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Watjer RM, Bonten TN, Sayed K, Quint KD, van der Beek MT, Mertens BJA, Numans ME, Eekhof JAH. How effective is topical miconazole or amorolfine for mild to moderately severe onychomycosis in primary care: the Onycho Trial - a randomised double-blind placebo-controlled trial. BMJ Open 2024; 14:e081914. [PMID: 38702077 PMCID: PMC11086198 DOI: 10.1136/bmjopen-2023-081914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVES To evaluate the efficacy of topical miconazole or amorolfine compared to placebo for mild to moderately severe onychomycosis. DESIGN Randomised, double-blind, placebo-controlled trial, with computer-generated treatment allocation at a 1:1:1 ratio. SETTING Primary care, recruitment from February 2020 to August 2022. PARTICIPANTS 193 patients with suspected mild to moderately severe onychomycosis were recruited via general practices and from the general public, 111 of whom met the study criteria. The mean age of participants was 51 (SD 13.1), 51% were female and onychomycosis was moderately severe (mean OSI 12.1 (SD 8.0)). INTERVENTIONS Once-daily miconazole 20 mg/g or once-weekly amorolfine 5% nail lacquer solution was compared with placebo (denatonium benzoate solution). MAIN OUTCOME MEASURES Complete, clinical and mycological cure at 6 months. Secondary outcomes were clinical improvement, symptom burden, quality of life, adverse effects, compliance, patient-perceived improvement and treatment acceptability. RESULTS Based on intention-to-treat analysis, none of the participants receiving miconazole or amorolfine reached complete cure compared with two in the placebo group (OR not estimable (n.e.), p=0.493 and OR n.e., p=0.240, respectively). There was no evidence of a significant difference between groups regarding clinical cure (OR n.e., p=0.493 and OR 0.47, 95% CI 0.04 to 5.45, p=0.615) while miconazole and amorolfine were less effective than placebo at reaching both mycological cure (OR 0.25, 95% CI 0.06 to 0.98, p=0.037 and OR 0.23, 95% CI 0.06 to 0.92, p=0.029, respectively) and clinical improvement (OR 0.26, 95% CI 0.08 to 0.91, p=0.028 and OR 0.25, 95% CI 0.07 to 0.85, p=0.021, respectively). There was no evidence of a significant difference in disease burden, quality of life, adverse reactions, compliance, patient-perceived improvement or treatment acceptability. CONCLUSIONS Topical miconazole and amorolfine were not effective in achieving a complete, clinical or mycological cure of mild to moderately severe onychomycosis, nor did they significantly alleviate the severity or symptom burden. These treatments should, therefore, not be advised as monotherapy to treat onychomycosis. TRIAL REGISTRATION NUMBER WHO ICTRP NL8193.
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Affiliation(s)
- Roeland M Watjer
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Tobias N Bonten
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Khisraw Sayed
- Leiden University Medical Center, Leiden, The Netherlands
| | - Koen D Quint
- Dermatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Bart J A Mertens
- Medical Statistics and Bioinformatics, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Just A H Eekhof
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Hill RC, Caplan AS, Elewski B, Gold JAW, Lockhart SR, Smith DJ, Lipner SR. Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance. Am J Clin Dermatol 2024; 25:359-389. [PMID: 38494575 DOI: 10.1007/s40257-024-00848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/19/2024]
Abstract
Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.
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Affiliation(s)
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Boni Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy A W Gold
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shawn R Lockhart
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Dallas J Smith
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY, 10021, USA.
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Rao MKP, Siddananjappa L, Sidana N, Deshmukh A, Diwari B, Podder I, Kumar S, Mittal R, Daultani P, Jaiswal A, Chinda M. Efficacy and Safety of Amorolfine Lotion 0.25% w/v Compared to Amorolfine Cream 0.25% w/w in Patients With Superficial Fungal Infections of the Skin: A Multi-center, Randomized, Open-Label, Active-Controlled, Non-inferiority Phase III Clinical Trial. Cureus 2024; 16:e60162. [PMID: 38868264 PMCID: PMC11166603 DOI: 10.7759/cureus.60162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Dermatophytosis, a major cause of superficial fungal infections, requires topical and systemic antifungals. Amorolfine, a morpholine derivative, is a new topical antifungal available in cream and lotion formulations. OBJECTIVE To evaluate the efficacy and safety of amorolfine lotion 0.25% compared to amorolfine cream 0.25% in patients with dermatophytosis. METHODS A multi-center randomized, two-arm, active-controlled, parallel, non-inferiority phase III clinical trial involving 284 dermatophytosis patients was conducted, with the test arm using amorolfine lotion and the reference arm using amorolfine cream. The study drugs were applied once daily in the evening for four weeks and patients were followed up for another two weeks. The primary endpoint was clinical cure, while secondary endpoints included mycological cure, composite cure, global efficacy assessment, and post-treatment relapse. Safety and tolerability were assessed. RESULTS Amongst the enrolled patients, 69.9% and 68.1% of patients had tinea corporis, while 30.1% and 31.9% had tinea cruris. The majority of patients in both groups (99.3% test and 97% reference) achieved a clinical cure at the end of treatment. Mycological cure was achieved by 98.6% and 96.3% respectively. A composite cure was achieved by 98.6% in the test arm versus 96.3% in the reference arm. A total of two AEs were reported in two (1.4%) patients in the test group and three AEs were reported in three (2.1%) patients in the reference group, all of the AEs were mild and resolved within three days without supportive medication. No severe adverse effects were reported in any of the study subjects. CONCLUSION Amorolfine lotion 0.25% w/v showed a non-inferior clinical, mycological, and composite cure in dermatophytosis patients, was well-tolerated, and had a similar safety profile to amorolfine cream 0.25% w/w.
