Comparative assessment of the efficacy and safety of sertaconazole (2%) cream versus terbinafine cream (1%) versus luliconazole (1%) cream in patients with dermatophytoses: a pilot study

Diagnostic ability of Peptidase S8 gene in the Arthrodermataceae causing dermatophytoses: A metadata analysis

An unambiguous identification of dermatophytes causing dermatophytoses is necessary for accurate clinical diagnosis and epidemiological implications. In the current taxonomy of the Arthrodermataceae, the etiological agents of dermatophytoses consist of seven genera and members of the genera Trichophyton are the most prevalent etiological agents at present. The genera Trichophyton consists of 16 species that are grouped as clades, but the species borderlines are not clearly delimited. The aim of the present study was to determine the discriminative power of subtilisin gene variants (SUB1-SUB12) in family Arthrodermataceae, particularly in Trichophyton. Partial and complete reads from 288 subtilisin gene sequences of 12 species were retrieved and a stringent filtering following two different approaches for analysis (probability of correct identification (PCI) and gene gap analysis) conducted to determine the uniqueness of the subtilisin gene subtypes. SUB1 with mean PCI value of 60% was the most suitable subtilisin subtype for specific detection of T.rubrum complex, however this subtype is not reported in members of T. mentagrophytes complex which is one of the most prevalent etiological agent at present. Hence, SUB7 with 40% PCI value was selected for testing its discriminative power in Trichophyton species. SUB7 specific PCR based detection of dermatophytes was tested for sensitivity and specificity. Sequences of SUB7 from 42 isolates and comparison with the ITS region showed that differences within the subtilisin gene can further be used to differentiate members of the T. mentagrophytes complex. Further, subtilisin cannot be used for the differentiation of T. benhamiae complex since all SUB subtypes show low PCI scores. Studies on the efficiency and limitations of the subtilisin gene as a diagnostic tool are currently limited. Our study provides information that will guide researchers in considering this gene for identifying dermatophytes causing dermatophytoses in human and animals.

Dermatophyte Infections Worldwide: Increase in Incidence and Associated Antifungal Resistance

The increase in incidence of superficial fungal infections combined with the emergence of antifungal resistance represents both a global health challenge and a considerable economic burden. Recently, dermatophytes, the main culprit causing superficial fungal infections, have started to exhibit antifungal resistance. This can be observed in some of the most common species such as Trichophyton rubrum and Trichophyton mentagrophytes. Importantly, the new subspecies, known as Trichophyton indotineae, has been reported to show high resistance to terbinafine, a first-line treatment for dermatophyte infections. Compounding these issues is the realization that diagnosing the causative infectious agents requires using molecular analysis that goes beyond the conventional macroscopic and microscopic methods. These findings emphasize the importance of conducting antifungal susceptibility testing to select the appropriate antifungal necessary for successful treatment. Implementing these changes may improve clinical practices that combat resistant dermatophyte infections.

Comparative evaluation of the efficacy of itraconazole with terbinafine cream versus itraconazole with sertaconazole cream in dermatophytosis: A within person pilot study

Background

Current trend of rising drug-resistant dermatophyte infection is alarming and fretted by dermatologists. Dilemma prevails regarding use of the same or different class of antifungal agents topically and systemically. The aim was to study the efficacy of oral itraconazole 200 mg with 1% terbinafine cream versus oral itraconazole 200 mg with 2% sertaconazole cream in dermatophytosis.

Methods

This within-person open-label pilot study enrolled 50 patients with dermatophytosis. Two lesions of comparable size within each patient were randomly allotted to group A and B and treated with 2% sertaconazole and 1% terbinafine cream, respectively. Both groups received itraconazole 200 mg once daily for 4 weeks. The remaining lesions received 1% terbinafine cream. Response and adverse effects were assessed at 2 and 4 weeks. Reduction in erythema, scaling, pruritus and clinical, and mycological cure constituted efficacy outcomes.

Results

The mean duration of lesions was 2.82 ± 1.35 months. Complete clinical cure was observed in 50% and 48%, whereas mycological cure was attained in 56% and 52% patients in groups A and B, respectively, after 4 weeks, which was statistically insignificant. Reduction in erythema, scaling, and pruritus after 4 weeks when compared between the two groups, was also statistically insignificant.

