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Ramzi SHT, Arif SA, Majid A, Kumar S, Shumail H, Qudsia F, Zainab Y, Varrassi G, Khatri M. Efficacy of Terbinafine and Itraconazole Combination Therapy Versus Terbinafine or Itraconazole Monotherapy in the Management of Fungal Diseases: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e48819. [PMID: 38106696 PMCID: PMC10722332 DOI: 10.7759/cureus.48819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023] Open
Abstract
Fungal infections constitute a common dermatological illness rampant in underdeveloped countries. Combination drug therapy is becoming increasingly well-established owing to drug resistance because of monotherapy. Different studies have been conducted previously to compare the medical regimens for the treatment of fungal infections. However, there is insufficient research on the difference in cure rates and recurrence rates with each regimen. To the best of our knowledge, this meta-analysis is the first to compare the effect of the most widely used oral antifungal medications and their combination usage. A meta-analysis of randomized controlled trials (RCTs) assesses the efficacy of terbinafine or itraconazole monotherapy versus combination therapy in fungal diseases. We queried PubMed and Cochrane Central from their inception to April 2022 for published studies, RCTs, and observational studies without any language restriction that compared itraconazole and terbinafine combination therapy with monotherapy in patients with fungal infections. The results from the studies were presented as risk ratios (RRs) with 95% confidence intervals (CIs) and were pooled using a random-effects model, and a p-value of ≤0.05 was considered significant for the analysis. Endpoints of interest included cure rates and recurrence rates. Cure rates were increased significantly for combination therapy compared to terbinafine monotherapy (RR=2.01 (1.37, 2.94); p=0.0003; I2=67%). On sensitivity analysis, a significant association was observed between combination therapy and itraconazole monotherapy in terms of cure rates (RR=1.91 (1.41, 2.57); p<0.0001; I2=0%) and recurrence rates (RR=0.08 (0.02, 0.44); p=0.003; I2=0%). The findings of this meta-analysis suggest that itraconazole and terbinafine combination therapy has a better cure rate when compared to terbinafine monotherapy.
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Affiliation(s)
| | | | - Abdul Majid
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical University, Karachi, PAK
| | - Hooria Shumail
- Medicine, King Edward Medical University (KEMU), Lahore, PAK
| | - Faiza Qudsia
- Medicine, King Edward Medical University (KEMU), Lahore, PAK
| | - Yumna Zainab
- Medicine, Multan Medical and Dental College, Multan, PAK
| | | | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
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Conrado PCV, Vaine AA, Arita GS, Sakita KM, Gonçalves RS, Caetano W, de Souza M, Baesso ML, Malacarne LC, Razzolini E, Vicente VA, Kioshima ES, de Mendonça PDSB. Promising onychomycosis treatment with hypericin-mediated photodynamic therapy: case reports. Photodiagnosis Photodyn Ther 2023; 42:103498. [PMID: 36882144 DOI: 10.1016/j.pdpdt.2023.103498] [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: 02/01/2023] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Onychomycosis (OM) is a common nail plate disorder caused by dermatophyte molds, yeasts, and non-dermatophyte molds, which use keratin in the nail plate as an energy source. OM is characterized by dyschromia, increased nail thickness, subungual hyperkeratosis, and onychodystrophy, and is typically treated with conventional antifungals despite frequent reports of toxicity, fungal resistance, and OM recurrence. Photodynamic therapy (PDT) with hypericin (Hyp) as a photosensitizer (PS) stands out as a promising therapeutic modality. When excited by a specific wavelength of light and in the presence of oxygen, to lead to photochemical and photobiological reactions on the selected targets. METHODS OM diagnosis was made in three suspected cases, and the causative agents were identified by classical and molecular methods, and confirmed by attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR). Susceptibility of planktonic cells of the clinical isolates to conventional antifungals and PDT-Hyp was evaluated, and photoacoustic spectroscopy (PAS) of Hyp permeation in nail fragments ex vivo was analyzed. Furthermore, the patients opted to undergo PDT-Hyp treatment and were subsequently followed up. The protocol was approved by the human ethics committee (CAAE, number 14107419.4.0000.0104). RESULTS The etiological agents of OM in patients ID 01 and ID 02 belonged to the Fusarium solani species complex, being identified as Fusarium keratoplasticum (CMRP 5514) and Fusarium solani (CMRP 5515), respectively. For patient ID 03, the OM agent was identified as Trichophyton rubrum (CMRP 5516). PDT-Hyp demonstrated a fungicidal effect in vitro, with reductions of ≥3 log10 (p<0.0051 and p<0.0001), and the PAS analyses indicated that Hyp could completely permeate through both healthy and OM-affected nails. After four sessions of PDT-Hyp, mycological cure was observed in all three cases, and after seventh months, clinical cure was confirmed. PDT-Hyp showed satisfactory results in terms of efficacy and safety, and thus can be considered a promising therapy for the clinical treatment of OM.