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Affiliation(s)
- M Kanaka Prasad Rao
- General Medicine, Rajiv Gandhi Institute of Medical Sciences, Srikakulam, IND
| | | | - Neetu Sidana
- Dermatology, Apex Hospitals Pvt. Ltd., Jaipur, IND
| | - Ashish Deshmukh
- Dermatology, Mahatma Gandhi Mission Medical College, Aurangabad, IND
| | - Binayak Diwari
- Skin and Venereal Diseases, Hi-Tech Medical College and Hospital, Bhubaneswar, IND
| | - Indrasish Podder
- Dermatology and Veneriology, College of Medicine and Sagore Dutta Hospital, Kolkata, IND
| | - Surendra Kumar
- Skin, Venereal Diseases and Leprosy, Sawai Man Singh (SMS) Medical College and Hospital, Jaipur, IND
| | - Ravindra Mittal
- New Product Development, Zydus Healthcare Ltd., Ahmedabad, IND
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Khalifa A, Alreshidi IG, Alaradi LA, Alrashidi YM. Tinea Unguium and Tinea Pedis and Their Correlation With Diabetes Mellitus in the General Population in the Hail Region, Saudi Arabia: A Cross-Sectional Study. Cureus 2023; 15:e40116. [PMID: 37425521 PMCID: PMC10329282 DOI: 10.7759/cureus.40116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Background Tinea pedis or foot ringworm is an infection of the feet affecting the soles, interdigital clefts of toes, and nails, with a dermatophyte fungus. It is also called athlete's foot. Onychomycosis of the nail is caused by dermatophytes called Tinea unguium. An abnormal nail not caused by a fungal infection is a type of dystrophic nail. Onychomycosis can infect both fingernails and toenails, but onychomycosis of the toenail is much more prevalent. Aim The study aimed to assess the knowledge, perception, and awareness among a sample from Ha'il City, Saudi Arabia, of the definitions, risk factors, symptoms, diagnosis, complications, and treatment of both Tinea pedis and Tinea unguium, along withtheir correlation with diabetic patients. Material A cross-sectional survey was distributed throughout Ha'il City. An online questionnaire was designed and distributed via various social media apps, which included questions concerning participants' sociodemographic information, alongside questions regarding the risk factors, signs, symptoms, complications, and management of both Tinea pedis and Tinea unguium. Methods SPSS for Windows v22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for statistical analysis. Results The overall awareness of the study's participants about Tinea Pedis and Tinea unguium infection was low (34.82%).
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Hammoudi Halat D, Younes S, Mourad N, Rahal M. Allylamines, Benzylamines, and Fungal Cell Permeability: A Review of Mechanistic Effects and Usefulness against Fungal Pathogens. MEMBRANES 2022; 12:membranes12121171. [PMID: 36557078 PMCID: PMC9781035 DOI: 10.3390/membranes12121171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 05/30/2023]
Abstract
Allylamines, naftifine and terbinafine, and the benzylamine, butenafine, are antifungal agents with activity on the fungal cell membrane. These synthetic compounds specifically inhibit squalene epoxidase, a key enzyme in fungal sterol biosynthesis. This results in a deficiency in ergosterol, a major fungal membrane sterol that regulates membrane fluidity, biogenesis, and functions, and whose damage results in increased membrane permeability and leakage of cellular components, ultimately leading to fungal cell death. With the fungal cell membrane being predominantly made up of lipids including sterols, these lipids have a vital role in the pathogenesis of fungal infections and the identification of improved therapies. This review will focus on the fungal cell membrane structure, activity of allylamines and benzylamines, and the mechanistic damage they cause to the membrane. Furthermore, pharmaceutical preparations and clinical uses of these drugs, mainly in dermatophyte infections, will be reviewed.
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Affiliation(s)
- Dalal Hammoudi Halat
- Department of Pharmaceutical Sciences, School of Pharmacy, Lebanese International University, Bekaa 146404, Lebanon
| | - Samar Younes
- Department of Biomedical Sciences, School of Pharmacy, Lebanese International University, Bekaa 146404, Lebanon
| | - Nisreen Mourad
- Department of Pharmaceutical Sciences, School of Pharmacy, Lebanese International University, Bekaa 146404, Lebanon
| | - Mohamad Rahal
- Department of Pharmaceutical Sciences, School of Pharmacy, Lebanese International University, Bekaa 146404, Lebanon
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Foessleitner P, Farr A, Deinsberger J. Risk of fetal malformation, spontaneous abortion, and adverse pregnancy outcomes after gestational terbinafine exposure: a systematic review. J DERMATOL TREAT 2022; 33:3073-3079. [PMID: 35930463 DOI: 10.1080/09546634.2022.2110837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Fungal skin and nail infections are common health issues affecting an estimated 10%-20% of the world's population. The antifungal agent terbinafine shows broad-spectrum activity against a wide range of fungal species and is commonly prescribed as a first-line treatment for dermatomycoses and onychomycoses. However, owing to insufficient data regarding embryotoxicity and adverse pregnancy outcomes, treatment with terbinafine is currently not recommended in pregnancy and breastfeeding. This systematic review aimed to evaluate the effects of gestational terbinafine exposure on congenital malformations, spontaneous abortions, and adverse pregnancy outcomes. PubMed/MEDLINE, EMBASE, and clinicaltrials.org were searched to retrieve relevant reports up to March 2022. Two investigators independently screened the articles, extracted the data, and performed a quality assessment using the Newcastle-Ottawa Scale. Two cohort and two case-control studies were eligible for inclusion. Overall, the study showed the absence of an increased risk of congenital malformations, spontaneous abortion, preterm birth, small for gestational age, low birth weight, or stillbirth, following systemic or topical terbinafine exposure during pregnancy. In conclusion, the use of systemic and topical terbinafine during pregnancy can be regarded as safe for mothers and unborn children. The current recommendation concerning gestational terbinafine administration should be reconsidered.