Conclusion

Same class of oral and topical antifungal agents has comparable efficacy with different classes of oral and topical antifungal agents in dermatophyte infection.

Luliconazole topical dermal drug delivery for superficial fungal infections: Penetration hurdles and role of functional nanomaterials

Luliconazole is the first and only anti-fungal agent approved for the short-term treatment of superficial fungal infections. However, commercially available conventional topical dermal drug delivery cargo of luliconazole is associated with certain limitations like lower skin permeation and shorter skin retention of drug. Therefore, present review is an attempt to decode the penetration hurdles in luliconazole topical dermal drug delivery. Moreover, we also summarized the activity of functional nanomaterials based drug delivery systems employed by the scientific fraternity to improve luliconazole efficacy in superficial fungal infections on case-to-case basis. In addition, efforts have also been made to unbox the critically acclaimed mechanism of action of luliconazole against fungal cells. Under the framework of future prospects, we have analyzed the combination of luliconazole with isoquercetin using in-silico docking technique for offering synergistic antifungal activity. Isoquercetin exhibited a good affinity for superoxide dismutase (SOD), a fungal target owing to the formation of hydrogen bond with Glu132, Glu133, and Arg143, in addition to few hydrophobic interactions. On the other hand, luliconazole inhibited lanosterol-14α-demethylase and consequently blocked ergosterol. In addition, nanotechnology and artificial neural network (ANN) derived integrated drug delivery systems may also be explored for augmenting the luliconazole therapeutic efficacy in topical fungal infections. Synergy of ANN models along with topical nanoscaled drug delivery may help to achieve critical quality attributes (CQA) to gain commercial success.

A Comparative Study on the Phenotypic Versus Molecular Identification of Clinical Dermatophytes

Dermatophytosis is the superficial infection of keratinized tissue like skin, hair, and nails, in humans and animals, by a group of closely related fungi known as dermatophytes. Phenotypic identification of dermatophytes, especially through classical methods can be difficult and uncertain at times, especially when differentiating species with overlapping characteristics. Alternative identification methods based on amplification and sequence analysis of the highly polymorphic internal transcribed spacer (ITS) sequences flanking the 5.8S ribosomal RNA gene has proven to be quite sensitive and reliable. The objective of our study was to compare the phenotypic and the ITS sequencing-based methods for the identification of clinically isolated dermatophyte specimens from Puducherry, India. A total of 13 clinical samples from 39 suspected cases were found positive for dermatophytes using KOH/DMSO preparations. Specimens were subsequently cultured in Sabouraud dextrose agar (SDA) supplemented with chloramphenicol, gentamicin, and cycloheximide. Dermatophytes were identified based on culture characteristics and microscopic examination in lactophenol cotton blue preparations. ITS sequencing was additionally performed after PCR amplification for species identification. Identification based on phenotype through microscopy and culture methods confirmed infections with Trichophyton mentagrophytes (n = 11), T. rubrum (n = 1), and Microsporum gypseum (n = 1). The strains were confirmed by ITS sequencing without any discrepancy with phenotypic identification. Identification of common dermatophytes based on phenotypic characteristics may be used as a reliable method of diagnosis where sophisticated methods like ITS sequencing and PCR are unavailable.

Pathogenesis, Immunology and Management of Dermatophytosis

Dermatophytic infections of the skin and appendages are a common occurrence. The pathogenesis involves complex interplay of agent (dermatophytes), host (inherent host defense and host immune response) and the environment. Infection management has become an important public health issue, due to increased incidence of recurrent, recalcitrant or extensive infections. Recent years have seen a significant rise in incidence of chronic infections which have been difficult to treat. In this review, we review the literature on management of dermatophytoses and bridge the gap in therapeutic recommendations.

Comparison of efficacy, safety, and cost-effectiveness of sertaconazole and luliconazole cream in patients with dermatophytoses: A prospective, randomized, open-label study

Objective:

To compare efficacy, safety, and cost-effectiveness of sertaconazole (2%) and luliconazole (1%) cream in patients with dermatophytoses.

Materials and Methods:

Sixty-four patients with tinea corporis and tinea cruris infections were enrolled in this single-center, randomized, open–label, parallel study. Following inclusion and exclusion criteria, patients were randomly divided into two treatment groups and received either sertaconazole 2% cream applied topically twice daily for 4 weeks and luliconazole 1% cream once daily for 2 weeks. At follow-up, efficacy was assessed clinically using 4-point physician global assessment (PGA) scale, composite score, and mycologically by KOH mount. Safety was assessed by monitoring adverse drug events at each visit.

