Ciclopirox 8% nail lacquer topical solution for the treatment of onychomycosis in patients with diabetes: a multicenter, open-label study

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

Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.

New Formulation-Microporation Combination Approaches to Delivering Ciclopirox across Human Nails

Topical treatments for onychomycosis are of interest to those seeking to avoid systemic drug interactions and to improve systemic safety. This work aimed to develop aqueous-based, simple, and cost-effective vehicles that provide high solubility for ciclopirox and enable the delivery of an active through channels created by nail microporation. Following solubility tests, aqueous gels and thermogels based on hydroxypropylmethylcellulose and poloxamer 407, respectively, were loaded with 8% and 16% ciclopirox. Their performance was then compared to the marketed lacquer Micolamina® in in vitro release tests with artificial membranes and in in vitro permeation tests with human nail clippings with and without poration. Finally, a microbiological assay compared the best gel formulations and the reference product. Little correlation was observed between the in vitro release and the permeation data, and the drug release was highly membrane-dependent. Ciclopirox nail retention in single-dose, porated nails tests was larger than in daily-dosing, non-porated nail conditions. The series of new gel and thermogel vehicles delivered ciclopirox more effectively than Micolamina® in single-dose, porated nail experiments. The inhibition of Trichophyton rubrum activity was significantly increased with microporated nails when the gel formulations were applied but not with Micolamina®. Overall, the results suggest that the new vehicles could be successfully combined with nail microporation to improve the drug delivery and efficacy of topical antifungal medication while reducing the dosing frequency, facilitating patients' adherence.

Onychomycosis associated with diabetic foot syndrome: A systematic review

BACKGROUND

A systematic review was conducted to investigate the prevalence of onychomycosis in patients with diabetes. The association of onychomycosis with risk factors in patients with diabetic foot syndrome was also examined.

METHODS

The recommendations in the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist were applied, and the included studies were assessed using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) method. Searches were conducted in October 2022 using PubMed (Medline) and Scopus for clinical studies, clinical trials, comparative studies, observational studies, and randomised clinical trials or controlled clinical trials addressing the prevalence and consequences of onychomycosis in patients with diabetes, diagnoses or treatments. Two authors performed the study selection and data extraction, and any discrepancies between the two reviewers were resolved through discussion with a third reviewer.

RESULTS

The systematic review included ten studies that met the inclusion criteria, and these studies enrolled 5664 patients with diabetes. Among these patients, 29.18% had onychomycosis that was mainly caused by Trichophyton rubrum. A significant association was found between the occurrence of onychomycosis and the presence of diabetic neuropathy (p = .012) and elevated glycosylated haemoglobin values (p = .039). There was no significant association between onychomycosis and ulceration (p = .185). Eight studies had a grade 4 level of evidence and a grade C recommendation, and one study had a grade 1b level of evidence and a grade A recommendation.

CONCLUSION

The information described in the literature is insufficient and heterogeneous regarding the association of risk factors and ulceration in patients with diabetic foot compared with developing onychomycosis. There is also a need to implement onychomycosis diagnostic testing instead of relying only on a clinical diagnosis. Additional prospective, randomised, comparative studies are needed to increase the quality of studies in the literature.

Race reporting and representation in onychomycosis clinical trials: A systematic review

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.

Efficacy and Safety of Efinaconazole 10% Solution in the Treatment of Onychomycosis in Diabetic Patients

Onychomycosis is especially common among diabetic patients. The purpose of this study was to investigate the efficacy of 10% efinaconazole solution among diabetic subjects, without restriction by nail plate involvement or glycemic control. Forty subjects were enrolled, with 36 reaching their final 50-week follow-up visit. Mycological cure was attained by 21 subjects (58.33%); 8 subjects (20%) attained either clinical cure (0% clinical involvement) or treatment success (≤10% clinical involvement). Glycemic control did not affect clinical outcome. The medication was well tolerated, with 4 local adverse events and no significant adverse events. The medication may represent a useful option for diabetic patients.

Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients

Background

Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser.

Methods

We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013–December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2–6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy.

Results

Clinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed.

Conclusions

The 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.