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Affiliation(s)
- Philipp Foessleitner
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Alex Farr
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Emerging Trends in the Use of Topical Antifungal-Corticosteroid Combinations. J Fungi (Basel) 2022; 8:jof8080812. [PMID: 36012800 PMCID: PMC9409645 DOI: 10.3390/jof8080812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 12/10/2022] Open
Abstract
A broad range of topical antifungal formulations containing miconazole or terbinafine as actives are commonly used as efficacious choices for combating fungal skin infections. Their many benefits, owing to their specific mechanism of action, include their ability to target the site of infection, enhance treatment efficacy and reduce the risk of systemic side effects. Their proven efficacy, and positioning in the treatment of fungal skin infections, is enhanced by high patient compliance, especially when appropriate vehicles such as creams, ointments and gels are used. However, inflammation as a result of fungal infection can often impede treatment, especially when combined with pruritus (itch), an unpleasant sensation that elicits an urge to scratch. The scratching that occurs in response to pruritus frequently accelerates skin damage, ultimately aggravating and spreading the fungal infection. To help overcome this issue, a topical antifungal-corticosteroid combination consisting of miconazole or terbinafine and corticosteroids of varying potencies should be used. Due to their inherent benefits, these topical antifungal-corticosteroid combinations can concomitantly and competently attenuate inflammation, relieve pruritus and treat fungal infection.
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Tinea Gladiatorum: Epidemiology, Clinical Aspects, and Management. J Clin Med 2022; 11:jcm11144066. [PMID: 35887830 PMCID: PMC9315553 DOI: 10.3390/jcm11144066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tinea gladiatorum (TG) is a fungal skin infection that occurs among wrestlers and other contact sport athletes with a varied prevalence rate. The most common causative factor responsible as well for local outbreaks of the infection is an anthropophilic dermatophyte species—Trichophyton tonsurans (T. tonsurans). The purpose of this study was to gather current data about TG, including epidemiology, possible diagnosing methods, clinical features, treatment approaches, and potential prevention techniques. We also performed a systematic review of studies describing TG incidence. The prevalence of the disease varied from 2.4% up to 100%. That wide range of variability forces medical practitioners to update knowledge about TG and points to the fact that it still may be a diagnostic and therapeutic challenge. Spreading awareness among athletes and trainers is one of the most important preventive steps.
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Parinyarux P, Thavornwattanayong W, Soontornpas C, Rawangnam P. Towards Better CARE for Superficial Fungal Infections: A Consultation Guide for the Community Pharmacy. PHARMACY 2022; 10:pharmacy10010029. [PMID: 35202078 PMCID: PMC8878117 DOI: 10.3390/pharmacy10010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/03/2022] [Accepted: 02/09/2022] [Indexed: 12/10/2022] Open
Abstract
Superficial fungal infections (SFIs) are among the most common skin diseases worldwide and are common in many parts of Asia. Community pharmacists are well-placed to help identify and manage SFIs. However, effective management may be hindered by a suboptimal consultation process, attributed to the misalignment between consumers’ and pharmacists’ viewpoints. The Fungal CARE (Care, Assess, Recommend, Empower) guide, a patient-centered collaborative framework, was developed to improve pharmacist-led SFI consultations in community pharmacy. A survey on real-world consumer experiences with SFIs provided insights for aligning the Fungal CARE guide with consumer perspectives. To further optimize the guide, community pharmacists were surveyed on their current practice and challenges of managing SFIs, as well as views on the usefulness of the Fungal CARE guide. The pharmacists’ survey indicated that respondents engaged with some but not all of consumers’ top concerns with SFIs, such as emotional and social aspects. Pharmacists identified their greatest challenges as poor compliance with SFI treatment and limited confidence in identifying and/or managing SFIs. Encouragingly, when presented with the Fungal CARE guide, nearly all pharmacists agreed it would be helpful and would use it in practice. Implementing the Fungal CARE guide may help improve pharmacist-led consultations for SFIs and encourage better treatment outcomes.
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Affiliation(s)
| | - Wiwat Thavornwattanayong
- Faculty of Pharmacy, Silpakorn University, Nakorn Pathom 73000, Thailand
- Correspondence: ; Tel.: +66-3425-5800
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10
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Pathogenesis, Immunology and Management of Dermatophytosis. J Fungi (Basel) 2021; 8:jof8010039. [PMID: 35049979 PMCID: PMC8781719 DOI: 10.3390/jof8010039] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Erber AC, Ewing V, Turner M, Molla M, Murbe G, Enquoselassie F, Davey G, Lang T. Setting up a pragmatic clinical trial in a low-resource setting: A qualitative assessment of GoLBeT, a trial of podoconiosis management in Northern Ethiopia. PLoS Negl Trop Dis 2021; 15:e0009582. [PMID: 34319977 PMCID: PMC8370641 DOI: 10.1371/journal.pntd.0009582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/17/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background Clinical trials are often perceived as being expensive, difficult and beyond the capacity of healthcare workers in low-resource settings. However, in order to improve healthcare coverage, the World Health Organization (WHO) World Health Report 2013 stated that all countries need to become generators as well as recipients of data. This study is a methodological examination of the steps and processes involved in setting up the Gojjam Lymphoedema Best Practice Trial (GoLBeT; ISRCTN67805210), a highly pragmatic clinical trial conducted in northern Ethiopia. Challenges to the trial and strategies used to deal with them were explored, together with the reasons for delays. Methodology and principal findings Qualitative research methods were used to analyse emails and reports from the period between trial inception and recruitment. This analysis was complemented by interviews with key informants from the trial operational team. The Global Health Research Process Map was used as a framework against which to compare the steps involved in setting up the trial. A mini-group discussion was conducted with the trial operational team after study completion for reflection and further recommendations. This study showed that the key areas of difficulty in setting up and planning this trial were: the study design, that is, deciding on the study endpoint, where and how best to measure it, and assuring statistical power; recruitment and appropriate training of staff; planning for data quality; and gaining regulatory approvals. Collaboration, for example with statisticians, the trial steering committee, the study monitors, and members of the local community was essential to successfully setting up the trial. Conclusions and significance Lessons learnt from this trial might guide others planning pragmatic trials in settings where research is not common, allowing them to anticipate possible challenges and address them through trial design, planning and operational delivery. We also hope that this example might encourage similar pragmatic studies to be undertaken. Such studies are rarely undertaken or locally led, but are an accessible and efficient way to drive improved outcomes in public health. Podoconiosis is a disease of the lymphatic vessels of the lower extremities, caused by chronic exposure to irritant soils. It results in leg swelling, commonly complicated by acute dermatolymphangioadenitis (ADLA, or ‘acute attacks’), characterised by severe pain, fever and disability. The Gojjam Lymphoedema Best Practice Trial (GoLBeT) trial is a successfully completed randomised controlled trial of podoconiosis treatment that was conducted in the highlands of northern Ethiopia. In this study we report the steps involved in the setup of this trial, from inception to recruitment. The challenges faced are discussed, along with recommendations on how these could be overcome.