Results:

The primary efficacy variables including changes in pruritus, erythema, vesicle, and desquamation (4-point PGA) were significantly (P < 0.0001) improved in both the groups, at the end of treatment. There was a significant reduction in mean total composite score (pruritus, erythema, vesicle, and desquamation) after the end of treatment in the sertaconazole group (P = 0.0002) compared to the luliconazole group. Both the groups showed equal negative mycological assessment. Both the study drugs were well tolerated. Only one patient in the sertaconazole group showed allergic contact dermatitis.

Conclusion:

Sertaconazole was better than luliconazole in relieving signs and symptoms during the study and follow-up period, but cost-effectiveness wise, luliconazole was better than sertaconazole.

Multipotentiality of Luliconazole against Various Fungal Strains: Novel Topical Formulations and Patent Review

BACKGROUND

Luliconazole is a broad-spectrum antifungal agent with impactful fungicidal and fungistatic activity. It has shown exceptional potency against miscellaneous fungal strains like Candida, Aspergillus, Malassezia, Fusarium species and various dermatophytes.

OBJECTIVE

Luliconazole belongs to class Ⅱ of the Biopharmaceutical Classification System with low aqueous solubility. Although it is available conventionally as 1% w/v topical cream, it has limitations of lower skin permeation and shorter skin retention. Therefore, nanoformulations based on various polymers and nanostructure carriers can be employed to overcome the impediments regarding topical delivery and efficacy of luliconazole.

METHODS

In this review, we have tried to provide insight into the literature gathered from authentic web resources and research articles regarding recent research conducted on the subject of formulation development, patents, and future research requisites of luliconazole.

RESULTS

Nanoformulations can play a fundamental role in improving topical delivery by escalating dermal localization and skin penetration. Fabricating luliconazole into nanoformulations can overcome the drawbacks and can efficiently enhance its antimycotic activity.

CONCLUSION

It has been concluded that luliconazole has exceptional potential in the treatment of various fungal infections, and therefore, it should be exploited to its maximum for its innovative application in the field of mycology.

Development, Optimization, and Evaluation of Luliconazole Nanoemulgel for the Treatment of Fungal Infection

The present study aimed to optimize luliconazole nanoemulsion using Box–Behnken statistical design, which was further incorporated into the polymeric gel of Carbopol 934. The formulation was characterized for its size, entrapment efficiency, ex vivo permeation, and mechanism of release. The size of the dispersed globules of the optimized drug-loaded nanoemulsion was found to be 17 ± 3.67 nm with a polydispersity index (PDI) less than 0.5. Although the surface charge was recorded at –9.53 ± 0.251, the stability was maintained by the polymeric matrix that prevented aggregation and coalescence of the dispersed globules. The luliconazole-nanoemulgel (LUL-NEG) was characterized for drug content analysis, viscosity, pH, and refractive index, where the results were found to be 99.06 ± 0.59%, 9.26 ± 0.08 Pa.s, 5.65 ± 0.17, and 1.31 ± 0.08, respectively. The permeation across the rat skin was found to be significantly higher with LUL-NEG when compared with LUL gel. Furthermore, the skin irritation test performed in experimental animals revealed that the blank NEG, as well as the LUL-NEG, did not produce any signs of erythema following 48 h exposure. In addition, the histopathological findings of the experimental skins reported no abnormal signs at the formulation application site. Finally, the NEG formulation was found to create a statistically significant zone of inhibition ( $P$  < 0.05) when compared to all other test groups. Overall, it could be summarized that the nanoemulgel approach of delivering luliconazole across the skin to treat skin fungal infections could be a promising strategy.

The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

Superficial mycoses, a matter of concern: Global and Indian scenario-an updated analysis

Superficial mycoses of skin, nails and hair are among the common fungal infections. They are caused by dermatophytes, non-dermatophyte moulds, yeasts and yeast-like fungi. Such fungal infections are widespread all over the world and are predominant in tropical as well as subtropical regions. Environmental factors, such as warm, humid and pitiable hygienic conditions, are conducive for their growth and proliferation. Although it does not cause mortality, it is known to be associated with excessive morbidity which may be psychological or physical. This affects the quality of life of the infected individuals which leads to a negative impact on their occupational, emotional and social status. Such infections are increasing on a global scale and, therefore, are of serious concern worldwide. This review article covers the global and Indian scenario of superficial mycoses taking into account the historical background, aetiological agents, prevalence, cultural and environmental factors, risk factors, pathogenesis and hygienic practices for the prevention of superficial mycoses.

