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Topical and Oral Combination Therapy for Toenail Onychomycosis
An Updated Review
Although effective, oral antifungal therapy is still not completely successful. Recent studies have shown that combination therapy with oral and topical agents offers an increased cure rate for patients. We review the main drug combinations that have been tested. Additional measures, such as mechanical intervention, may help improve response rates further. (J Am Podiatr Med Assoc 96(2): 116–119, 2006)
Toenail onychomycosis is a common condition that is equally challenging for podiatrists and patients. This case study documents a 26-year-old woman with bilateral total dystrophic onychomycosis of at least 5 years’ duration. She had previously failed to respond to treatment with ciclopirox nail lacquer 8% and, despite hiding her condition with nail polish, was suffering from embarrassment, distress, and low self-esteem. At initial consultation, 100% of both great toenails was affected. After discussion of all treatment options, the patient opted for topical efinaconazole 10% solution, once daily for 48 weeks. Significant improvement was noted at the first (4-week) assessment period. This improvement was maintained through each subsequent virtual consultation, and complete cure was seen at a 30-week follow-up visit. To the author’s knowledge, this is the first published report on the use of efinaconazole in total dystrophic onychomycosis. It suggests that the product may be effective in patients with even the most severe and treatment-recalcitrant disease, who are unwilling or unable to tolerate systemic antifungal therapy.
Background:
Onychomycosis is one of the most common diseases of the toenails. The costs of diagnosis and treatment are substantial, and as the population ages, the overall cost burden will continue to escalate. The purpose of this study was to correlate dermoscopic features with pathologic diagnosis to support the accuracy of point-of-care diagnosis by dermoscopic examination.
Methods:
Nail unit pathology reports of 52 patients with abnormal great toenails were compared with the dermoscopic features detected by nail unit dermoscopy.
Results:
The dermoscopic analysis predicted the laboratory diagnosis in 90.4% of the study patients. The specific dermoscopic findings of short spikes (P < .001), long striae (P < .001), aurora borealis (P < .001), irregular termination (P = .003), dermatophytoma (P = .011), transverse onycholysis (P = .018), and dry scale (P = .04) patterns were all significantly associated with pathology test results consistent with oncyhomycosis. Transverse onycholysis (P = .018) was significantly associated with negative pathology results consistent with the diagnosis of nail dystrophy.
Conclusions:
Point-of-care examination by dermoscopy positively correlates with histopathologic tests and could be used to diagnose onychomycosis while reducing diagnostic costs.
Background: Complementary and alternative medicine (CAM) is one of the fastest growing areas of health care. This has necessitated an increased awareness and understanding of CAM by conventional health professionals.
Methods: A questionnaire seeking information about use of and attitudes toward CAM was mailed to 1,365 Australian podiatric physicians.
Results: Ninety-one percent of Australian podiatric physicians surveyed have used at least one CAM therapy in the past 12 months, and 93% have treated patients with CAM or have recommended its use to patients. Overall, the respondents rated their knowledge of various CAM therapies as “average,” and responses on the CAM Health Belief Questionnaire indicated that respondents tended not to endorse CAM health beliefs, with statements about CAM therapies being seen as “a threat to public safety” and effects being “usually due to the placebo effect” producing the strongest responses.
Conclusions: Complementary and alternative medicine therapies are already being used in podiatric medical practice, and there are significant opportunities for further research into CAM education and clinical research relevant to podiatric medicine. (J Am Podiatr Med Assoc 99(2): 121–128, 2009)
Treatment of Toenail Onychomycosis with Oral Terbinafine Plus Aggressive Debridement
IRON-CLAD, a Large, Randomized, Open-Label, Multicenter Trial
This study was conducted to investigate the efficacy of oral terbinafine with and without aggressive debridement for the treatment of toenail onychomycosis. Onychomycosis patients aged 18 to 75 years received 12 weeks of terbinafine, 250 mg/day, alone (n = 255) or with aggressive debridement (n = 249). Both groups showed marked improvement from baseline at all time points. At week 48, complete, mycologic, and clinical cure rates were higher in the terbinafine plus debridement group compared with the terbinafine alone group, although significance was reached only for clinical cure (59.8% versus 51.4%; P = .023). Although approximately 39% of the patients received at least one antidiabetic, antihypertensive, or cholesterol-lowering agent concomitantly, including statins, the incidence of treatment-emergent adverse events was low and the adverse events were generally mild to moderate in severity. No clinically significant changes in liver transaminase levels were observed 6 weeks after treatment or after 12 weeks in those tested. These results support the well-established safety and efficacy of terbinafine for treatment of onychomycosis. (J Am Podiatr Med Assoc 96(6): 465–473, 2006)
Nodular Amyloidosis
Clinical Recognition of an Unusual Entity
Nodular amyloidosis is a protein deposition disorder that is important to recognize in the clinical setting. Identification and differentiation from primary systemic amyloidosis, which has an identical cutaneous presentation, but serious systemic implications, is of particular significance. Our case report highlights two patients who presented with isolated involvement of the plantar surface and ungual phalanges, each with concomitant tinea pedis. Recognition and diagnosis of cutaneous amyloidosis enables discrimination from systemic disease, and if found, prompt institution of appropriate treatment.