An upcoming drug for onychomycosis: Tavaborole

Fungal infection of the nail as well as nail bed is termed as ‘onychomycosis’. It is caused by dermatophytes, non-dermatophytic fungal species and yeasts like Candida albicans. It is traditionally treated by topical antifungals, systemic agents like ketoconazole, griseofulvin, itraconazole, fluconazole, etc. Chemical avulsion or surgical removal of nail can also be tried to treat this disease. In spite of all these treatment options available, podiatrists were always in search of an ideal drug molecule with lesser side effects and which may improve the patient compliance. This exhaustive search led to the discovery of a better antifungal agent, known as “Tavaborole.” A systematic literature search was carried out using databases such as PubMed, Cochrane Reviews, Google Scholar, etc. Detailed information about onychomycosis and tavaborole was gathered. Tavaborole is the first oxaborole antifungal agent approved by FDA in July 2014. It is marketed under the trade name “Kerydin.” It acts by inhibiting protein synthesis in the fungus. It inhibits an enzyme known as cytosolic leucyl-transfer RNA synthetase, or LeuRS, which plays a key role in fungal essential protein synthesis. Dermatitis at the site of topical application, erythema, exfoliation and ingrowing toe nail has been reported in 1% of subjects. Tavaborole may offer a promising role in the treatment of onychomycosis and may compell podiatrists to offer its use in onychomycosis. The present study describes about chemical nature, mechanism of action and two completed phase 3 clinical trial findings of Tavaborole.

The Dermatologist's Approach to Onychomycosis

Onychomycosis is a fungal infection of the toenails or fingernails that can involve any component of the nail unit, including the matrix, bed, and plate. It is a common disorder that may be a reservoir for infection resulting in significant medical problems. Moreover, onychomycosis can have a substantial influence on one's quality of life. An understanding of the disorder and updated management is important for all health care professionals. Aside from reducing quality of life, sequelae of the disease may include pain and disfigurement, possibly leading to more serious physical and occupational limitations. Dermatologists, Podiatrists, and other clinicians who treat onychomycosis are now entering a new era when considering treatment options-topical modalities are proving more effective than those of the past. The once sought after concept of viable, effective, well-tolerated, and still easy-to-use monotherapy alternatives to oral therapy treatments for onychomycosis is now within reach given recent study data. In addition, these therapies may also find a role in combination and maintenance therapy; in order to treat the entire disease the practitioner needs to optimize these topical agents as sustained therapy after initial clearance to reduce recurrence or re-infection given the nature of the disease.

Management of Onychomycosis in Canada in 2014

Background

Onychomycosis has several clinical presentations and is caused by various infectious organisms.

Objective

To provide guidance for selection of appropriate treatment.

Methods

The literature on onychomycosis management was reviewed to generate an evidence-based decision tree.

Results and Conclusion

Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.

Laser treatment of onychomycosis: an in vitro pilot study

BACKGROUND

Laser treatment of onychomycosis is the object of considerable interest. Laser therapy could be a safe and cost-effective treatment modality without the disadvantages of drugs. Some studies have described the inhibitory effects of lasers on the growth of fungal colonies. We therefore examined the effects of various laser wavelengths, which have previously shown inhibitory potential, on the fungal isolate Trichophyton rubrum.

PATIENTS AND METHODS

Isolates of fungal colonies were placed clockwise on culture plates. Each culture plate was irradiated on one half with one of the following treatment regimens: 1064 nm-Q-switched Nd:YAG laser at 4 J/cm(2) and 8 J/cm(2) ; 532 nm-Q-switched Nd:YAG laser at 8 J/cm(2) ; 1064 nm-long-pulsed Nd:YAG laser at 45 J/cm(2) or 100 J/cm(2) . The other half remained untreated. Standardized photographs were taken and areas of treated and untreated colonies were compared for growth inhibition.

RESULTS

There was no inhibition of fungal growth in any of the treated plates. Differences in size between treated and untreated colonies were not significant (p > 0.10).

CONCLUSIONS

In this in vitro study Nd:YAG laser treatment of Trichophyton rubrum colonies failed to inhibit fungal growth. Nevertheless there might be an effectiveness in vivo which has to be clarified by clinical studies.

Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review

BACKGROUND

Effective treatment of tinea pedis and onychomycosis is crucial for patients with diabetes as these infections may lead to foot ulcers and secondary bacterial infections resulting in eventual lower limb amputation. Although numerous studies have assessed the effectiveness of antifungal drug and treatment regimens, most exclude patients with diabetes and examine otherwise healthy individuals. While these studies are useful, results cannot necessarily be extrapolated to patients with diabetes. The purpose of this study was to therefore identify the best evidence-based treatment interventions for tinea pedis or onychomycosis in people with diabetes.

METHODS

The question for this systemic review was: 'what evidence is there for the safety and/or efficacy of all treatment interventions for adults with tinea pedis and/or onychomycosis in people with diabetes'? A systematic literature search of four electronic databases (Scopus, EbscoHost, Ovid, Web of Science) was undertaken (6/1/11). The primary outcome measure for safety was self-reported adverse events likely to be drug-related, while the primary outcome measures assessed for 'efficacy' were mycological, clinical and complete cure.

