Effectiveness and safety of topical amphotericin B in 30% dimethyl sulfoxide cream versus 30% dimethyl sulfoxide cream for nondermatophyte onychomycosis treatment: A pilot study

Background: Although topical amphotericin B cream is effective for the treatment of nondermatophyte mold onychomycosis in vitro, studies of its effectiveness and safety in vivo are limited. Objectives: We studied the effectiveness and safety of topical 0.3% amphotericin B in 30% dimethyl sulfoxide cream (amphotericin B cream) in nondermatophyte mold onychomycosis using the vehicle cream 30% dimethyl sulfoxide cream as control. Methods: This randomized controlled study was conducted between January 2019 and November 2020. Patients diagnosed with nondermatophyte mold onychomycosis were randomly divided into two groups of ten patients each: one treated with amphotericin B cream and the other with the vehicle cream. Clinical and mycological cure as well as safety were evaluated. Results: Ten patients each treated with amphotericin B cream and the vehicle cream were included in the study, but only nine patients in the vehicle cream group were available for follow up. All the 19 evaluable patients had distal lateral subungual onychomycosis and the great toenails were affected in 18 (94.7%) of these. Mycological cure was achieved in 8 (80%) patients treated with amphotericin B cream and in 4 (44.4%) patients using the control (vehicle) cream. Clinical cure was achieved in 7 (70%) patients treated with amphotericin B cream, but only in 2 (22.2%) patients on the control cream. No adverse events were observed. Limitations: The small sample size and the fact that PCR fungal identification that provides accurate identification of fungal species was not performed are limitations of our study. Conclusion: Topical amphotericin B cream was both very effective and safe in the treatment nondermatophyte mold onychomycosis. The control (vehicle) cream containing 30% dimethyl sulfoxide also demonstrated some antifungal activity.

Comparative Efficacy of Antifungal Agents Used in the Treatment of Oropharyngeal Candidiasis among HIV-Infected Adults: A Systematic Review and Network Meta-Analysis

The objective of this study was to assess the comparative efficacy and safety of different antifungal agents used for the treatment of oropharyngeal candidiasis (OPC) in adult patients with HIV. A systematic search was performed on the four major databases (Medline, Embase, CENTRAL and Scopus) to identify randomized controlled trials (RCTs) that evaluated the efficacy of antifungal agents in HIV patients with OPC. A network meta-analysis was performed from the data extracted from the selected studies. The agents were ranked according using surface under the cumulative ranking (SUCRA). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of evidence. A total of 15 trials were included in the quantitative analysis involving the data from a total of 2883 participants. Fluconazole was ranked as the most effective antifungal agent to achieve clinical cure (SUCRA = 0.87) in OPC followed by posaconazole and itraconazole. Posaconazole was ranked the most efficacious agent in achieving mycological cure (SUCRA = 0.81), followed by fluconazole. While nystatin was ranked the safest, the effect estimates of none of the other systemic antifungal agents were significantly higher than fluconazole. Based on the available evidence, fluconazole can be considered as the most effective drug in the treatment of OPC among HIV-infected adults and has a favorable safety profile, followed by posaconazole.

COMPARATIVE STUDY OF EFFICACY OF ORAL TERBINAFINE ALONE AND ORAL TERBINAFINE WITH TOPICAL 8% CICLOPIROX OLAMINE IN ONYCHOMYCOSIS

Onychomycosis is a common fungal infection of nail plate caused by dermatophytes, non dermatophyte molds & yeasts. Tinea unguium on the other hand refers specifically to infection caused by dermatophytes. Onychomycosis represents 50% of all nail disorders and 30% of all mycotic infections of skin.1 It is distributed worldwide with prevalence of 3% to 9%. It is generally considered as a disease of middle aged and elderly affecting a large and significant number of people. There has been a recent increase in the incidence as well as a spectrum of causative pathogens associated with onychomycosis. 50 patients of onychomycosis who attended our outpatient department were randomly selected. These 50 patients were equally divided into two groups A and B. Patients in group A (25) were given only oral terbinafine 250mg/once daily for 12 weeks. Patients in group B (25) were given oral terbinafine 250mg/once daily for 12 weeks along with 8% Ciclopirox Olamine nail lacquer which is applied topically once daily at night. In our present study combination therapy give high mycological cure rates than oral terbinafine monotherapy. Combination therapy (oral terbinafine 250mg daily dose with 8% ciclopirox olamine nail lacquer) showed 70 % clinical cure rate and 60 % mycological cure.