Onychomycosis is an extremely common condition that is increasing in prevalence. Although often innocuous, it may be complicated by discomfort and secondary bacterial infections. Recently introduced oral medications may be highly effective in the eradication of this condition; however, they may carry with them significant expense and potentially serious side effects. Prior to the initiation of antifungal oral therapy, definitive diagnosis is mandatory. This study compares the sensitivity of potassium hydroxide (KOH) preparations, surgical pathology diagnostic testing (SPDT), and culture techniques for the detection of onychomycosis in 50 cases of clinically suspected onychomycosis. Analysis showed that SPDT was significantly more sensitive when compared to KOH and culture. The results suggest that SPDT may be the true gold standard for the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 91(7): 351-355, 2001)
Ciclopirox 8% Nail Lacquer Topical Solution for the Treatment of Onychomycosis in Patients with Diabetes
A Multicenter, Open-Label Study
Background: An open-label, noncomparative study was conducted to assess the safety and efficacy of ciclopirox 8% nail lacquer topical solution in patients with type 2 diabetes mellitus.
Methods: Forty-nine diabetic patients with distal subungual onychomycosis were treated once daily for 48 weeks with ciclopirox 8% nail lacquer, a topical nail solution approved for the treatment of patients with mild-to-moderate onychomycosis.
Results: Treatment resulted in clinical improvement in 63.4% of patients. Most patients (85.7%) had a mycologic outcome of improvement or cure, with 54.3% attaining mycologic cure. Consideration of mycologic and clinical outcomes generated a treatment outcome of improvement, success, or cure in 84.4% of patients. Moreover, patients experienced improvement in the diseased area of the nail (63.4%), nail surface (56.1%), nail color (48.8%), and nail thickness (65.9%). Ciclopirox 8% nail lacquer was safe, with treatment-related adverse events limited to infection in one patient, which resolved in 15 days; the patient completed the study. No treatment-related serious adverse events were observed.
Conclusion: Ciclopirox 8% nail lacquer is a safe and effective treatment for distal subungual onychomycosis in patients with type 2 diabetes mellitus receiving insulin or oral hypoglycemic therapy. (J Am Podiatr Med Assoc 97(3): 195–202, 2007)
Fungal Lung
The Risk of Fungal Exposure to Nail Care Professionals
Foot and nail care specialists spend a great portion of their day using nail drills to reduce nail thickness and smooth foot calluses. This process generates a large amount of dust, some of which is small enough to breathe in and deposit into the deepest regions of the respiratory tract, potentially causing health problems. Foot and nail dust often contains fungi, from both fungus-infected and healthy-appearing nails. Although the majority of healthy individuals can tolerate inhaled fungi, the immune systems of older, immunocompromised, and allergy-prone individuals often react using the inflammatory T helper cell type 2 pathway, leading to mucus overproduction, bronchoconstriction, and, in severe cases, lung tissue damage. To protect vulnerable podiatry professionals, wearing a surgical mask, using a water spray suppression system on nail drills, installing air filtration systems, and considering drilling technique can help reduce exposure to nail dust.
Onychomycosis is a very common disease, especially in podiatric medical practice. It can be associated with significant patient distress, major disability and pain, and is challenging to treat successfully. This is a case study of a 41-year-old man with distal lateral subungual onychomycosis of 5 years' duration. Forty percent of the great toenail was affected and a total of six toenails were involved. Baseline fungal cultures were positive for Trichophyton rubrum. This patient was treated with efinaconazole 10% solution, a new topical antifungal, once daily for 48 weeks. Mycological cure was noted at the first assessment period (12 weeks), and compete cure was seen at follow-up. This case study alerts physicians to a promising new topical treatment for onychomycosis under development, and to the importance of mycological cure as an early indicator of treatment success.