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Affiliation(s)
- Pollyanna Cristina Vincenzi Conrado
- Program in Biosciences and Pathophysiology, Department of Clinical Analysis and Biomedicine, State University of Maringa (UEM), Maringa, Parana, Brazil
| | | | - Glaucia Sayuri Arita
- Program in Biosciences and Pathophysiology, Department of Clinical Analysis and Biomedicine, State University of Maringa (UEM), Maringa, Parana, Brazil
| | - Karina Mayumi Sakita
- Program in Biosciences and Pathophysiology, Department of Clinical Analysis and Biomedicine, State University of Maringa (UEM), Maringa, Parana, Brazil
| | | | - Wilker Caetano
- Department of Chemistry, State University of Maringa, Parana, Brazil
| | - Monique de Souza
- Department of Physics, State University of Maringa, Parana, Brazil
| | | | | | - Emanuel Razzolini
- Department of Pathology Basic, Federal University of Parana State, Curitiba, Parana, Brazil
| | | | - Erika Seki Kioshima
- Program in Biosciences and Pathophysiology, Department of Clinical Analysis and Biomedicine, State University of Maringa (UEM), Maringa, Parana, Brazil
| | - Patrícia de Souza Bonfim de Mendonça
- Program in Biosciences and Pathophysiology, Department of Clinical Analysis and Biomedicine, State University of Maringa (UEM), Maringa, Parana, Brazil.
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Combination Therapy Should Be Reserved as Second-Line Treatment of Onychomycosis: A Systematic Review of Onychomycosis Clinical Trials. J Fungi (Basel) 2022; 8:jof8030279. [PMID: 35330281 PMCID: PMC8949799 DOI: 10.3390/jof8030279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/15/2022] Open
Abstract
Onychomycosis is the most common nail disease encountered in clinical practice. Its importance extends well beyond aesthetics, often causing pain, difficulty with ambulation and performing daily activities, and impairing quality of life. Many patients fail to achieve cure with antifungal monotherapy and recurrences are common. Combination therapy has therefore gained considerable interest, given the potential for drug synergy and prevention of antifungal resistance, but it has not been well studied. A systematic review of onychomycosis medication only, as well as medication and procedural (laser, debridement, photodynamic therapy), clinical or randomized controlled trials evaluating combination vs. monotherapies was performed. After exclusions, 30 studies were included in the final analysis. There were conflicting results for medication-only trials, with some showing significant benefit of combination therapy over monotherapy, however, trials were not robustly designed and lacked sufficient follow-up. Procedural studies also lacked long-term follow-up, and failed to demonstrate efficacy in some severe onychomycosis cases. Considering the high cure rates demonstrated in pivotal antifungal monotherapy trials, and conflicting results, costs, and safety concerns associated with combination therapy, we recommend that combination therapy be reserved as second-line treatment options in patients with poor prognostic factors or for those who failed monotherapy for onychomycosis.
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Gupta AK, Venkataraman M, Talukder M. Onychomycosis in Older Adults: Prevalence, Diagnosis, and Management. Drugs Aging 2022; 39:191-198. [PMID: 35102533 DOI: 10.1007/s40266-021-00917-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/03/2022]
Abstract
The risk of having onychomycosis increases with age. Data suggest that the prevalence of onychomycosis may be ≥ 20% in subjects aged ≥ 60 years and ≥ 50% in those aged ≥ 70 years. Older males are 2.1 times more prone to onychomycosis than are females. Although most nail dystrophies (approximately 50%) are caused by onychomycosis, proper clinical assessment followed by mycological examination is recommended to exclude other conditions such as nail trauma, lichen planus, and psoriasis. The US FDA-approved onychomycosis treatments are systemic antifungals (terbinafine and itraconazole) for severe onychomycosis and topical antifungals (ciclopirox 8%, efinaconazole 10%, and tavaborole 5%) for mild-to-moderate onychomycosis. Oral fluconazole is used off-label, and itraconazole may be considered for non-dermatophyte onychomycosis. Recently, fosravuconazole was approved in Japan for onychomycosis treatment. Although the treatment options and durations are the same for older patients as for other age groups, a clinical decision should take into account various age-related factors such as comorbidities, polypharmacy, hepatic and renal insufficiency, and noncompliance. Clinicians should also consider possible drug interactions and side effects when choosing a particular antifungal. Since the recurrence rate of onychomycosis is high, older patients should practice sanitization techniques, consider lifestyle changes, and perhaps consider using a topical antifungal as long-term maintenance therapy one to three times per week to prevent the recurrence of onychomycosis or to treat early disease.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada. .,Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Mesbah Talukder