RESULTS

The systematic review identified six studies that examined the safety and/or efficacy of treatment interventions for onychomycosis in people with diabetes. No studies were identified that examined treatment for tinea pedis. Of the studies identified, two were randomised controlled trials (RCTs) and four were case series. Based on the best available evidence identified, it can be suggested that oral terbinafine is as safe and effective as oral itraconazole therapy for the treatment of onychomycosis in people with diabetes. However, efficacy results were found to be poor.

CONCLUSIONS

This review indicates that there is good evidence (Level II) to suggest oral terbinafine is as safe and effective as itraconazole therapy for the treatment of onychomycosis in people with diabetes. Further research is needed to establish the evidence for other treatment modalities and treatment for tinea pedis for people with diabetes. Future efforts are needed to improve the efficacy of treatment intervention.

Antimycotic ciclopirox olamine in the diabetic environment promotes angiogenesis and enhances wound healing

Diabetic wounds remain a major medical challenge with often disappointing outcomes despite the best available care. An impaired response to tissue hypoxia and insufficient angiogenesis are major factors responsible for poor healing in diabetic wounds. Here we show that the antimycotic drug ciclopirox olamine (CPX) can induce therapeutic angiogenesis in diabetic wounds. Treatment with CPX in vitro led to upregulation of multiple angiogenic genes and increased availability of HIF-1α. Using an excisional wound splinting model in diabetic mice, we showed that serial topical treatment with CPX enhanced wound healing compared to vehicle control treatment, with significantly accelerated wound closure, increased angiogenesis, and increased dermal cellularity. These findings offer a promising new topical pharmacologic therapy for the treatment of diabetic wounds.

Factors associated with presence and severity of toenail onychomycosis in patients with diabetes: a cross-sectional study

OBJECTIVE

To identify the factors associated with toenail onychomycosis in patients with diabetes.

METHODS

In this cross-sectional, observational study, the presence and severity (area of nail involvement and nail thickness) of toenail onychomycosis and related factors were examined. One hundred and thirteen patients with diabetes were surveyed at the Diabetic Foot Outpatient Clinic at the University hospital. Toenails of all patients enrolled in the survey were examined whether onychomycosis was present or absent by mycological examination. The severity of onychomycosis was assessed by clinical evaluation, using the area of nail involvement and the nail thickness.

RESULTS

Fifty eight (51.3%) patients had toenail onychomycosis. The presence of onychomycosis was significantly associated with not washing of feet every day (the unadjusted model, OR: 3.45, 95% CI: 1.24-9.65, P=0.018). The median area of nail involvement was 50.0% (range 5.0-100.0%). A larger area of involvement was significantly related to a lower toe brachial index (β=-67.46, P=0.040). The median nail thickness with onychomycosis was 1.14 mm (range 0.68-9.86 mm). Increasing thickness was significantly correlated with higher hemoglobin A(1)c levels (β=0.98, P=0.003).

CONCLUSIONS

This study suggested that daily washing of feet may reduce the risk of onychomycosis in patients with diabetes. This suggested that education regarding the importance of the washing of feet every day and support for continuous self-care might be effective in the prevention of onychomycosis in patients with diabetes. Furthermore, good control of blood glucose might prevent increasing nail thickness. This study may highlight importance of early nursing educational intervention to improve patients' daily life style for prevention of onychomycosis induced diabetic foot ulcers.

Toenail onychomycosis in diabetic patients: issues and management

Diabetes mellitus may be associated with serious sequelae, such as renal disease, retinopathy, and diabetic foot. A recent large prospective study has shown that onychomycosis is among the most significant predictors of foot ulcer. As the severity of onychomycosis may be associated with the length of time the individual has had the infection, early intervention is advisable owing to the progressive nature of the fungal infection. If left untreated, toenails can become thick, causing pressure and irritation, and thus act as a trigger for more severe complications. In the treatment of onychomycosis, compliance and drug interactions are important considerations, as diabetic patients frequently take concomitant medications. Terbinafine and itraconazole have been investigated for the treatment of onychomycosis in diabetic patients and have been shown to have efficacy and safety profiles comparable to those in the nondiabetic population. Data from clinical trials and postmarketing surveillance suggest that drug interactions resulting in hypoglycemia may not be an important issue when itraconazole and terbinafine are used to treat diabetic patients receiving concomitant hypoglycemic medications. Patient advice and education in improved foot care are an integral part of onychomycosis management, and help achieve long-term cure and reduce the complications of diabetic foot.