The Success of Topical Treatment of Onychomycosis Seems to Be Influenced by Fungal Features

Aim. To evaluate the topical treatment of onychomycosis using a 10% hydroalcoholic propolis extract (PE) in two aleatorily chosen patients and analyze possible risk factors from hosts including some particularities of the isolated fungi that may justify the outcomes achieved. Materials and Methods. A topical treatment, with PE, was started in two cases of toe onychomycosis due to T. rubrum. The in vitro PE antifungal activity against these isolates was confirmed. Moreover, the ability of the fungi to infect the human nail was evaluated also in an ex vivo study, analyzed by histopathology. Results. Within four months, both patients showed evident improvement, but with different outcomes. The possible host-related risk factors justifying the poorer outcome in patient 1 include a longer duration time of onychomycosis (50 years). Some particularities in the T. rubrum strain isolated from this patient in relation to that found in patient 2 were observed: (1) the hypha morphology suggesting a major adaptation of the fungus to the host; (2) a 16 times greater propolis concentration was required in vitro; and (3) a faster ability to start a growth using the nail as the only nutritional source. Additionally, this isolate was more efficient in producing a biofilm on the nail surface. Conclusions. A partial clinical and complete mycological cure for the two patients was achieved after four months of PE daily use. Despite a complete recovery, a different outcome was observed between both cases. A more persistent onychomycosis, added to greater fungal potential to produce biofilm on the nail, seems to influence greatly the success of a topical treatment with PE.

Efficacy of lasers for the management of dermatophyte toenail onychomycosis

Background: Onychomycosis is a chronic fungal nail infection caused predominantly by dermatophytes, and less commonly by non-dermatophyte molds (NDMs) and Candida species. Onychomycosis treatment includes oral and topical antifungals, the efficacy of which is evaluated through randomized, double-blinded, controlled trials (RCTs) for USA FDA approval. The primary efficacy measure is complete cure (complete mycological and clinical cure). The secondary measures are clinical cure (usually {less than or equal to}10 % involvement of target nail) and mycological cure (negative microscopy and culture). Some lasers are FDA-approved for the mild temporary increase in clear nail; however, some practitioners attempt to use lasers to treat and cure onychomycosis. Methods: A systematic review of the literature was performed in July 2020 to evaluate the efficacy rates demonstrated by RCTs of laser monotherapy for dermatophyte onychomycosis of the great toenail. Results: RCTs assessing the efficacy of laser monotherapy for dermatophyte toenail onychomycosis are limited. Many studies measured cure rates via nails instead of patients, and performed only microscopy or culture, not both. Only one included study reported mycological cure rate in patients as negative light microscopy and culture (0%). The combined clinical cure rates in short- and long-pulsed laser studies were (13.0-16.7% and 25.9%, respectively). There was no study that reported the complete cure rate, however, one did report treatment success (mycological cure (negative microscopy and culture) and {less than or equal to}10% clinical involvement) in nails as 16.7%. Conclusions: The effectiveness of lasers as a therapeutic intervention for dermatophyte toenail onychomycosis is limited based on complete, mycological, and clinical cure rates. However, it may be possible to use different treatment parameters or lasers with a different wavelength to increase the efficacy. Lasers could be a potential management option for older patients and onychomycosis patients with coexisting conditions such as diabetes, liver and/or kidney diseases for whom systemic antifungal agents are contraindicated or have failed.

A Randomized Open Labeled Parallel Group Study to Compare the Efficacy and Safety of Topical Terbinafine and Miconazole in Patients with Tinea Corporis

Topical preparations of allylamines and imidazoles are the commonly used medications for the treatment of tinea corporis, having extended efficacy and good safety profile. In our study, we have compared topical terbinafine, an allylamine and topical miconazole, which is an imidazole to assess their efficacy and safety in tinea corporis infection. Hundred patients with tinea corporis infection were equally randomized to receive either terbinafine (1%) or miconazole (2%) for 4 weeks. The reduction in clinical symptoms (pruritus, erythema, vesicle, and desquamation), attaining mycological cure, reduction in composite score, as well as physician global assessment were evaluated from baseline to the end of intervention, and at follow up visit, and compared between the groups. Incidence of adverse drug reactions was also noted for safety analysis. Baseline demographic characteristics of terbinafine and miconazole groups were similar. The study demonstrated statistical significance reduction in clinical symptom scores, attaining Mycological cure, composite score and Physician Global Assessment from baseline to 4th week and follow up week between both groups with a p value <0.05. Compared to terbinafine group, patients received miconazole as intervention had significant successful outcome at the end of treatment (4 weeks) and during the follow-up visit at 5 weeks. Topical miconazole is found to be better and an ideal drug in patients with tinea corporis for the improvement in clinical cure and successful treatment outcome compared to topical terbinafine. Both the drugs are well tolerated drug with the incidence of side effects like itching, irritation, dryness which are comparatively lesser in miconazole group.