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
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Chang MJ, Qiu Y, Lipner SR. Race reporting and representation in onychomycosis clinical trials: A systematic review. Mycoses 2021; 64:954-966. [PMID: 33655595 DOI: 10.1111/myc.13262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Onychomycosis is the most common nail disease seen in clinical practice. Inclusion of diverse groups in onychomycosis clinical trials subjects is necessary to generalise efficacy data. OBJECTIVES We aimed to systematically review race and ethnicity reporting and representation, as well as, treatment outcomes in onychomycosis clinical trials. METHODS A PubMed search for onychomycosis clinical trials was performed in August 2020. Primary clinical trial data were included and post hoc analyses were excluded. Categorical variables were compared using chi-squared and Fisher's exact tests. Statistical significance was set at p < .05. Photos in articles were categorised by Fitzpatrick skin type. RESULTS Only 32/182 (17.5%) trials reported on race and/or ethnicity and only one trial compared treatment efficacy in different subgroups. Darker skin colours were infrequently depicted in articles. Topical treatment, location with ≥1 US-based site, industry funding type and publication date after 2000 were significantly associated with reporting of racial/ethnic data (p < .05 for all comparisons). LIMITATIONS Demographics on excluded subjects and methods of recruitment were not available. Assigning Fitzpatrick skin type is inherently subjective. CONCLUSIONS This study highlights a need for consistent reporting of races and ethnicities of onychomycosis clinical trial participants with subgroup analyses of treatment efficacies.
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Affiliation(s)
| | - Yuqing Qiu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Skin Appendage Disord 2021; 7:351-358. [PMID: 34604322 PMCID: PMC8436613 DOI: 10.1159/000516112] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022] Open
Abstract
There is an increase in the incidence of onychomycosis, especially in at-risk populations. Onychomycosis is difficult to treat, as the efficacy of most antifungal agents is relatively low. Nondermatophyte molds (NDMs) and mixed infection (dermatophyte plus NDM) onychomycosis are contributing to growing antifungal resistance, as they are often underestimated and ignored due to incorrect diagnosis. There is a need for a paradigm shift in the management of onychomycosis to a patient-centered, holistic approach with an emphasis on laboratory diagnosis prior to initiating treatment, which enables the rational choice of the antifungal agent. Additionally, in the case of resistant infections, antifungal susceptibility testing is recommended. Strategies for effective management of onychomycosis include disinfection of fungal reservoirs in shoes and socks and prophylaxis posttreatment using topical antifungal agents. These measures may reduce the recurrence of onychomycosis and improve long-term clinical success.
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Affiliation(s)
- Aditya K. Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil H. Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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Mochizuki T, Tsuboi R, Iozumi K, Ishizaki S, Ushigami T, Ogawa Y, Kaneko T, Kawai M, Kitami Y, Kusuhara M, Kono T, Sato T, Sato T, Shimoyama H, Takenaka M, Tanabe H, Tsuji G, Tsunemi Y, Hata Y, Harada K, Fukuda T, Matsuda T, Maruyama R. Guidelines for the management of dermatomycosis (2019). J Dermatol 2020; 47:1343-1373. [DOI: 10.1111/1346-8138.15618] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | - Ryoji Tsuboi
- Department of Dermatology Tokyo Medical University TokyoJapan
| | - Ken Iozumi
- Department of Dermatology Tokyo Metropolitan Police Hospital TokyoJapan
| | - Sumiko Ishizaki
- Department of Dermatology Tokyo Women’s Medical University Medical Center East TokyoJapan
| | | | - Yumi Ogawa
- Department of Dermatology Juntendo University TokyoJapan
| | - Takehiko Kaneko
- Graduate School of Human Ecology Wayo Women’s University IchikawaJapan
| | - Masaaki Kawai
- Department of Dermatology Juntendo University Koshigaya Hospital KoshigayaJapan
| | - Yuki Kitami
- Department of Dermatology Showa University TokyoJapan
| | | | - Takeshi Kono
- Department of Dermatology Nippon Medical School Chibahokusoh Hospital InzaiJapan
| | | | - Tomotaka Sato
- Department of Dermatology Teikyo University Medical Center IchiharaJapan
| | - Harunari Shimoyama