Autoimplantation Therapy in Extensive and Recalcitrant Dermatophytosis: A Case Series

Dermatophytosis is one of the most common diseases worldwide and is difficult to treat due to its recalcitrant nature. Conventional treatment modalities are associated with frequent relapses due to the absence of a host immune interaction. Here, we present a case series of three patients with difficult-to-treat and recalcitrant dermatophytosis who were treated with homologous autoimplantation. Complete clearance of dermatophytosis was observed after three months in two of the patients and after two and a half months in one patient without the use of any antifungals. No relapses were observed within six months of follow-up. The outcomes of the three patients presented in this case series support homologous autoimplantation as a safe and effective procedure for the treatment of recalcitrant dermatophytosis. The procedure requires only a single visit that can be performed either alone or in combination with other modalities.

Efficacy and Safety of Eberconazole vs Sertaconazole in Localised Tinea Infection

BACKGROUND

Topical antifungals especially azole group of drugs are effective agents in the treatment of dermatophytoses producing 100% clinical and mycological cure. Each of them vary having specific characteristics to tackle several clinical challenges like high relapse rate, recurrences and quality of life.

AIMS AND OBJECTIVES

To compare the efficacy and safety of Eberconazole and Sertaconazole in tinea infection.

MATERIALS AND METHODS

This was a randomized, observer-blinded, parallel-group study conducted at a dermatology out-patient department (OPD) of tertiary care teaching hospital in Puducherry. 85 patients with tinea corporis and tinea cruris infections who visited the dermatology OPD were enrolled in this study. The treatment phase involved two groups receiving either Sertaconazole 2% cream or Eberconazole 1% applied topically twice daily for 4 weeks. At the end of treatment phase, there was a 'follow-up phase' at the end of 4 weeks, where the patients were assessed clinically and mycologically. The data were analyzed using descriptive statistics using MS Excel version 2019 and SPSS version 15 for Windows.

RESULTS

The primary efficacy variables namely change in pruritus, erythema, induration, scaling and mycological cure significantly improved in both the groups, as compared to baseline (P < 0.001), in the treatment phase and follow-up phase. Intergroup comparison with respect to pruritus and scaling showed significant difference (P < 0.001), suggestive of better reduction of pruritus and scaling scores at 4 weeks with Sertaconazole when compared to Eberconazole.

CONCLUSIONS

Sertaconazole was better than Eberconazole in relieving signs and symptoms of dermatophytoses, especially pruritus, thereby improving patients' quality of life.

Efficacy, Safety, and Cost Evaluation of the Topical Luliconazole Therapy versus Topical Clotrimazole Therapy in Patients with Localized Dermatophytosis in a Tertiary Care Hospital: An Observational Study

Background:

Dermatophytosis is a superficial fungal infection that has high affinity for keratinized tissues of the body. The treatment of localized dermatophytosis is a major concern for the dermatologist especially in tropical countries like India. Various topical antifungals are available for the treatment of localized uncomplicated dermatophytosis. Luliconazole is an azole antifungal available that has potent activity against dermatophytes.

Objectives:

The objective of this study was to compare two treatment modalities for the treatment of localized dermatophytosis in terms of efficacy, safety, and cost evaluation.

Materials and Methods:

This was a prospective and observational study carried out for 6 months and included 200 patients (luliconazole group [n = 94] and clotrimazole group [n = 106]). Patients were followed up for 2, 4, and 6 weeks. Outcome parameters such as pruritis, erythema, scaling, vesiculations, and global assessment score were noted at 2, 4, and 6 weeks for the assessment of efficacy. The statistical analysis was done using Chi-square and Student's t-test.

Results:

Luliconazole and clotrimazole showed 56.38% and 23.58% cure rate at the end of two weeks respectively (P < 0.05). At the end of treatment, the cure rates were 98.93% and 95.28% in luliconazole and clotrimazole, respectively (P > 0.005). Both the drugs were equally safe. On cost-effective analysis, luliconazole was found to be more cost-effective than clotrimazole at the end of 2 weeks.