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Affiliation(s)
- Astrid C. Erber
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Victoria Ewing
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mark Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Office for National Statistics, Government Buildings, Newport, United Kingdom
| | - Meseret Molla
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gharib Murbe
- Centre for Global Health Research, Brighton & Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | | | - Gail Davey
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Health Research, Brighton & Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Trudie Lang
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Skin Fungal Infections in Children: Diagnostic Challenges. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00407-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Thakur R, Kalsi AS. Updates on Genital Dermatophytosis. Clin Cosmet Investig Dermatol 2020; 13:743-750. [PMID: 33061514 PMCID: PMC7537836 DOI: 10.2147/ccid.s262704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/12/2020] [Indexed: 11/23/2022]
Abstract
Dermatophytes are a group of keratinophilic fungi, which normally cause superficial infection of skin, hair and nails. Based on ecology, they are classified into three groups: anthropophilic, zoophilic and geophilic. Superficial dermatophytic infection of the genital region is called genital dermatophytosis, tinea genitalis or pubo-genital dermatophytosis. In this review, we would like to discuss briefly, the various clinical presentations of genital dermatophytosis, current changes in the taxonomy and nomenclature, introduction of new diagnostic techniques and briefly describe some common dermatophytes and their sources. Also, there are serious concerns associated with the recent development of antifungal resistance among the dermatophytes. We are also facing the scenario of hard-to-treat dermatophytosis.
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Affiliation(s)
- Rameshwari Thakur
- Microbiology and Infection Control, Shivam Orthocare, Una, Himachal Pradesh, India
- Department of Microbiology, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
| | - Avneet Singh Kalsi
- Research, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
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Bhattacharyya A, Sinha M, Singh H, Patel RS, Ghosh S, Sardana K, Ghosh S, Sengupta S. Mechanistic Insight Into the Antifungal Effects of a Fatty Acid Derivative Against Drug-Resistant Fungal Infections. Front Microbiol 2020; 11:2116. [PMID: 33013771 PMCID: PMC7505954 DOI: 10.3389/fmicb.2020.02116] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 08/11/2020] [Indexed: 12/23/2022] Open
Abstract
The prevalence of drug-resistant pathogenic fungi is a major global health challenge. There is an urgent need for novel drugs that can exert a potent antifungal activity and overcome resistance. Newly discovered anti-fungal properties of existing compounds can potentially offer a rapid solution to address this persistent threat. We rationalized that structures which disrupt the fungal cell membrane could address the above unmet need. As fatty acids underpin the formation and stability of cell membranes, we used computational simulations to evaluate the interactions between selected short chain fatty acids and a model cell membrane. Here, we report that caprylic acid could penetrate and perturb the membrane in silico. Based on the in silico findings, we identified a derivative of this fatty acid that disrupts fungal membranes as detected using steady-state fluorescence anisotropy. We show that this fatty acid derivative is potent against a variety of fungal pathogens like Candida and Trichophyton. We further demonstrated the ability of this fatty acid derivative to potentiate some azoles in vitro and enhance the efficacy of antifungal formulations in vivo. Our data suggests the emergence of a novel therapy for effective disease management and overcoming anti-fungal drug resistance.
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Affiliation(s)
| | - Mau Sinha
- Vyome Therapeutics Ltd., New Delhi, India
| | | | | | | | - Kabir Sardana
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Shamik Ghosh
- Vyome Therapeutics Ltd., New Delhi, India.,India Innovation Research Center, New Delhi, India
| | - Shiladitya Sengupta
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Rengasamy M, Shenoy MM, Dogra S, Asokan N, Khurana A, Poojary S, Jayaraman J, Valia AR, Sardana K, Kolalapudi S, Marfatia Y, Rao PN, Bhat RM, Kura M, Pandhi D, Barua S, Kaushal V. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT). Indian Dermatol Online J 2020; 11:502-519. [PMID: 32832435 PMCID: PMC7413465 DOI: 10.4103/idoj.idoj_233_20] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Madhu Rengasamy
- Department of Dermatology, Venereology and Leprosy, Madras Medical College, Chennai, Tamil Nadu, India
| | - Manjunath M Shenoy
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Deralakatte, Deralakatte, Mangalore, Karanataka, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelakandhan Asokan
- Department of Dermatology, Venereology and Leprosy, Government Medical College, Thrissur, Kerala, India
| | - Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Shital Poojary
- Department of Dermatology, Venereology and Leprosy, K. J. Somaiya Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Jyothi Jayaraman
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India
| | - Ameet R Valia
- Consultant Dermatologist, Harganga Mahal Annexe, Dadar TT, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
| | | | - Yogesh Marfatia
- Department of Dermatology, Venereology and Leprosy, SBKS Medical College, Piparia, Vadodara, Gujarat, India
| | - P Narasimha Rao
- Consultant Dermatologist, Masab Tank, Hyderabad, Telangana, India
| | - Ramesh M Bhat
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India
| | - Mahendra Kura
- Department of Dermatology, Venereology and Leprosy, Grant Medical College, Mumbai, Maharashtra, India
| | - Deepika Pandhi
- Department of Dermatology, Venereology and Leprosy, University College of Medical Sciences and GTBH, New Delhi, India
| | - Shyamanta Barua
- Department of Dermatology, Venereology and Leprosy, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Vibhor Kaushal