- Department of Dermatology Teikyo University Mizonokuchi Hospital KawasakiJapan
| | - Motoi Takenaka
- Department of Dermatology Nagasaki University NagasakiJapan
| | | | - Gaku Tsuji
- Department of Dermatology Kyushu UniversityGraduate School of Medical Sciences FukuokaJapan
| | - Yuichiro Tsunemi
- Department of Dermatology Saitama Medical University MoroyamaJapan
| | - Yasuki Hata
- Kanagawa Hata Dermatology Clinic YokohamaJapan
| | | | - Tomoo Fukuda
- Department of Dermatology Saitama Medical Center KawagoeJapan
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8
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Gupta AK, Venkataraman M, Shear NH, Piguet V. Onychomycosis in children - review on treatment and management strategies. J DERMATOL TREAT 2020; 33:1213-1224. [PMID: 32799713 DOI: 10.1080/09546634.2020.1810607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Onychomycosis is an uncommon condition in children with increasing global prevalence. Health practitioners should confirm the diagnosis through mycology examination and examine family members of affected individuals for onychomycosis and tinea pedis. OBJECTIVE To comprehensively summarize the treatment and management strategies for pediatric onychomycosis. METHODS We performed a comprehensive literature search in the PubMed database to identify clinical studies on treatment for mycologically-confirmed dermatophyte onychomycosis in children <18 years. The exclusion criteria were combination therapy, case reports, reviews, systematic reviews and duplicate studies. RESULTS Per-weight dosing regimens of systemic antifungal agents such as terbinafine, itraconazole, and fluconazole are found to be safe in children and are used off-label for the treatment of pediatric onychomycosis with high efficacy. Topical antifungal agents such as ciclopirox, efinaconazole, and tavaborole have established safety and efficacy in children. Children respond better than adults to topical therapy due to their thinner, faster growing nails. There is no data on the efficacy of medical devices for onychomycosis in children. CONCLUSION Efinaconazole topical solution 10% and tavaborole topical solution 5% are FDA approved for the treatment of onychomycosis in children ≥6 years; ciclopirox topical solution 8% nail lacquer is approved in children ≥12 years.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | - Neil H Shear
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Vincent Piguet
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
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Different Numbers of Long-Pulse 1064-nm Nd-YAG Laser Treatments for Onychomycosis: A Pilot Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1216907. [PMID: 32051822 PMCID: PMC6995308 DOI: 10.1155/2020/1216907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 11/17/2022]
Abstract
Purpose To examine the benefits of different numbers of 1064-nm Nd-YAG laser treatments in patients with onychomycosis. Methods This was a pilot study of patients with onychomycosis who were divided into three groups: four treatment sessions (group A), eight sessions (group B), and 12 sessions (group C). Only infected nails of degrees II–III (Scoring Clinical Index for Onychomycosis) were included. Treatment was given once a week using a long-pulse Nd-YAG 1064-nm laser. Patients were followed at 8, 16, and 24 weeks after the first treatment. Side effects were recorded. Results Treatments were completed for 442 nails in 102 patients. The efficacy rates at 8, 16, and 24 weeks were 35.5%, 38.7%, and 37.4% for group A; 31.4%, 41.7%, and 44.0% for group B; and 27.7%, 50.0%, and 55.4% for group C, respectively. There was a significant difference in the efficacy rate at 24 weeks (P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all Conclusions The 1064-nm Nd-YAG laser had clinical benefits against onychomycosis. Higher numbers of treatments provided better long-term (24-week) benefits, but had no impact on the short-term outcomes. The efficacy of laser treatment on degree II onychomycosis was better than for degree III.
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Abstract
Atopic dermatitis (AD) was once thought to be a benign childhood disease that remitted with increasing age. However, recent studies have transformed the understanding of AD, particularly in adult patients. AD is common in adults and can lead to substantial disability by negatively affecting sleep, mental health, and quality of life. There seem to be different genetic, immunologic, and epidemiologic risk factors for AD in adults than in children. This article examines the pathophysiology, epidemiology, heterogeneous clinical presentation, burden, diagnosis, and treatment of adult AD.
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Affiliation(s)
- Jonathan I Silverberg
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern Medicine Multidisciplinary Eczema Center, Chicago, IL, USA.