Conclusion:

Therapeutic efficacy of luliconazole was more as significant proportion of patients achieved complete clearance of lesions at faster rate within 2 weeks with convenient once daily application.

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT)

Background and Aims:

Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India.

Methods:

Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either “agree” or “disagree” to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs.

Results:

Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis.

Conclusion:

Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.

Tinea corporis: an updated review

Background

Tinea corporis is a common fungal infection that mimics many other annular lesions. Physicians must familiarize themselves with this condition and its treatment.

Objective

This article aimed to provide a narrative updated review on the evaluation, diagnosis, and treatment of tinea corporis.

Methods

A PubMed search was performed with Clinical Queries using the key term ‘tinea corporis.’ The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English language. The information retrieved from the mentioned search was used in the compilation of the present article.

Results

Tinea corporis typically presents as a well-demarcated, sharply circumscribed, oval or circular, mildly erythematous, scaly patch or plaque with a raised leading edge. Mild pruritus is common. The diagnosis is often clinical but can be difficult with prior use of medications, such as calcineurin inhibitors or corticosteroids. Dermoscopy is a useful and non-invasive diagnostic tool. If necessary, the diagnosis can be confirmed by microscopic examination of potassium hydroxide wet-mount preparations of skin scrapings from the active border of the lesion. Fungal culture is the gold standard to diagnose dermatophytosis especially if the diagnosis is in doubt and results of other tests are inconclusive or the infection is widespread, severe, or resistant to treatment. The standard treatment of tinea corporis is with topical antifungals. Systemic antifungal treatment is indicated if the lesion is multiple, extensive, deep, recurrent, chronic, or unresponsive to topical antifungal treatment, or if the patient is immunodeficient.

Conclusion

The diagnosis of tinea corporis is usually clinical and should pose no problem to the physician provided the lesion is typical. However, many clinical variants of tinea corporis exist, rendering the diagnosis difficult especially with prior use of medications, such as calcineurin inhibitors or corticosteroids. As such, physicians must be familiar with this condition so that an accurate diagnosis can be made and appropriate treatment initiated.

Chemistry and Pharmacology of Luliconazole (Imidazole Derivative): A Novel Bioactive Compound to Treat Fungal Infection-A Mini Review

Background:

Currently, ringworm treatment drugs include two major categories: first, propylene amine drugs, such as terbinafine, butenafine and naftifine, which exert their bactericidal effects through inhibiting squalene cyclase, causing the lack of ergosterol and accumulation of squalene. The second category of imidazole drugs includes miconazole, econazole, clotrimazole, ketoconazole and bifonazole.

Mechanism:

These synthetic antifungal agents exhibits their action by inhibiting the lanosterol 14α- demethylation activity of fungal cell, leading to the prevention of the ergosterol synthesis of cell membrane, changing the cell membrane permeability, and resulting in the loss of important intracellular fungal material and causing fungal death.

Applications:

At present, Imidazole antifungal agents are commonly used drugs in clinical treatment of ringworm with extensive clinical applications.

Conclusion:

The present review covers the chemistry and detailed pharmacology aspects of luliconazole.

Impact on quality of life in patients with dermatophytosis

BACKGROUND/OBJECTIVES

Dermatophytosis can have a significant effect on patient's psychosocial and economic life. Despite this, knowledge on the quality of life (QoL) in patients with dermatophytosis is limited. The objective of the present study was to assess the quality of life in patients with dermatophytosis.

METHODS

This was a cross-sectional study conducted in the Department of Dermatology at a tertiary care hospital from August 2018 to December 2018. All the patients with dermatophytosis aged ≥16 years were included and evaluated for impact on quality of life. The association of Dermatology Life Quality Index (DLQI) scores with disease characteristics was assessed using t-test, ANOVA and Pearson's correlation test, as applicable.

RESULTS

A total of 348 patients were analysed. The mean ± SD DLQI score in our study was 13.4 ± 7.3. Dermatophytosis was found to have a very large effect on the QoL in majority (44.8%) of our patients. DLQI questions pertaining to symptoms and feelings and daily activity had the highest impact on patients. The DLQI score was significantly affected by the number of sites involved (P < 0.001), body surface area (P < 0.001) and the severity of symptoms (P = 0.007).

