New Topical Therapies for Onychomycosis

For more than 15 years the only available topical therapy for onychomycosis was ciclopirox, which offered rather low cure rates. In 2014 two new topical agents were approved: eficonazole (Jublia) and tavaborole (Kerydin).

Ciclopirox

Ciclopirox, available as an 8% nail lacquer, is indicated for treatment of mild to moderate onychomycosis. It is available as an 8% topical solution formulated as a nail lacquer. Ciclopirox is applied daily and then removed with alcohol weekly. Nail trimming is advised along with its use.

Two clinical studies evaluated the efficacy and safety of ciclopirox in more than 450 patients with onychomycosis of the great toenails.  After 48 weeks of application and monthly debridement of free nail, complete cure rates were 5.5% (vs 0.9% with vehicle) and 8.5% (vs 0% with vehicle) in the two studies, respectively. Mycological cure rates (i.e. negative fungal cultures) were 29% with ciclopirox vs 11% with vehicle and 36% with ciclopirox vs 9% with vehicle in the two studies, respectively. The most common adverse effects were application site reactions.

Efinaconazole (Jublia)

Efinaconazole, a triazole, was approved by the FDA in June 2014 for the treatment of onychomycosis of the toenails caused byT rubrum or T mentagrophytes. Efinaconazole is applied topically once daily for 48 weeks. Nail debridement is not required.

Clinical studies evaluated the efficacy of efinaconazole in more than 1600 patients with onychomycosis. Complete cure rates after 52 weeks 18.5% vs 4.7% with vehicle in data combined from two studies. Mycological cure rates at week 52 were  56.3% vs 16.6% with vehicle. Application site dermatitis and vesicles were the most commonly reported adverse events.

Tavaborole (Kerydin)

In July 2014 tavaborole, an oxaborole antifungal, was approved by the FDA for the treatment of onychomycosis of the toenails caused by T rubrum or T mentagrophytes. Tavaborole is applied once daily for 48 weeks. Debridement is not required.

The efficacy of tavaborole was evaluated in two clinical trials in almost 1200 patients. In the two studies, complete cure rates were 6.5% with tavaborole vs 0.5% with vehicle and 9.1% with tavaborole vs 1.5% vehicle, respectively. in the two studies, mycological cure rates were 31.1% with tavaborole vs 7.2% with vehicle and 35.9% with tavaborole vs 12.2% with vehicle, respectively.

Overall, the cure rates with these new vehicles is an advance over prior care. These topical treatments are an option for those unable to take oral antifungal medications, or may be useful adjuncts to oral or laser therapy.

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Tinea Versicolor (Pityriasis Versicolor)

About tinea versicolor

Tinea versicolor is the fungal form of the yeast organism Pityrosporum ovale (the fungal form was previously known as Malssezia furfur until it was demonstrated that it was the hyphal form of Pityrosporum ovale.) It is a common fungal infection of the superficial layers of the stratum corneum. The lesions are round, have a fine scale, and can be white, pink or tan, with white being most frequently observed. They may become confluent. The neck, trunk, and upper arms are most often affected; the face and extremities are usually spared. The condition is usually asymptomatic, but may be associated with mild pruritus (itching). Patients usually seek care for cosmetic concerns. In winter months, the lesions appear darker that the surrounding skin, while in the summer months they typically appear as white spots. The lesions do not tan and therefore become more noticeable following sun exposure. There is also a hyperpigmented variety. Although immunosuppression can be a risk factor, most patients with the condition are otherwise in good health.

Is tinea versicolor contagious?

The yeast form of the organism is a frequent skin colonizer. It is only with conversion to the hyphal form that infection occurs. Conjugal cases are not common. Not everyone exposed to, or colonized by, the organism develops the disease. For unknown reasons, some individuals are susceptible.

With what can tinea versicolor be confused?

The differential diagnosis includes vitiligo and pityriasis alba. If the lesions are tan or pink with scale they may be confused with seborrheic dermatitis.

How is tinea versicolor diagnosed?