- Consultant Dermatologist, Dr. Kaushal's Skin Clinic, Agra, Uttar Pradesh, India
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16
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Leung AK, Lam JM, Leong KF, Hon KL. Tinea corporis: an updated review. Drugs Context 2020; 9:dic-2020-5-6. [PMID: 32742295 PMCID: PMC7375854 DOI: 10.7573/dic.2020-5-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/18/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin Fon Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
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17
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Hon KL, Chow CM, Luk DCK, Leung AKC. A spreading rash on the back of a teenager. Paediatr Child Health 2020; 26:197-199. [PMID: 34131454 DOI: 10.1093/pch/pxaa034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 01/10/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kam Lun Hon
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong.,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital
| | - Chung Mo Chow
- Department of Paediatrics, Prince of Wales Hospital, New Territories, Hong Kong
| | - David C K Luk
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
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18
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Cowdell F, Jadotte YT, Ersser SJ, Danby S, Lawton S, Roberts A, Dyson J. Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings. Cochrane Database Syst Rev 2020; 1:CD011377. [PMID: 32006460 PMCID: PMC6996088 DOI: 10.1002/14651858.cd011377.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence. OBJECTIVES To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings. SEARCH METHODS We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers. SELECTION CRITERIA Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence. MAIN RESULTS We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave-on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath. In five studies, treatment duration ranged from five days to six months; only one study had post-treatment follow-up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel. Three studies each had high risk of attrition, detection, and performance bias. Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice-daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed-days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin-moisturising regimen) (P = 0.004), but this is based on very low-quality evidence, so we are uncertain of this result. Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave-on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water-in-oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low-quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid-volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low. One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low-quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable. Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow-up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low. Outcomes of erythema and clinical score of itch were not assessed in any included studies. AUTHORS' CONCLUSIONS Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low-quality evidence. Low-quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care. Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient-reported outcomes, such as comfort and acceptability.
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Affiliation(s)
- Fiona Cowdell
- Birmingham City UniversityFaculty of Health, Education and Life SciencesCity South CampusWestbourne Road, EdgbastonBirminghamUKB15 3TN
| | - Yuri T Jadotte
- Renaissance School of Medicine at Stony Brook UniversityDepartment of Family, Population and Preventive MedicineStony BrookNYUSA11794‐8434
| | - Steven J Ersser
- Bournemouth UniversityDepartment of Nursing ScienceRoom B401, 4th floor, Bournemouth House17 Christchurch RdBournemouthUKBH1 3LT
| | - Simon Danby
- The University of SheffieldSheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular DiseaseBeech Hill RoadSheffieldUKS10 2RX
| | - Sandra Lawton
- Rotherham NHS Foundation TrustDepartment of DermatologyMoorgate RoadRotherhamUKS60 2UD
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with EczemaNottinghamUKNG5 4FG
| | - Judith Dyson
- City, University of LondonSchool of Health Sciences, Division of NursingLondonUK
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19
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Ebrahimi M, Zarrinfar H, Naseri A, Najafzadeh MJ, Fata A, Parian M, Khorsand I, Novak Babič M. Epidemiology of dermatophytosis in northeastern Iran; A subtropical region. Curr Med Mycol 2019; 5:16-21. [PMID: 31321333 PMCID: PMC6626711 DOI: 10.18502/cmm.5.2.1156] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and Purpose Dermatophytes as the causative agents of dermatophytosis (ringworm) are widely spread around the world. Accurate identification of dermatophytes in one area can be particularly important for epidemiological studies. Regarding this, the aim of the present study was to describe the species spectrum of dermatophytes, isolated from patients in Mashhad city, Iran, using the molecular-based method. Materials and Methods This study was conducted on 79 dermatophyte isolates obtained from the human skin, hair, and nail specimens. Species identification was performed by the polymerase chain reaction-restriction fragment length polymorphism analysis of ribosomal DNA internal transcribed spacer regions using MvaI restriction enzyme. Results The identified species included Trichophyton mentagrophytes/T. interdigitale species complex (n=37, 46.8%), Epidermophyton floccosum (n=12, 15.2%), T. rubrum (n=8, 10.1%), Microsporum canis (n=8, 10.1%), T. violaceum (n=5, 6.3%), T. tonsurans (n=4, 5.1%), Nannizzia gypsea (n=3, 3.8%), T. benhamiae (n=1, 1.3%), and T. verrucosum (n=1, 1.3%). The clinical forms of infection were tinea corporis (n=26, 32.8%), tinea cruris (n=22, 27.8%), tinea capitis (n=10, 12.6%), tinea unguium (n=7, 9%), tinea manuum (n=6, 8%), tinea pedis (n=5, 6.3%), and tinea faciei (n=3, 3.5%). Conclusion As the findings indicated, T. mentagrophytes/T. interdigitale species complex had the highest prevalence, and T. benhamiae appeared to be a new emerging agent of dermatophytosis in Mashhad, northeastern Iran.