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11
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Lipner SR. Pharmacotherapy for onychomycosis: new and emerging treatments. Expert Opin Pharmacother 2019; 20:725-735. [DOI: 10.1080/14656566.2019.1571039] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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12
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Brown M, Turner R, Wevrett SR. Use of in vitro performance models in the assessment of drug delivery across the human nail for nail disorders. Expert Opin Drug Deliv 2018; 15:983-989. [DOI: 10.1080/17425247.2018.1518425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Nitric Oxide-Releasing Macromolecule Exhibits Broad-Spectrum Antifungal Activity and Utility as a Topical Treatment for Superficial Fungal Infections. Antimicrob Agents Chemother 2018; 62:AAC.01026-17. [PMID: 29760128 DOI: 10.1128/aac.01026-17] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 04/30/2018] [Indexed: 11/20/2022] Open
Abstract
Cutaneous and superficial fungal infections affecting the skin, nails, and hair of humans are caused primarily by dermatophytes of the genera Trichophyton and Epidermophyton or by yeasts of the genera Candida and Malassezia. Onychomycosis is a common fungal infection of the nail that frequently coexists with tinea pedis, the most prevalent mycotic skin infection. Efficacy rates for current topical onychomycosis therapies are hampered by low drug penetration across the nail plate, which is theoretically obviated with nitric oxide (NO)-based topical therapies. The Nitricil technology platform is comprised of polysiloxane-based macromolecules that stably release therapeutic levels of NO. In the reported studies, NVN1000, the lead candidate of the platform, was assessed for its spectrum of in vitro activity against a broad range of filamentous fungi and yeast species commonly associated with cutaneous fungal infections. Time-kill assays demonstrated that NVN1000 exhibited fungicidal activity as early as 4 h. Additionally, the penetration of several unique NVN1000 NO-releasing drug product formulations (gel, cream, and lacquer) was evaluated following a single topical application in an in vitro infected human nail assay, with all formulations showing similar inhibition of fungal growth. Repeated topical application in this model demonstrated that a lower-strength dose of NO could achieve the same efficacy as a higher-strength dose after 7 days. Together, these in vitro results demonstrate that NO-releasing treatments rapidly penetrate the nail plate and eradicate the fungal infection, representing promising novel topical therapies for the treatment of onychomycosis and other cutaneous fungal infections.
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Khamidah N, Ervianti E. COMBINATION ANTIFUNGAL THERAPY FOR ONYCHOMYCOSIS. INDONESIAN JOURNAL OF TROPICAL AND INFECTIOUS DISEASE 2018. [DOI: 10.20473/ijtid.v7i1.6235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Onychomycosis is a fungal infection of the nail unit including the nail matrix, the nail bed and the nail plate by both dermatophyte and non-dermatophyte agents. It is disturbs not only cosmetic disfigurement, but also it may have an impact on patients’ emotional, social and occupational functioning, finally affecting the overall quality of life. The incidence rate tends to increase, management of onychomycosis is still challenging. Important problems regarding antifungal monotherapy have experienced many failures and recurrences. In general, pharmacological approaches for onychomycosis can be topical or oral antifungal. Antifungal monotherapies often lead to failure treatment, also high incidence of recurrence. One strategy for this problem is a combination antifungal therapy. In vitro studies show the synergistic effect of using combination two antifungals (both oral antifungal or combination topical and oral antifungal), hence it is mycologically or clinically expected to increase the success rate of onychomycosis therapy. This review tries to evaluate the previous study exploring the effectiveness of antifungal combination therapies on onychomycosis. Two oral antifungals usually used are terbinafine as fungicidal agent and itraconazole as fungistatic agent. There is combination between topical and oral antifungal such as itraconazole or terbinafine with amorolfine or ciclopirox, also other combination like griseofulvin and amorolfone or tioconazole. All the combination therapies show better result than monotherapy alone, but it is still difficult to conclude whether antifungal combinations in onychomycosis will increase effectiveness due to variations in therapeutic duration, result definition, and statistical evaluation on existing studies. Further research is required with longer duration of observation, uniform patient criteria and definition of success, random control and blinding to minimize bias.
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15
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Kreijkamp‐Kaspers S, Hawke K, Guo L, Kerin G, Bell‐Syer SEM, Magin P, Bell‐Syer SV, van Driel ML. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017; 7:CD010031. [PMID: 28707751 PMCID: PMC6483327 DOI: 10.1002/14651858.cd010031.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence-based choice for treatment. OBJECTIVES To assess the effects of oral antifungal treatments for toenail onychomycosis. SEARCH METHODS We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. SELECTION CRITERIA RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years.We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high-risk domain was 'blinding of personnel and participants'.We found high-quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine-treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate-quality evidence).There was high-quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu-like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate-quality evidence).Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low-quality evidence).There is moderate-quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate-quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low-quality evidence). Common adverse events in both groups included headache, viral infection, and nausea.Moderate-quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate-quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin-treated participants) along with nausea and vomiting (in azole-treated participants). Very low-quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants).There is low-quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low-quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin-treated participants) as well as taste loss and nausea (in terbinafine-treated participants). No studies addressed recurrence rate for this comparison.No study addressed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate-quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate-quality evidence).Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate-quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low-quality evidence).Only four comparisons assessed recurrence rate: low-quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them.Only a limited number of studies reported adverse events, and the severity of the events was not taken into account.Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding.
