of the current available drugs are totally effective. It is important to continue researching in this field to provide new antifungal agents and combined therapies.

Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial

Pedal onychomycosis is a common malady caused by dermatophytes, saprophytes, and yeasts. Traditional treatment options for this condition include toenail debridement, and pharmacological therapies that range from the application of topical agents to the oral administration of antifungal medications. In this study, 55 patients (289 toenails) were randomly allocated to either nail debridement (27 [49.09%] patients) or debridement plus application of topical antifungal nail lacquer (28 [50.91%] patients). The primary outcome was mycological cure, and secondary outcomes included foot-related quality of life, and a number of clinically important toenail characteristics. After a median follow-up of 10.5 months (range, 3.25-14.25) months), patients in the antifungal nail lacquer group improved statistically significantly more than did those in the debridement alone group, and displayed a 76.74% rate of mycological cure. None of the patients in the debridement-only group experienced mycological cure. Variables that statistically significantly decreased the likelihood of cure included yeast on culture, pedal hyperhidrosis, cigarette smoking, involvement of the lunula, and involvement of >50% of the transverse width of the nail. Variables statistically significantly associated with an increased likelihood of cure included intervention before 6 months' duration, treatment at a large, urban practice, black race, and loss of protective sensation.

LEVEL OF CLINICAL EVIDENCE

1.

In Vitro penetration of a novel oxaborole antifungal (AN2690) into the human nail plate

Onychomycosis is a challenging fungal infection to treat topically, likely due to the unique properties of the nail plate. This seemingly impenetrable barrier has high resistance to the passage of antifungal drugs in sufficient concentrations to kill the causative fungi deep in the nail bed. Recently, a new class of antifungal agent was described, termed oxaboroles, which have broad-spectrum activity. These oxaboroles were designed with properties believed to be required to allow for easier transit through the nail plate. Herein, we report (i) the nail penetration results of four oxaboroles that led to the selection of AN2690, (ii) the results of the nail penetration of AN2690 from four vehicles, and (iii) the nail penetration of AN2690 in its chosen vehicle compared to a commercial control, ciclopirox. AN2690 has superior penetration compared to ciclopirox, and achieves levels within and under the nail plate that suggest it has the potential to be an effective topical treatment for onychomycosis.

Management of onychomycosis with topicals

Of all superficial fungal infections, onychomycosis is the most difficult to manage. Practitioners of all disciplines realize its chronic nature, difficulty in eradication, and propensity to recur. Topical treatment of onychomycosis, as opposed to oral therapies, offers a distinct advantage by allowing the patient to apply medication directly to the affected area, thus decreasing the potential for serious adverse events, such as drug toxicity and drug interactions. In the past, a multitude of topical antifungal agents were used in the treatment of onychomycosis; however, an acceptable level of scientific evidence regarding their effectiveness was lacking and this was evident by poor success rates. The development of a comparatively effective topical agent, the only one so far to gain FDA approval, has renewed interest in this form of therapy. Improved versions are being developed that may overcome the shortcomings of the first approved topical agent.

How to improve cure rates for the management of onychomycosis

To improve the treatment of onychomycosis clinicians need to identify correctly the causative organism, choose a therapy that is effective against the pathogen, and take into consideration the pharmacokinetics (eg, bioavailability, drug interactions) of the oral agent. In addition, variations of the standard regimens may need to be considered (ie, booster or supplemental therapy). To reduce the recurrence of onychomycosis, once mycologic cure has been achieved, clinicians should educate their patients about proper foot care. Familiarity with the symptoms and signs of tinea pedis and onychomycosis may enable patients to seek appropriate care when the disease is at an early stage.