A KOH preparation of scraped scale is the mainstay of diagnosis. A “spaghettis and meatball” appearance of short hyphae and spores is characteristic. The organism cannot be cultured using typical fungal culture medium. Under Wood’s light examination the lesions will appear white but not “chalk white”.

How is tinea versicolor treated?

Topical selenium sulfide—found in anti-dandruff shampoos (e.g. Selsun)—is often effective when applied and left on for 10 minutes and then rinsed. When lesions are present, this should be repeated for three days, and then weekly for a month, though other regimens are possible (e.g. two times a week for 2-4 weeks). The entire area from the neck to the knees should be treated. Recurrence can be prevented with periodic application (e.g. every three months). Zinc pyrithione shampoo (Head & Shoulders), topical ketoconazole, and terbinafine spray (Lamisil) are also effective. A single 400 mg dose of oral ketoconazole (Nizoral) is very effective and easy to comply with.

What is the prognosis for tinea versicolor?

The tinea versicolor organism is eradicated rapidly with treatment, but pigmentation takes months to return to normal. The recurrence rate is high (approximately 50%), but prophylactic treatment with topical selenium sulfide or oral ketoconazole (400 mg every three months) can reduce this.

More on tinea versicolor

Image links Other useful links
American Academy of Pediatrics: Tinea Versicolor

MedlinePlus: Tinea Versicolor
Burkhart, CG et al. Tinea Versicolor. e-medicine. November 15, 2006
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Tinea Unguium (Onychomycosis)

About tinea unguium (onychomycosis)

Tinea unguium, also known as onychomycosis, is infection of the nail—usually the distal nail bed—with a dermatophytic fungus. The usual culprits are Tricophyton rubrum and Tricophyton mentagrophytes, with T. rubrum being the most common cause of distal subungual onychomycosis. The nail appears discolored with areas of yellowish-brown or white. Involvement of the nail undersurface results in debris buildup and nail separation. Infection of the top surface leads to a brittle white surface. Involvement of the proximal nail plate is a sign of HIV infection.

Tinea unguium is a common problem, with prevalence increasing with age. The toenails are affected more frequently that the fingernails. The most common complaint is regarding the thickened unsightly appearance of the nail, but the condition can also cause pain or discomfort.

With what can tinea unguium be confused?

Nail disease is difficult to diagnose by appearance alone. The nail plate appearance of tinea unguium can be confused with the changes caused by psoriasis, trauma, or aging. Psoriasis will usually have other skin findings, and trauma can usually be identified by history.

How is tinea unguium diagnosed?

A KOH preparation and fungal culture confirms the diagnosis. Sometimes, a nail biopsy is required.

How is tinea unguium treated?

As is the case for tinea capitis, fungal infection of the nail cannot be eradicated with topical therapy; oral anti-fungal agents such as terbinafine (e.g. Lamisil) or itraconazole (e.g. Sporanox) are required for weeks to months, during which time the drug accumulates in the nail. Systemic antifungal agents have side-effects and the risk-benefit must be considered. Monitoring of hepatic enzymes and hematologic parameters is recommended. Since these drugs remain in the nail for months, retreatment should not be considered for six months for fingernails and 12 months for toenails.  Recently, some have proposed laser treatment as an option.

What is the prognosis for tinea unguium?

After a course of treatment, nails will still not appear completely normal. Tinea unguium is difficult to cure, and recurrence is common, especially for toenails.

More on tinea unguium (onychomycosis)

Image links

DermnetNZ: Fact sheet and photos

Other useful links

Blumberg, M and Kantor GR. Onychomycosis. e-medicine. APril 3, 2007

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Tinea Pedis

What is Tinea Pedis?

Tinea pedis, more commonly known as “athlete’s foot,” is a dermatophytic infection of the feet. It occurs in three forms:

Interdigital. This appears as scaling and maceration between the toes. It is the type frequently seen in patient’s with sweaty feet.

Diffuse plantar scaling. This appears as general scaling of the soles and sides of the feet in what has been called a “moccasin’ distribution. It is common in elderly patients. Nail involvement may be present as well.