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Affiliation(s)
- Sanne Kreijkamp‐Kaspers
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Kate Hawke
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Linda Guo
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - George Kerin
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Sally EM Bell‐Syer
- CochraneCochrane Editorial UnitSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Parker Magin
- The University of NewcastleDiscipline of General Practice, School of Medicine and Public HealthNewbolds Buiding, University of Newcastle,University DriveNewcastleAustralia2308
| | | | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
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Gupta AK, Versteeg SG, Shear NH. Onychomycosis in the 21st Century: An Update on Diagnosis, Epidemiology, and Treatment. J Cutan Med Surg 2017. [PMID: 28639462 DOI: 10.1177/1203475417716362] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Onychomycosis accounts for 50% of all nail disease cases and is commonly caused by dermatophytes. Diabetes, human immunodeficiency virus, immunosuppression, obesity, smoking, and advancing age are predisposing factors of this fungal infection. Potassium hydroxide and culture are considered the current standard for diagnosing onychomycosis, revealing both fungal viability and species identification. Other diagnostic tests currently available include periodic acid-Schiff staining, polymerase chain reaction techniques, and fluorescent staining. Across 6 recently published epidemiology studies, the global prevalence of onychomycosis was estimated to be 5.5%, falling within the range of previously reported estimates (2%-8%). Newly approved onychomycosis treatments include efinaconazole, tavaborole, and laser therapy with lasers only approved to temporarily increase the amount of clear nail. Additional onychomycosis treatments being investigated include iontophoresis and photodynamic therapy with small open-label studies reported thus far. Preventative strategies, to help decrease recurrence and reinfection rates, include sanitisation of footwear and prophylactic topical antifungal agents.
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Affiliation(s)
- Aditya K Gupta
- 1 Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada.,2 Mediprobe Research, Inc, London, Ontario, Canada
| | | | - Neil H Shear
- 3 Department of Medicine (Dermatology, Clinical Pharmacology and Toxicology) and Department of Pharmacology, Sunnybrook and Women's College Health Science Centre and the University of Toronto, Toronto, Ontario, Canada
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17
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Tosti A, Elewski BE. Onychomycosis: Practical Approaches to Minimize Relapse and Recurrence. Skin Appendage Disord 2016; 2:83-87. [PMID: 27843933 DOI: 10.1159/000448056] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/28/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Toenail onychomycosis is a common disease in which treatment options are limited and treatment failures and disease recurrence are frequently encountered. It usually requires many months of treatment, and recurrence may occur in more than half of the patients within 1 year or more after the infection has been eradicated. Data on long-term treatment, follow-up and recurrence are limited. OBJECTIVE Our objective is to interpret these data and recommend practical approaches that should minimize recurrence based on our clinical experience. RESULTS Several factors have been suggested to play a role in the high incidence of recurrence, but only the extent of nail involvement and co-existing diabetes mellitus have been shown to have a significant impact. CONCLUSION The use of topical antifungals to prevent recurrences after complete cure was achieved has been suggested by various workers and used successfully in our practice. However, it has never been validated through clinical studies. Topical prophylaxis once weekly or twice monthly would seem appropriate in those patients most at risk. Prompt treatment of tinea pedis is essential, as is ensuring family members are free from disease. Patient education and pharmacologic intervention are equally important, and there are a number of simple strategies patients can employ. Managing onychomycosis is a significant long-term commitment for any patient, and minimizing recurrence is critical to meet their expectations.
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Affiliation(s)
- Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla, USA
| | - Boni E Elewski
- Department of Dermatology, University of Alabama at Birmingham School of Medicine, Birmingham, Ala., USA
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18
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Stensen W, Turner R, Brown M, Kondori N, Svendsen JS, Svenson J. Short Cationic Antimicrobial Peptides Display Superior Antifungal Activities toward Candidiasis and Onychomycosis in Comparison with Terbinafine and Amorolfine. Mol Pharm 2016; 13:3595-3600. [PMID: 27576445 DOI: 10.1021/acs.molpharmaceut.6b00654] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Novel antifungals are in high demand due to the challenges associated with resistant, persistent, and systemic fungal infections. Synthetic mimics of antimicrobial peptides are emerging as a promising class of compounds for antifungal treatment. In the current study, five synthetic cationic antimicrobial tripeptides were evaluated as antifungal therapeutics against 24 pathogenic strains of fungi. Three of the peptides displayed strong general antifungal properties at low micromolar inhibitory concentrations. The most promising peptide, compound 5, was selected and evaluated as an antifungal remedy for Candida albicans candidiasis in a human skin model and for the treatment of Trichophyton rubrum induced onychomycosis in an infected human nail model. Compound 5 was shown to display antifungal properties and a rapid mode of action superior to those of both the commercial comparators Loceryl and Lamisil. Compound 5 was also active against a clinical isolate of Candida albicans with acquired fluconazole resistance.