CONCLUSION

Dermatophytosis was found to have a significant impact on the QoL of affected patients. The DLQI score was influenced by the severity of the disease. This study also underscores the feasibility of DLQI score based QoL assessment in dermatophytosis.

Treatment, prevention and public health management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: a systematic review

We conducted a systematic review of the treatment, prevention and public health control of skin infections including impetigo, scabies, crusted scabies and tinea in resource‐limited settings where skin infections are endemic. The aim is to inform strategies, guidelines and research to improve skin health in populations that are inequitably affected by infections of the skin and the downstream consequences of these. The systematic review is reported according to the PRISMA statement. From 1759 titles identified, 81 full text studies were reviewed and key findings outlined for impetigo, scabies, crusted scabies and tinea. Improvements in primary care and public health management of skin infections will have broad and lasting impacts on overall quality of life including reductions in morbidity and mortality from sepsis, skeletal infections, kidney and heart disease.

Therapy of Skin, Hair and Nail Fungal Infections

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.

Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India)

Background

Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. Current treatment recommendations appear to lose their relevance in the current clinical scenario. The objective of the current consensus was to provide an experience-driven approach regarding the diagnosis and management of tinea corporis, cruris and pedis.

Methods

Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi process consisting of two workshops and five rounds of questionnaires, elaborating definitions, diagnosis and management. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. More than 75% of concordance in response was set to reach the consensus.

Result

KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was recommended for naïve and recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine and itraconazole should be the preferred systemic drugs. Minimum duration of treatment should be 2–4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea management was strongly discouraged.

Conclusion

This consensus guideline will help to standardise care, provide guidance on the management, and assist in clinical decision-making for healthcare professionals.

Efficacy and tolerability of topical sertaconazole versus topical terbinafine in localized dermatophytosis: A randomized, observer-blind, parallel group study

OBJECTIVE

Epidermal dermatophyte infections most commonly manifest as tinea corporis or tinea cruris. Topical azole antifungals are commonly used in their treatment but literature suggests that most require twice-daily application and provide lower cure rates than the allylamine antifungal terbinafine. We conducted a head-to-head comparison of the effectiveness of the once-daily topical azole, sertaconazole, with terbinafine in these infections.

MATERIALS AND METHODS

We conducted a randomized, observer-blind, parallel group study (Clinical Trial Registry India [CTRI]/2014/09/005029) with adult patients of either sex presenting with localized lesions. The clinical diagnosis was confirmed by potassium hydroxide smear microscopy of skin scrapings. After baseline assessment of erythema, scaling, and pruritus, patients applied either of the two study drugs once daily for 2 weeks. If clinical cure was not seen at 2 weeks, but improvement was noted, application was continued for further 2 weeks. Patients deemed to be clinical failure at 2 weeks were switched to oral antifungals.

RESULTS

Overall 88 patients on sertaconazole and 91 on terbinafine were analyzed. At 2 weeks, the clinical cure rates were comparable at 77.27% (95% confidence interval [CI]: 68.52%-86.03%) for sertaconazole and 73.63% (95% CI 64.57%-82.68%) for terbinafine (P = 0.606). Fourteen patients in either group improved and on further treatment showed complete healing by another 2 weeks. The final cure rate at 4 weeks was also comparable at 93.18% (95% CI 88.75%-97.62%) and 89.01% (95% CI 82.59%-95.44%), respectively (P = 0.914). At 2 weeks, 6 (6.82%) sertaconazole and 10 (10.99%) terbinafine recipients were considered as "clinical failure." Tolerability of both preparations was excellent.

CONCLUSION

Despite the limitations of an observer-blind study without microbiological support, the results suggest that once-daily topical sertaconazole is as effective as terbinafine in localized tinea infections.

New Antifungal Agents and New Formulations Against Dermatophytes

A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353-67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.

A critical appraisal of once-daily topical luliconazole for the treatment of superficial fungal infections

Luliconazole is a novel imidazole derivative, which has demonstrated in vitro efficacy against dermatophytes and Candida. The results from Phase III trials show that luliconazole 1% cream applied once daily for 2 weeks successfully resolved the clinical signs and symptoms as well as eradicated the pathologic fungi, which cause tinea pedis. A 1-week treatment with luliconazole 1% cream also produced favorable clinical and mycological results in clinical trials for tinea corporis and tinea cruris. Across trials, adverse events consisted mainly of localized reactions following application. The development of a new antifungal agent is timely due to mounting resistance among existing treatments. Because luliconazole requires a short duration of treatment, it may assist in reducing disease recurrence as a result of patient nonadherence.