Comparative Evaluation of Ketoconazole 400 mg Single Dose Versus Ketoconazole 200 mg Daily for Five Days in Pityriasis Versicolor

Introduction: Many treatments have been attempted in pityriasis versicolor with different reports of success. No direct comparative study between Ketoconazole 400 mg single dose against Ketoconazole 200 mg od for 5 days have been made earlier. The aim of this study was to study and compare the therapeutic efficacy of oral ketoconazole 400 mg single dose with oral ketoconazole 200 mg once daily for 5 days in pityriasis versicolor. Methods: This was a randomized controlled trial. Patients were randomized to receive either ketoconazole 400 mg single dose (group A) or ketoconazole 200 mg daily for 5 days (group B). Altogether 80 patients were taken, 40 in each group. Patients were assessed after 8 weeks and both clinical and mycological evaluation was done. The treatment success (mycological cure) was defined by a negative KOH at 8 weeks post treatment. Chi-square test was used to identify the significance of the variables. Results: The mycological cure at 8 weeks was 46% in group A and 74% in group B and the result was significant. No significant adverse event was noted in any of the groups. Conclusions: There was significant difference in the treatment outcome in both the groups. Ketoconazole 200 mg daily for 5 days had superior efficacy than ketoconazole 400 mg single dose. There was no significant difference in the adverse events. Key words: Ketoconazole, Pityriasis versicolor

Tinea gladiatorum due to Trichophyton tonsurans in a school wrestling team in Mexico: A case series

Background and Purpose: Tinea gladiatorum is a type of dermatophytosis that occurs in combat athletes, such as wrestlers and judo fighters, as a result of Trichophyton species. Herein, we aimed to present a small outbreak of tinea gladiatorum in a high school in Mexico. Materials and Methods: Seven individuals belonging to the school fighting team were mycologically studied with direct examinations and cultures. In four cases, T. tonsurans was isolated and identified by morphological and proteomic methods (Matrix-assisted laser desorption/ionization- time-of-flight mass spectrometry). Out of the four subjects, two cases had clinical lesions presented as tinea corporis, and two cases were healthy carriers. Trichophyton tonsurans was also isolated from one of the four training mats (25%). All positive patients were treated with systemic or topical antifungals and achieved clinical and mycological cure. Conclusion: We report the first outbreak of tinea gladiatorum caused by T. tonsurans among a group of high school wrestlers in Mexico.

Inactivation of Dermatophytes Causing Onychomycosis and Its Therapy Using Non-Thermal Plasma

Onychomycosis is one of the most common nail disorders. Its current treatment is not satisfactorily effective and often causes adverse side effects. This study aims to determine the optimal conditions for non-thermal plasma (NTP) inactivation of the most common dermatophytes in vitro and to apply it in patient`s therapy. The in vitro exposure to NTP produced by negative DC corona discharge caused full inactivation of Trichophyton spp. if applied during the early growth phases. This effect decreased to negligible inactivation with the exposure applied six days after inoculation. In a group of 40 patients with onychomycosis, NTP therapy was combined with nail plate abrasion and refreshment (NPAR) or treatment with antimycotics. The cohort included 17 patients treated with NPAR combined with NTP, 11 patients treated with antimycotics and NTP, and 12 patients treated with NPAR alone. The combination of NPAR and NTP resulted in clinical cure in more than 70% of patients. The synergistic effect of NPAR and NTP caused 85.7% improvement of mycological cure confirmed by negative microscopy and culture of the affected nail plate. We conclude that NTP can significantly improve the treatment of onychomycosis.

Evaluation of mycological cure of Unani medicine vs modern medicine: A comparative clinical trial

Introduction: Qooba (Dermatophytosis) is a clinical condition caused by fungal infection of skin in humans and other vertebras. The fungi that cause dermatophytosis feed on keratin, the material found in the outer layer of skin, hair and nails. Aims & objective: The purpose of this study was to evaluate mycological cure of Unani medicine in comparison with Modern medicine. Methods: The study was conducted on 60 cases of qooba (dermatophytosis). Patients were randomly allocated to test (A) and control (B) groups. Group A patients were given Unani medicines ‘zimad daad’ and 'naqooh shahtara’ while, group B patients were treated with allopathic medicines. The duration of treatment was fixed as 30 days. Results & Discussion: All the patients were kept under strict observation and assessment for mycological cure rate was done weekly. At the end of the study clinical and statistical results demonstrate the efficacy of naqooh shahtara and zimad daad in the mycological cure of fungal infections. The effect of drug on mycological cure of disease was found to be extremely significant. Conclusion: The combination can also serve as mycological cure for fungal infections without any apparent side effects.