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Affiliation(s)
- Wenche Stensen
- Department of Chemistry, UiT The Arctic University of Norway , Tromsø, Norway.,Lytix Biopharma AS , Tromsø, Norway
| | | | - Marc Brown
- MedPharm Ltd , Guildford, U.K.,TDDT, University of Hertfordshire , Hatfield, Hertfordshire, U.K
| | - Nahid Kondori
- Department of Clinical Microbiology, Sahlgrenska University Hospital , Gothenburg, Sweden
| | - John Sigurd Svendsen
- Department of Chemistry, UiT The Arctic University of Norway , Tromsø, Norway.,Lytix Biopharma AS , Tromsø, Norway
| | - Johan Svenson
- Department of Chemistry, Materials and Surfaces, SP Technical Research Institute of Sweden , Borås, Sweden
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19
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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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20
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Vlahovic TC, Joseph WS, Scher RK, Tosti A, Plasencia J, Pariser DM, Markinson BC. Diagnosis and Management of Onychomycosis Perspectives from a Joint Podiatric Medicine-Dermatology Roundtable. J Am Podiatr Med Assoc 2016; 106:155-62. [PMID: 27031556 DOI: 10.7547/14-170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Onychomycosis is a fungal infection, and, as such, one of the goals of treatment should be eradication of the infective agent. Despite this, in contrast to dermatologists, many podiatric physicians do not include antifungals in their onychomycosis treatment plans. Before initiating treatment, confirmation of mycologic status via laboratory testing (eg, microscopy with potassium hydroxide preparation, histopathology with periodic acid-Schiff staining, fungal culture, and polymerase chain reaction) is important; however, more podiatric physicians rely solely on clinical signs than do dermatologists. These dissimilarities may be due, in part, to differences between specialties in training, reimbursement patterns, or practice orientation, and to explore these differences further, a joint podiatric medicine-dermatology roundtable was convened. In addition, treatment options have been limited owing to safety concerns with available oral antifungals and relatively low efficacy with previously available topical treatments. Recently approved topical treatments-efinaconzole and tavaborole-offer additional options for patients with mild-to-moderate disease. Debridement alone has no effect on mycologic status, and it is recommended that it be used in combination with an oral or topical antifungal. There is little to no clinical evidence to support the use of lasers or over-the-counter treatments for onychomycosis. After a patient has achieved cure (absence of clinical signs or absence of fungus with minimal clinical signs), lifestyle and hygiene measures, prophylactic/maintenance treatment, and proactive treatment for tinea pedis, including in family members, may help maintain this status.
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Affiliation(s)
- Tracey C. Vlahovic
- Department of Podiatric Medicine and Orthopedics, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Warren S. Joseph
- Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Huntingdon Valley, PA
| | - Richard K. Scher
- General Dermatology, Weill Cornell Medical College, New York, NY
| | - Antonella Tosti
- Dermatology and Cutaneous Surgery, Leonard Miller School of Medicine, University of Miami, Miami, FL
| | | | - David M. Pariser
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, VA
| | - Bryan C. Markinson
- The Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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McClean M, Silverberg JI. Statistical reporting in randomized controlled trials from the dermatology literature: a review of 44 dermatology journals. Br J Dermatol 2015; 173:172-83. [PMID: 25989239 DOI: 10.1111/bjd.13907] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The validity of randomized controlled trials (RCTs) is determined by several statistical factors. OBJECTIVES To determine the level of recent statistical reporting in RCTs from the dermatology literature. METHODS We searched MEDLINE for all RCTs published between 1 May 2013 and 1 May 2014 in 44 dermatology journals. RESULTS Two hundred and ten articles were screened, of which 181 RCTs from 27 journals were reviewed. Primary study outcomes were met in 122 (67.4%) studies. Sample size calculations and beta values were reported in 52 (28.7%) and 48 (26.5%) studies, respectively, and nonsignificant findings were supported in only 31 (17.1%). Alpha values were reported in 131 (72.4%) of studies with 45 (24.9%) having two-sided P-values, although adjustment for multiple statistical tests was performed in only 16 (9.9% of studies with ≥ two statistical tests performed). Sample size calculations were performed based on a single outcome in 44 (86.3%) and multiple outcomes in six (11.8%) studies. However, among studies that were powered for a single primary outcome, 20 (45.5%) made conclusions based on multiple primary outcomes. Twenty-one (41.2%) studies relied on secondary/unspecified outcomes. There were no differences for primary outcome being met (Chi-square, P = 0.29), sample size calculations (P ≥ 0.55), beta values (P = 0.89), alpha values (P = 0.65), correction for multiple statistical testing (P = 0.59), two-sided alpha (P = 0.64), support of nonsignificant findings (Fisher's exact, P = 0.23) based on the journal's impact factor. CONCLUSIONS Levels of statistical reporting are low in RCTs from the dermatology literature. Future work is needed to improve these levels of reporting.