Vesiculopustular. This form manifests as vesicles and pustules on the insteps of the feet. It is often misdiagnosed, since vesicles and pustules are an uncommon presentation of dermatophytic infections.

With what can tinea pedis  confused?

Maceration alone, without dermatophytic infection, can occur in patient’s with sweaty feet and be confused with interdigital tinea pedis. Diffuse plantar scaling secondary to tinea pedis may be mistaken for dry skin. Contact dermatitis, dyshidrotic eczema, and pustular psoriasis of the palms and soles can mimic vesiculopustular tinea pedis.

See: Tinea Diagnosis, Treatment and Prognosis

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Tinea Manuum

What is Tinea Manuum?

Tinea manuum is dermatophytic infection of the palm. It is relatively uncommon, and almost always occurs in patient’s that also have tinea pedis (athlete’s foot). It usually only involves one hand, giving rise to the “one hand, two feet” syndrome of tinea manuum plus tinea pedis. It appears as diffuse scaling of the palm, usually with a well-demarcated border..

With what can tinea manuum be confused?

Chronic irritant contact dermatitis can also cause scaling of the palm; however, this condition is usually bilateral. Psoriasis can also effect the palms.

See: Tinea Diagnosis, Treatment and Prognosis

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Tinea Faciale

What is Tinea Faciale?

This dermatophytic infection of the face appears typically as a serpiginous, erythemetous rash with a sharply demarcated border.

With what can tinea faciale confused?

Chronic irritant contact dermatitis can also cause scaling on the face, as can seborrheic dermatitis. Tineal faciale may occasionally mimic the rash of a photodermatitis or the butterfly rash of systemic lupus erythematosus.

See: Tinea Diagnosis, Treatment and Prognosis

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Tinea Cruris

About Tinea Cruris

Tinea cruris, less glamorously known as “jock itch, is a dermatophytic infection of the groin. Patients also commonly have tinea pedis (athlete’s foot). Moisture from perspiration is likely the predisposing risk factor for both of these rashes.

Tinea cruris may not be annular, but it will be seripiginous, elevated, and scaling. The scrotum is usually uninvolved.

With what cantinea cruris confused?

Candidiasis in the groin area is bright red with ill-defined margins and satellite lesions. Unlike dermatophytic infections, the scrotum is usually involved. Intertrigo is another possible diagnosis that can be confused with tinea cruris, but in intertrigo, the KOH preparation will be negative. Tinea cruris can occasionally be confused with psoriasis and seborrheic dermatitis, which can both effect the groin. Erythrasma, caused by Corynebacterium minutissimum, also effect the groin. It fluoresces coral pink under Wood’s lamp exam.

See: Tinea Diagnosis, Treatment and Prognosis

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Tinea Corporis

About Tinea Corporis

Tinea corporis, also known as “ringworm”, is a fungal infection of the body. History of exposure to an infected pet or dog is common. The classic lesion is annular (hence the name “ringworm”), with an elevated, scaling border and a central clearing. Some lesions may be serpiginous rather than annular.

With what can tinea corporis be confused?

Tinea corporis can be confused with other round lesions, such as nummular eczema. It may also be confused with Pityriasis rosea, psoriasis, impetigo, erythema annulare centrificum, and granulmoa annulare.

See: Tinea Diagnosis, Treatment and Prognosis

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Tinea Diagnosis, Treatment and Prognosis

With the exceptions of tinea capitis and tinea unguium, which typically require systemic antifungal treatment, most tinea infections are diagnosed and treated in a similar fashion, and carry a similar prognosis.

Tinea diagnosis
The dictum “if it scales scrape it” is the guiding principle in diagnosing fungal infection. A simple KOH preparation revealing hyphae is diagnostic for dermatophytic or candidal infection. The clinical presentation is usually sufficient to distinguish between these two cases. Scales can also be cultured, either to distinguish between dermatophytic and candidal infection, or in cases of high clinical suspicion and a negative KOH test. Biopsy is not indicated. A Wood’s light exam is of no use in dermatophytic skin infection. However, it will cause fluorescence of infected scalp hairs in some varieties of tinea capitis.