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Affiliation(s)
- Maryam Ebrahimi
- Department of Biology, Damghan Branch, Islamic Azad University of Damghan, Damghan, Iran
| | - Hossein Zarrinfar
- Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Naseri
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Javad Najafzadeh
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Cutaneous Leishmaniasis Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdolmajid Fata
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Cutaneous Leishmaniasis Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahmoud Parian
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Imaneh Khorsand
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Monika Novak Babič
- Department of Biology, Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
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20
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May PJ, Tong SYC, Steer AC, Currie BJ, Andrews RM, Carapetis JR, Bowen AC. Treatment, prevention and public health management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: a systematic review. Trop Med Int Health 2019; 24:280-293. [PMID: 30582783 PMCID: PMC6850630 DOI: 10.1111/tmi.13198] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Philippa J May
- Northern Territory Centre for Disease Control, Casuarina, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Australia.,Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | - Andrew C Steer
- Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, University of Melbourne, Parkville, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia.,Royal Darwin Hospital, Casuarina, Australia
| | - Ross M Andrews
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia.,National Centre for Epidemiology & Population Health, Australian National University, Canberra, Australia
| | - Jonathan R Carapetis
- Perth Children's Hospital, Nedlands, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, University of Western Australia, Nedlands, Australia.,School of Medicine, University of Western Australia, Nedlands, Australia
| | - Asha C Bowen
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia.,Perth Children's Hospital, Nedlands, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, University of Western Australia, Nedlands, Australia.,School of Medicine, University of Western Australia, Nedlands, Australia.,University of Notre Dame Australia, Fremantle, Australia
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21
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Hay R. Therapy of Skin, Hair and Nail Fungal Infections. J Fungi (Basel) 2018; 4:E99. [PMID: 30127244 PMCID: PMC6162762 DOI: 10.3390/jof4030099] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/28/2022] Open
Abstract
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.
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22
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Rajagopalan M, Inamadar A, Mittal A, Miskeen AK, Srinivas CR, Sardana K, Godse K, Patel K, Rengasamy M, Rudramurthy S, Dogra S. Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC DERMATOLOGY 2018; 18:6. [PMID: 30041646 PMCID: PMC6057051 DOI: 10.1186/s12895-018-0073-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/22/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Murlidhar Rajagopalan
- Department of Dermatology, Apollo Hospital, Chennai, India. .,Department of Dermatology, Apollo Hospital, Greams Road No: 21, Greams Lane, Off Greams Road, Chennai, India.
| | - Arun Inamadar
- Department of Dermatology, SBMP Medical College, BLDE Deemed University, Bijapur, India
| | - Asit Mittal
- Department of Dermatology, R.N.T. Medical College and Hospital, Udaipur, India
| | - Autar K Miskeen
- Dr Miskeen's Central Clinical Microbiology Lab, Thane, India
| | - C R Srinivas
- Department of Dermatology, PSG Hospitals, Peelamedu, Coimbatore, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Kiran Godse
- Department of Dermatology, Padmashree Dr D Y Patil University, Navi Mumbai, India
| | - Krina Patel
- Department Of Dermatology, GMERS Medical College & Hospital, Sola, Ahmedabad, India
| | - Madhu Rengasamy
- Department of Dermatology (Mycology), Madras Medical College, Chennai, India
| | - Shivaprakash Rudramurthy
- Mycology Division, Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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23
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Avancini J, Zucchi P. Prevalence of dermatoses in patients referred for evaluation in an outpatient clinic of specialties. An Bras Dermatol 2018; 93:513-516. [PMID: 30066756 PMCID: PMC6063128 DOI: 10.1590/abd1806-4841.20186640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 05/24/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Brazilian Unified Health System presents a long waiting period for a dermatology appointment, varying from 34 to 239 days. OBJECTIVES Analyze the prevalence of cutaneous diseases evaluated by dermatologists in a specialized center, in patients referred from the primary care, and to present possible interventions for the primary units. METHODS Retrospective analyses of the International Codes of Diseases (ICD-10) described in every dermatology appointment in a specialty center in Sao Paulo from January 2014 to August 2015. RESULTS A total of 7.350 consultations were included. Superficial mycosis corresponded to 1,058 (14.4%) of the main complaints and dermatophytosis was the most frequently used ICD, corresponding to 481 individual consultations (6.5%), followed by onychomycosis, responsible for 464 consultations (6.3%), acne in 347 (4,7%). and contact dermatitis in 311 consultations (4,2%). STUDY LIMITATIONS The study was based on retrospective analysis of ICD described and no previous orientation for a solid use of the codes was performed to the dermatology team; consultations in which the ICD was not informed or a non-especific ICD was used were excluded; different dermatologists were responsible for the consultations. CONCLUSION Superficial mycosis corresponded to 14.4% of the chief complaints in the studied period and was the most frequent cause of reference from primary care doctors to dermatologists. Prevalence data obtained in the present study could assist the capacitation policies in the primary care system, focusing the dermatology teaching in the most prevalent dermatological disorders.