Topical forms of sertaconazole in the treatment of fungal infections of the skin

The data of foreign and domestic clinical studies on the efficacy and safety of sertaconazole (SK)is discussed. Broad spectrum of activity of SK and lack of resistance to the drug is established. Several studies opens new opportunities for the SK for the treatment of dermatosis, in the pathogenesis of which play an important role of opportunistic infection. High efficiency and compliance, a significantly greater safety index than that of the other members of the azole group, suggest the SK as a formulation that extends the capabilities of the outer antimycotic therapy of fungal infections of the skin.

Luliconazole for the treatment of fungal infections: an evidence-based review

Luliconazole is an imidazole antifungal agent with a unique structure, as the imidazole moiety is incorporated into the ketene dithioacetate structure. Luliconazole is the R-enantiomer, and has more potent antifungal activity than lanoconazole, which is a racemic mixture. In this review, we summarize the in vitro data, animal studies, and clinical trial data relating to the use of topical luliconazole. Preclinical studies have demonstrated excellent activity against dermatophytes. Further, in vitro/in vivo studies have also shown favorable activity against Candida albicans, Malassezia spp., and Aspergillus fumigatus. Luliconazole, although belonging to the azole group, has strong fungicidal activity against Trichophyton spp., similar to that of terbinafine. The strong clinical antifungal activity of luliconazole is possibly attributable to a combination of strong in vitro antifungal activity and favorable pharmacokinetic properties in the skin. Clinical trials have demonstrated its superiority over placebo in dermatophytosis, and its antifungal activity to be at par or even better than that of terbinafine. Application of luliconazole 1% cream once daily is effective even in short-term use (one week for tinea corporis/cruris and 2 weeks for tinea pedis). A Phase I/IIa study has shown excellent local tolerability and a lack of systemic side effects with use of topical luliconazole solution for onychomycosis. Further studies to evaluate its efficacy in onychomycosis are underway. Luliconazole 1% cream was approved in Japan in 2005 for the treatment of tinea infections. It has recently been approved by US Food and Drug Administration for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis. Topical luliconazole has a favorable safety profile, with only mild application site reactions reported occasionally.

Topical antifungal treatments for tinea cruris and tinea corporis

BACKGROUND

Tinea infections are fungal infections of the skin caused by dermatophytes. It is estimated that 10% to 20% of the world population is affected by fungal skin infections. Sites of infection vary according to geographical location, the organism involved, and environmental and cultural differences. Both tinea corporis, also referred to as 'ringworm' and tinea cruris or 'jock itch' are conditions frequently seen by primary care doctors and dermatologists. The diagnosis can be made on clinical appearance and can be confirmed by microscopy or culture. A wide range of topical antifungal drugs are used to treat these superficial dermatomycoses, but it is unclear which are the most effective.

OBJECTIVES

To assess the effects of topical antifungal treatments in tinea cruris and tinea corporis.

SEARCH METHODS

We searched the following databases up to 13th August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials. We handsearched the journal Mycoses from 1957 to 1990.

SELECTION CRITERIA

Randomised controlled trials in people with proven dermatophyte infection of the body (tinea corporis) or groin (tinea cruris).

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out study selection, data extraction, assessment of risk of bias, and analyses.