The use of topical therapies to treat onychomycosis

The management of onychomycosis using topical agents has improved with the introduction of ciclopirox and amorolfine nail lacquers; other topical agents may be less effective. The combination of a nail lacquer with an oral antifungal agent may further improve efficacy rates in certain clinical presentations (eg, among those individuals with severe onychomycosis). Topical agents have a favorable adverse events profile. Further studies are required on the treatment of onychomycosis with nail lacquers.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Treatment of onychomycosis in the diabetic patient population

Onychomycosis is a common medical condition in patients with diabetes. Conflicting data exist as to whether diabetes predisposes patients to the disease. Controversy notwithstanding, patients with diabetes have several medical conditions (obesity, peripheral neuropathy, and retinopathy) that can inhibit the identification or mask the progression of fungal nail infections. In addition, vascular insufficiency, impaired wound healing, and compromised immunologic status associated with diabetic foot increase the risk of secondary infections in diabetic patients with onychomycosis. Such factors contribute to an increased morbidity and decreased quality of life in these patients and underscore the need for effective antifungal treatment. Oral antifungal agents are generally well tolerated, but serious adverse events independent of or associated with a number of significant drug interactions have been reported. The availability of a topical therapy, ciclopirox topical solution, 8% (Penlac Nail Lacquer), provides clinicians with an additional effective and well-tolerated treatment option. In order to further increase the efficacy of topical or oral treatment, mechanical intervention (e.g., debridement) may be combined with either of these options. Choice of appropriate treatment and careful monitoring of fungal nail infections can prevent significant morbidity in patients with diabetes.

Recent advances in dermatology

Novel therapies for dermatologic diseases are now widely available to the clinician. The topical immune modulators tacrolimus and pimecrolimus are likely to change the way in which inflammatory dermatoses are treated. Antiviral and antitumor effects of imiquimod, another immune-response modifier, are being studied to determine the ways in which it may affect the treatment of cutaneous viral infections and skin cancers. New topical treatments for onychomycosis and the current lack of effective treatments for nondermatophyte onychomycosis indicate the need for more effective treatment for this common disease. Exciting developments in skin substitutes and growth factors for acute and chronic wound care hold much promise for the future.

Single-blind, randomized, prospective study on terbinafine and itraconazole for treatment of dermatophyte toenail onychomycosis in the elderly

BACKGROUND

The 2 most common agents used to treat dermatophyte onychomycosis of the toe are terbinafine (continuous) and itraconazole (pulse). Although comparative studies have been performed evaluating the efficacy of these 2 agents in adults, no such studies have been reported specifically in the elderly subset.

OBJECTIVE

This prospective, randomized, single-blind, non--industry-sponsored, comparative study evaluated the efficacy and safety of terbinafine (continuous) and itraconazole (pulse) therapies in the treatment of dermatophyte onychomycosis of the toe in the elderly population.

METHODS

Elderly patients (> or =60 years old) with dermatophyte onychomycosis of at least 1 great toe were randomly assigned to receive either terbinafine 250 mg/day for 12 weeks or itraconazole (pulse) 200 mg twice a day for 1 week, given for 3 pulses. At month 6 from the start of therapy, if there was less than 50% reduction in the affected nail plate area compared with baseline, or if there was less than 3 mm outgrowth of unaffected nail plate as measured in midline, then patients who had been administered terbinafine (continuous) therapy were given an extra 4 weeks of the drug (total of 16 weeks of therapy), and those who had received itraconazole (pulse) therapy were given an extra pulse (fourth pulse). Patients were evaluated at 1.5, 3, 6, 12, and 18 months from the start of therapy. The efficacy measures included mycologic cure rate and clinical efficacy (mycologic cure plus clinical cure or clinical improvement so that 10% or less of nail plate was clinically involved).

RESULTS

There were 101 elderly patients enrolled in the study with 50 and 51 patients receiving terbinafine and itraconazole, respectively. The terbinafine group consisted of 28 men and 22 women, age (mean +/- standard error [SE]) 68.0 +/- 0.9 years, duration of onychomycosis (mean +/- SE) 18.2 +/- 1.4 years, number of nails involved (mean +/- SE) 5.5 +/- 0.5, and percent baseline nail plate area involved (mean +/- SE) 67.5% +/- 4.2%. The corresponding figures for the itraconazole (pulse) group were 24 men and 27 women, age (mean +/- SE) 68.8 +/- 0.8 years, duration of onychomycosis (mean +/- SE) 16.1 +/- 1.7 years, number of nails involved (mean +/- SE) 6.0 +/- 0.7, and percent baseline nail plate area involved (mean +/- SE) 74.9% +/- 3.8%, respectively, with no significant difference between the groups. At month 6, the number of patients that required an extra 4 weeks of terbinafine in the allylamine group or an extra itraconazole pulse in the triazole group was 13 of 50 and 23 of 51, respectively. The mycologic cure rate and clinical efficacy at 18 months from the start of therapy for the terbinafine group were 64.0% and 62.0%, respectively. The corresponding figures for the itraconazole (pulse) group were 62.7% and 60.8%, respectively, with no significant difference between the 2 groups. There were no dropouts during therapy. For both groups the drug appeared safe with no significant adverse events (AEs) or clinically significant laboratory abnormalities. All the AEs were mild and transient. There was high compliance with both regimens.