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Affiliation(s)
- João Avancini
- Dermatology Division, Hospital das Clínicas, Faculdade de
Medicina da Universidade de São Paulo, São Paulo (SP), Brazil
- Master’s Student in Administration, Health Economics and
Management. Universidade Federal de São Paulo, São Paulo (SP), Brazil
| | - Paola Zucchi
- Discipline of Health Economics and Management, Universidade Federal
de São Paulo, São Paulo (SP), Brazil
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Parekh M, Ramaiah G, Pashilkar P, Ramanujam R, Johnston P, Ilag LL. A pilot single centre, double blind, placebo controlled, randomized, parallel study of Calmagen® dermaceutical cream and lotion for the topical treatment of tinea and onychomycosis. Altern Ther Health Med 2017; 17:464. [PMID: 28923039 PMCID: PMC5604504 DOI: 10.1186/s12906-017-1970-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/11/2017] [Indexed: 12/02/2022]
Abstract
Background Most of the current anti-fungal treatments are chemical-based, fungistatic, have low efficacy in the treatment of tinea and toxicity concerns, while onychomycosis remains recalcitrant to most antifungal therapies. The study aimed to establish the fungicidal, efficacy and safety profile of Calmagen® dermaceutical cream and lotion containing AMYCOT® as a topical treatment in patients with severe to very severe presentations of fungal skin (tinea) and nail infections (onychomycosis). Methods A randomized, placebo-controlled, double blind, parallel, single centre study was conducted on 28 subjects with severe to very severe tinea or onychomycosis. All patients were randomized in a ratio of 1:1 for treatment or placebo group. Subjects in the treatment arm received Calmagen® cream or lotion, while subjects in the placebo arm received a similar inert topical preparation. Tinea subjects were treated with cream for four weeks, while onychomycosis subjects were treated with lotion for 12 weeks. Mycological cure, the primary endpoint, was assessed by three parameters: KOH (potassium hydroxide) smear, fungal culture and live spore count. Clinical cure was defined as Investigator Global Assessment (IGA) response of ‘cleared’ or ‘excellent’. Results All three parameters constituting mycological cure were confirmed in 92.8% (13/14) of subjects in the treatment arm, while all 14 subjects in the placebo arm remained positive for KOH smear. Calmagen® cream and lotion treatment showed a significant improvement in all three parameters: KOH smear, (95% CI (Calmagen): 79.4, 100.0; 95% CI (placebo): 0.0, 0.0; p < 0.0001); fungal culture (95% CI (Calmagen); 100.0, 100.0; 95% CI (Placebo): 17.0, 100.0; p < 0.0019); and live spore count (95% CI (Calmagen): 100.0, 100.0; 95% CI (Placebo): 17.0, 100.0; p < 0.0019). Clinical cure was achieved in all subjects in the treatment arm while none in the placebo arm were clinically cured. No treatment-related adverse effects were observed in either group. Conclusions The Calmagen® cream and lotion containing AMYCOT® represent a potentially safe and efficacious natural alternative in the treatment of Tinea and onychomycosis. Trial registration This trial has been registered with the clinical trial registry-India (CTRI; registration number: CTRI/2012/03/002522).
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Dev T, Saginatham H, Sethuraman G. Tinea Faciei: Challenges in the Diagnosis. J Pediatr 2017; 187:331. [PMID: 28433202 DOI: 10.1016/j.jpeds.2017.03.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/17/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Tanvi Dev
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
| | - Himabindu Saginatham
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
| | - Gomathy Sethuraman
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
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Kreijkamp‐Kaspers S, Hawke K, Guo L, Kerin G, Bell‐Syer SEM, Magin P, Bell‐Syer SV, van Driel ML. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017; 7:CD010031. [PMID: 28707751 PMCID: PMC6483327 DOI: 10.1002/14651858.cd010031.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence-based choice for treatment. OBJECTIVES To assess the effects of oral antifungal treatments for toenail onychomycosis. SEARCH METHODS We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. SELECTION CRITERIA RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years.We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high-risk domain was 'blinding of personnel and participants'.We found high-quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine-treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate-quality evidence).There was high-quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu-like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate-quality evidence).Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low-quality evidence).There is moderate-quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate-quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low-quality evidence). Common adverse events in both groups included headache, viral infection, and nausea.Moderate-quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate-quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin-treated participants) along with nausea and vomiting (in azole-treated participants). Very low-quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants).There is low-quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low-quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin-treated participants) as well as taste loss and nausea (in terbinafine-treated participants). No studies addressed recurrence rate for this comparison.No study addressed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate-quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate-quality evidence).Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate-quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low-quality evidence).Only four comparisons assessed recurrence rate: low-quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them.Only a limited number of studies reported adverse events, and the severity of the events was not taken into account.Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding.
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Affiliation(s)
- Sanne Kreijkamp‐Kaspers
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Kate Hawke
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Linda Guo
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - George Kerin
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Sally EM Bell‐Syer
- CochraneCochrane Editorial UnitSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Parker Magin
- The University of NewcastleDiscipline of General Practice, School of Medicine and Public HealthNewbolds Buiding, University of Newcastle,University DriveNewcastleAustralia2308
| | | | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
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Abstract
Fungal infections in humans resulting from human or animal contact are relatively uncommon, but they include a significant proportion of dermatophyte infections. Some of the most commonly encountered diseases of the integument are dermatomycoses. Human or animal contact may be the source of all types of tinea infections, occasional candidal infections, and some other types of superficial or deep fungal infections. This narrative review focuses on the epidemiology, clinical features, diagnosis and treatment of anthropophilic dermatophyte infections primarily found in North America. Other human-acquired and zoonotic fungal infections also are discussed in brief.
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Affiliation(s)
- Dennis J Baumgardner
- Aurora University of Wisconsin Medical Group, Aurora Health Care, Milwaukee, WI; Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI; Center for Urban Population Health, Milwaukee, WI
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Kaul S, Yadav S, Dogra S. Treatment of Dermatophytosis in Elderly, Children, and Pregnant Women. Indian Dermatol Online J 2017; 8:310-318. [PMID: 28979861 PMCID: PMC5621188 DOI: 10.4103/idoj.idoj_169_17] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually straightforward, treatment of dermatophytosis becomes notably challenging in certain population groups - pregnant women, children, and elderly. Treatment with topical azoles/allylamines alone is effective in limited cutaneous disease in all three groups. Terbinafine is the preferred oral agent in elderly population for treatment of extensive cutaneous disease and onychomycosis due to its lack of cardiac complications and lower propensity for drug interactions. If required, additional physical/mechanical modalities can be employed for symptomatic onychomycosis. Data for systemic therapy in children mainly pertains to the treatment of tinea capitis. At present, very little data exists regarding the safety of systemic antifungals in pregnancy and there is an effort to restrict treatment to topical therapies because of their negligible systemic absorption.