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Affiliation(s)
- M McClean
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Suite 1600, 676 N. St Clair St, Chicago, IL, 60611, U.S.A
| | - J I Silverberg
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Suite 1600, 676 N. St Clair St, Chicago, IL, 60611, U.S.A.,Department of Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Suite 1600, 676 N. St Clair St, Chicago, IL, 60611, U.S.A
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22
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Wanitphakdeedecha R, Thanomkitti K, Bunyaratavej S, Manuskiatti W. Efficacy and safety of 1064-nm Nd:YAG laser in treatment of onychomycosis. J DERMATOL TREAT 2015; 27:75-9. [DOI: 10.3109/09546634.2015.1034078] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tamura T, Asahara M, Yamamoto M, Yamaura M, Matsumura M, Goto K, Rezaei-Matehkolaei A, Mirhendi H, Makimura M, Makimura K. In vitro susceptibility of dermatomycoses agents to six antifungal drugs and evaluation by fractional inhibitory concentration index of combined effects of amorolfine and itraconazole in dermatophytes. Microbiol Immunol 2014; 58:1-8. [PMID: 24215461 DOI: 10.1111/1348-0421.12109] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/25/2013] [Accepted: 10/28/2013] [Indexed: 11/28/2022]
Abstract
To investigate the antifungal drug susceptibility of fungi responsible for dermatomycoses, minimum inhibition concentration (MIC) tests were performed in 44 strains of dermatophytes, including Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton verrucosum, Trichophyton tonsurans, Microsporum canis, Microsporum gypseum and Epidermophyton floccosum, with six antifungal drugs (amorolfine, terbinafine, butenafine, ketoconazole, itraconazole and bifonazole) by broth microdilution assay according to Clinical Laboratory Standard Institute protocols. Six possible dermatomycosis-causing non-dermatophytic fungi were also tested. The two major causes of tinea, T. rubrum and T. mentagrophytes, showed significantly different sensitivities to ketoconazole and bifonazole. Clinically derived dermatophytes were sensitive to the six antifungal drugs tested. However, non-dermatophytes, especially Fusarium spp., tended to be resistant to these antifungal drugs. In Trichophyton spp., the MICs of non-azole drugs had narrower distributions than those of azoles. To evaluate the effects of antifungal drug combinations, the fractional inhibitory concentration index was calculated for the combination of amorolfine and itraconazole as representative external and internal drugs for dermatophytes. It was found that this combination had synergistic or additive effects on most dermatophytes, and had no antagonistic effects. The variation in susceptibility of clinically derived fungal isolates indicates that identification of causative fungi is indispensable for appropriately choosing effective antifungal drugs in the early stages of infection. The results of combination assay suggest that multiple drugs with different antifungal mechanisms against growth of dermatophytes should be used to treat refractory dermatomycoses, especially onychomycosis.
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Affiliation(s)
- Takashi Tamura
- Department of Clinical Laboratory Science, Graduate School of Medical Technology; Eiken Chemical, 4-19-9 Taito, Taito-ku, Tokyo, 110-8408, Japan
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Ohsumi K, Watanabe M, Fujie A. AS2077715 is a selective inhibitor of fungal mitochondrial cytochrome bc₁ complex. J Antibiot (Tokyo) 2014; 67:713-6. [PMID: 24865866 DOI: 10.1038/ja.2014.67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/14/2014] [Accepted: 02/27/2014] [Indexed: 11/09/2022]
Abstract
AS2077715 is a novel antifungal metabolite produced by the newly isolated fungal strain Capnodium sp. 339855. This compound has an analogous structure to funiculosin, an inhibitor of mitochondrial cytochrome bc1 complex (complex III). AS2077715 inhibited ubiquinol-cytochrome c reductase activity of Trichophyton mentagrophytes complex III with an IC50 of 0.9 ng ml(-1), while 6000-20,000 ng ml(-1) AS2077715 was required to obtain comparable inhibition of mammalian complex III. This inhibitor also suppressed the growth of T. mentagrophytes with a MIC of 0.08 μg ml(-1), while cytotoxicity for mammalian cells was >6 μg ml(-1). These results indicate that AS2077715 is a selective inhibitor of fungal mitochondrial complex III. AS2077715 in doses of 1 μg ml(-1) or greater showed fungicidal activity against T. mentagrophytes within 2 h of incubation. This early-onset effect of fungicidal activity was also exhibited by other complex III inhibitors. These results suggest that inhibition of complex III is a promising strategy for designing anti-Trichophyton agents and that AS2077715 can be a potential drug candidate for treating Trichophyton infections.
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Affiliation(s)
- Keisuke Ohsumi
- Drug Discovery Research, Astellas Pharma Inc., Ibaraki, Japan
| | - Masato Watanabe
- Drug Discovery Research, Astellas Pharma Inc., Ibaraki, Japan
| | - Akihiko Fujie
- Drug Discovery Research, Astellas Pharma Inc., Ibaraki, Japan
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