CONCLUSIONS

In the elderly, for the treatment of dermatophyte toe onychomycosis, both terbinafine (continuous) and itraconazole (pulse) therapies are effective, safe, and associated with high compliance.

Pharmacoeconomic analysis of ciclopirox nail lacquer solution 8% and the new oral antifungal agents used to treat dermatophyte toe onychomycosis in the United States

BACKGROUND

Recently a novel topical nail lacquer, ciclopirox solution 8%, has been approved for the treatment of onychomycosis.

OBJECTIVE

This was undertaken to determine the most cost-effective treatment for the treatment of dermatophyte onychomycosis of the toes in the United States in 2000.

METHODS

The nature of the problem was defined. The drug comparators were ciclopirox nail lacquer, terbinafine, itraconazole (pulse), itraconazole (continuous), fluconazole, and griseofulvin. A decision analytic model that reflected the manner in which pedal tinea unguium is managed was produced. Studies that have evaluated the efficacy of the nail lacquer and the oral antifungal agents for this indication were identified. Appropriate studies were used in a meta-analysis to determine the mycologic and clinical response rates when the drug comparators are used for the treatment for toe dermatophyte onychomycosis. For each drug comparator a cost of regimen analysis was carried out. This is the sum of the drug acquisition cost, the cost of medical management, and the cost of managing adverse effects. Next, the expected cost of management was calculated, disease free days were determined, and a sensitivity analysis was conducted.

RESULTS

For each comparator the meta-analytic average mycologic cure (MC) rate and clinical response (CR) rates were: ciclopirox nail lacquer (MC: 52.6 +/- 4.2%, CR: 52.4 +/- 9.0%), griseofulvin (MC: 41.1 +/- 20.4%, CR: 33.7 +/- 14.1%), itraconazole (continuous) (MC: 66.3 +/- 4.2%, CR: 70.3 +/- 4.2%), itraconazole (pulse) (MC: 70.8 +/- 5.7%, CR: 73.6 +/- 4.6%), terbinafine (MC: 77.2 +/- 4.0%, CR: 75.3 +/- 2.9%), and fluconazole (MC: 65.6 +/- 7.1%, CR: 66.5 +/- 11.7%). The cost of regimen for the drug comparators was: ciclopirox nail lacquer $325.2, griseofulvin $1413.1, itraconazole (continuous) $1410.2, itraconazole (pulse) $811.7, terbinafine $890.1, and fluconazole $966.8. The cost/mycologic cure rate and expected cost/expected symptom free day were, ciclopirox nail lacquer ($618.2, 1.69), griseofulvin $3438.2, 5.3), itraconazole (continuous) ($2126.9, 3.52), itraconazole (pulse) ($1146.4, 2.01), terbinafine ($1153.0, 2.14), and fluconazole ($1473.7, 2.10). The relative cost-effectiveness was ciclopirox nail lacquer 1.00, itraconazole (pulse) 1.19, fluconazole 1.24, terbinafine 1.27, itraconazole (continuous) 2.08, and griseofulvin 3.13. Sensitivity analysis indicated that ciclopirox nail lacquer was a cost effective alternative compared with the oral regimens of terbinafine, itraconazole (continuous), and griseofulvin when clinical response rate was used as the primary efficacy parameter.

CONCLUSION

Ciclopirox nail lacquer solution 8% is a recent addition to the armamentarium of therapies available to the physician and patient for the treatment of onychomycosis. The nail lacquer is a cost effective agent compared with the oral antifungal therapies, terbinafine, itraconazole, fluconazole, and griseofulvin.