Tinea treatment

Topical antifungal agents are the mainstay of treatment for localized dermatophytic infections. Imidazole agents, such as clotrimazole (e.g. Lotrimin) and miconazole (e.g. Micatin) are available over-the-counter, while others (e.g. econazole])  require a prescription. Other drugs (non-imidazoles) include naftitine (e.g. Naftin), terbinafine (e.g. Lamisil), and ciclopirox olamine (e.g. Loprox). The medication needs to be applied for 1 to 2 weeks after the lesions have cleared. For difficult to treat infections, such as refractory tinea pedis, suppressive therapy with an antifungal powder should be considered. For widespread disease or disease resistant to topical treatments, systemic therapy is required. Systemic therapy is also required for scalp or nail involvement.  Effective oral antifungal agents include: griseofulvin, ketoconazole (e.g. Nizoral), itraconazole (e.g. Sporanox), fluconazole (e.g. Diflucan), and terbinafine (e.g. Lamisil).  Note that Mycolog (active agent in Nystatin) is not effective against dermatophytic infections; it is only active against candida albicans.

Tinea treatment

Many acute dermatophytic infections resolve without treatment—probably due to cellular immunity provoked by dermatophyte antigens— but most benefit from a course of therapy. The degree of inflammation is, in fact, dependent on the character of the immune response.  Persistent infections are attributed to a lack of immune response, either due to dermatophyte-specific immune deficiency, or because dermatophyte antigens remain superficial and fail to gain access to the vasculature. Dermatophyte infections do not penetrate beyond the epidermis. Complications, including secondary bacterial infection, are uncommon. However, interdigital tinea pedis can sometimes create a port of entry for bacteria, leading to lower extremity cellulitis.

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Tinea Capitis

About tinea capitis

Tinea capitis is a superficial dermatophytic fungal infection of the scalp, usually caused by Tricophyton tonsurans, Microsporum canis, or Microsporum audouinii. Clinically, the disease ranges from scaling patches to a boggy, inflamed, pustule-studded plaque (kerion) accompanied by regional lymphadenopathy (swelling of lymph nodes). Patchy alopecia (hair loss) studded with broken hair shafts, caused by some fungal species, can create an appearance termed “black dot” ringworm. The disease is common in school-age children, occurring in epidemics.

With what can tinea capitis be confused?

The differential diagnosis of tinea capitis depends on the degree of inflammation present. Minimally inflamed scale can appear similar to seborrheic dermatitis. Inflammation, can result from scalp infection (cellulitis). Areas of patchy hair loss can be confused with alopecia areata or trichotillomania. Residual scarring can be confused with hair loss from discoid lupus erythematosus.

How is tinea capitis diagnosed?

There may be a history of a family member, classmate, or pet with patchy hair loss. Most cases of tinea capitis are due to Tricophyton tonsurans, especially in African Americans. Unlike Microsporum canis and Microsporum audouinii, Tricophyton tonsurans does not fluoresce under Wood’s lamp (ultraviolet light) examination, limiting the usefulness of this investigation. A diagnosis must be made by KOH preparation and culture of broken hair shafts (not just scale, which may have a low diagnostic yield). Biopsy is not usually required.

How is tinea capitis treated?

Topical antifungal agents are not effective in treating tinea capitis. Systemic therapy is required with antifungals such as griseofulvin, terbinafine or itraconzole. Shampooing with an antifungal shampoo (e.g. 2.5% selenium sulfide, 2% ketoconazole, or 1-2% zinc pyrithione) may be helpful as well, and should be used prophylactic ally by close contacts.

What is the prognosis for tinea capitis?

With systemic treatment, tinea capitis usually resolves in several months. Untreated, some cases will resolve spontaneously over months, while others may last for years. In children, resolution often occurs with puberty, even without treatment. Severe inflammatory disease can led to scarring and permanent hair loss.

Further information on tinea capitis

Image links

DermnetNZ: Fact sheet and photos

Other useful links

Kao GF. Tinea Capitis. e-medicine. May 25, 2006

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