MAIN RESULTS

Of the 364 records identified, 129 studies with 18,086 participants met the inclusion criteria. Half of the studies were judged at high risk of bias with the remainder judged at unclear risk. A wide range of different comparisons were evaluated across the 129 studies, 92 in total, with azoles accounting for the majority of the interventions. Treatment duration varied from one week to two months, but in most studies this was two to four weeks. The length of follow-up varied from one week to six months. Sixty-three studies contained no usable or retrievable data mainly due to the lack of separate data for different tinea infections. Mycological and clinical cure were assessed in the majority of studies, along with adverse effects. Less than half of the studies assessed disease relapse, and hardly any of them assessed duration until clinical cure, or participant-judged cure. The quality of the body of evidence was rated as low to very low for the different outcomes.Data for several outcomes for two individual treatments were pooled. Across five studies, significantly higher clinical cure rates were seen in participants treated with terbinafine compared to placebo (risk ratio (RR) 4.51, 95% confidence interval (CI) 3.10 to 6.56, number needed to treat (NNT) 3, 95% CI 2 to 4). The quality of evidence for this outcome was rated as low. Data for mycological cure for terbinafine could not be pooled due to substantial heterogeneity.Mycological cure rates favoured naftifine 1% compared to placebo across three studies (RR 2.38, 95% CI 1.80 to 3.14, NNT 3, 95% CI 2 to 4) with the quality of evidence rated as low. In one study, naftifine 1% was more effective than placebo in achieving clinical cure (RR 2.42, 95% CI 1.41 to 4.16, NNT 3, 95% CI 2 to 5) with the quality of evidence rated as low.Across two studies, mycological cure rates favoured clotrimazole 1% compared to placebo (RR 2.87, 95% CI 2.28 to 3.62, NNT 2, 95% CI 2 to 3).Data for several outcomes were pooled for three comparisons between different classes of treatment. There was no difference in mycological cure between azoles and benzylamines (RR 1.01, 95% CI 0.94 to 1.07). The quality of the evidence was rated as low for this comparison. Substantial heterogeneity precluded the pooling of data for mycological and clinical cure when comparing azoles and allylamines. Azoles were slightly less effective in achieving clinical cure compared to azole and steroid combination creams immediately at the end of treatment (RR 0.67, 95% CI 0.53 to 0.84, NNT 6, 95% CI 5 to 13), but there was no difference in mycological cure rate (RR 0.99, 95% CI 0.93 to 1.05). The quality of evidence for these two outcomes was rated as low for mycological cure and very low for clinical cure.All of the treatments that were examined appeared to be effective, but most comparisons were evaluated in single studies. There was no evidence for a difference in cure rates between tinea cruris and tinea corporis. Adverse effects were minimal - mainly irritation and burning; results were generally imprecise between active interventions and placebo, and between different classes of treatment.

AUTHORS' CONCLUSIONS

The pooled data suggest that the individual treatments terbinafine and naftifine are effective. Adverse effects were generally mild and reported infrequently. A substantial number of the studies were more than 20 years old and of unclear or high risk of bias; there is however, some evidence that other topical antifungal treatments also provide similar clinical and mycological cure rates, particularly azoles although most were evaluated in single studies.There is insufficient evidence to determine if Whitfield's ointment, a widely used agent is effective.Although combinations of topical steroids and antifungals are not currently recommended in any clinical guidelines, relevant studies included in this review reported higher clinical cure rates with similar mycological cure rates at the end of treatment, but the quality of evidence for these outcomes was rated very low due to imprecision, indirectness and risk of bias. There was insufficient evidence to confidently assess relapse rates in the individual or combination treatments.Although there was little difference between different classes of treatment in achieving cure, some interventions may be more appealing as they require fewer applications and a shorter duration of treatment. Further, high quality, adequately powered trials focusing on patient-centred outcomes, such as patient satisfaction with treatment should be considered.

Luliconazole demonstrates potent in vitro activity against dermatophytes recovered from patients with onychomycosis

The in vitro activities of luliconazole, amorolfine, ciclopirox, and terbinafine were determined against 320 dermatophyte isolates from large toenails of onychomycosis patients enrolled into an ongoing phase 2b/3 clinical study. The geometric mean MIC for luliconazole was 0.00022 μg/ml against all isolates, compared to 0.0194 to 0.3107 μg/ml for the three other agents. The in vitro potency of luliconazole was maintained regardless of the dermatophyte species.

Luliconazole: a review of a new antifungal agent for the topical treatment of onychomycosis

Luliconazole is a novel, broad-spectrum, imidazole antifungal under development in the USA as a treatment for dermatophytic skin and nail infections. In vitro, luliconazole is one of the most potent antifungal agents against filamentous fungi including dermatophytes. Luliconazole has been formulated in a 10% solution with unique molecular properties, which allow it to penetrate the nail plate and rapidly achieve fungicidal levels in the nail unit. These properties make luliconazole a potent compound in the treatment of onychomycosis. This article reviews the development of luliconazole solution, 10% its molecular properties, preclinical and clinical data and its future perspectives for the treatment of fungal infections.