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Affiliation(s)
- Subuhi Kaul
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Savita Yadav
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
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May P, Bowen A, Tong S, Steer A, Prince S, Andrews R, Currie B, Carapetis J. Protocol for the systematic review of the prevention, treatment and public health management of impetigo, scabies and fungal skin infections in resource-limited settings. Syst Rev 2016; 5:162. [PMID: 27659511 PMCID: PMC5034664 DOI: 10.1186/s13643-016-0335-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/09/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Impetigo, scabies, and fungal skin infections disproportionately affect populations in resource-limited settings. Evidence for standard treatment of skin infections predominantly stem from hospital-based studies in high-income countries. The evidence for treatment in resource-limited settings is less clear, as studies in these populations may lack randomisation and control groups for cultural, ethical or economic reasons. Likewise, a synthesis of the evidence for public health control within endemic populations is also lacking. We propose a systematic review of the evidence for the prevention, treatment and public health management of skin infections in resource-limited settings, to inform the development of guidelines for the standardised and streamlined clinical and public health management of skin infections in endemic populations. METHODS The protocol has been designed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. All trial designs and analytical observational study designs will be eligible for inclusion. A systematic search of the peer-reviewed literature will include PubMed, Excertpa Medica and Global Health. Grey literature databases will also be systematically searched, and clinical trials registries scanned for future relevant studies. The primary outcome of interest will be the clinical cure or decrease in prevalence of impetigo, scabies, crusted scabies, tinea capitis, tinea corporis or tinea unguium. Two independent reviewers will perform eligibility assessment and data extraction using standardised electronic forms. Risk of bias assessment will be undertaken by two independent reviewers according to the Cochrane Risk of Bias tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to conduct meta-analysis. The final body of evidence will be reported against the Grades of Recommendation, Assessment, Development and Evaluation grading system. DISCUSSION The evidence derived from the systematic review will be used to inform the development of guidelines for the management of skin infections in resource-limited settings. The evidence derived will be intended for use by clinicians, public health practitioners and policy makers in the treatment of skin infections and the development of skin infection control programmes. The review will identify any gaps in the current evidence to provide direction for future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015029453.
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Affiliation(s)
- Philippa May
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box 855, West Perth, WA 6872 Australia
| | - Asha Bowen
- Telethon Kids Institute, University of Western Australia, West Perth, Australia
| | - Steven Tong
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | - Andrew Steer
- Murdoch Children’s Research Institute, University of Melbourne, Parkville, Australia
| | | | - Ross Andrews
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | - Bart Currie
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, West Perth, Australia
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Treating Common Fungal Infections in Children. CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0110-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Starace M, Alessandrini A, Piraccini BM. Tinea Incognita following the Use of an Antipsoriatic Gel. Skin Appendage Disord 2016; 1:123-5. [PMID: 27171394 DOI: 10.1159/000441193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/18/2015] [Indexed: 11/19/2022] Open
Abstract
Tinea incognita is a dermatophyte infection of the skin whose clinical presentation has been modified by the misuse of steroids or, as has been described recently, calcineurin inhibitors. We report a case of pustular psoriasis treated with an antipsoriatic cream, composed of topical steroids and a vitamin D3 derivative, which gave rise to a tinea incognita. Our case underlines that clinical features of fungal infection can be modified by the increasing use of self-prescribed topical therapies, usually applied to treat incorrectly 'self-diagnosed' diseases. Moreover, we suggest that a mycological examination should be performed in every atypical presentation of skin lesion, and to rule out tinea pedis, in any disease of the feet that requires topical application of steroids.
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Affiliation(s)
- Michela Starace
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Aurora Alessandrini
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Bianca Maria Piraccini
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Sahoo AK, Mahajan R. Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review. Indian Dermatol Online J 2016; 7:77-86. [PMID: 27057486 PMCID: PMC4804599 DOI: 10.4103/2229-5178.178099] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The prevalence of superficial mycotic infection worldwide is 20–25% of which dermatophytes are the most common agents. Recent developments in understanding the pathophysiology of dermatophytosis have confirmed the central role of cell-mediated immunity in countering these infections. Hence, a lack of delayed hypersensitivity reaction in presence of a positive immediate hypersensitivity (IH) response to trichophytin antigen points toward the chronicity of disease. Diagnosis, though essentially clinical should be confirmed by laboratory-based investigations. Several new techniques such as polymerase chain reaction (PCR) and mass spectroscopy can help to identify the different dermatophyte strains. Management involves the use of topical antifungals in limited disease, and oral therapy is usually reserved for more extensive cases. The last few years have seen a significant rise in the incidence of chronic dermatophyte infections of skin which have proven difficult to treat. However, due to the lack of updated national or international guidelines on the management of tinea corporis, cruris, and pedis, treatment with systemic antifungals is often empirical. The present review aims to revisit this important topic and will detail the recent advances in the pathophysiology and management of tinea corporis, tinea cruris, and tinea pedia while highlighting the lack of clarity of certain management issues.
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Affiliation(s)
- Alok Kumar Sahoo
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Chen F, Di H, Wang Y, Cao Q, Xu B, Zhang X, Yang N, Liu G, Yang CG, Xu Y, Jiang H, Lian F, Zhang N, Li J, Lan L. Small-molecule targeting of a diapophytoene desaturase inhibits S. aureus virulence. Nat Chem Biol 2016; 12:174-9. [PMID: 26780405 DOI: 10.1038/nchembio.2003] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/13/2015] [Indexed: 02/07/2023]
Abstract
The surge of antibiotic resistance in Staphylococcus aureus has created a dire need for innovative anti-infective agents that attack new targets, to overcome resistance. In S. aureus, carotenoid pigment is an important virulence factor because it shields the bacterium from host oxidant killing. Here we show that naftifine, a US Food and Drug Administration (FDA)-approved antifungal drug, blocks biosynthesis of carotenoid pigment at nanomolar concentrations. This effect is mediated by competitive inhibition of S. aureus diapophytoene desaturase (CrtN), an essential enzyme for carotenoid pigment synthesis. We found that naftifine attenuated the virulence of a variety of clinical S. aureus isolates, including methicillin-resistant S. aureus (MRSA) strains, in mouse infection models. Specifically, we determined that naftifine is a lead compound for potent CrtN inhibitors. In sum, these findings reveal that naftifine could serve as a chemical probe to manipulate CrtN activity, providing proof of concept that CrtN is a druggable target against S. aureus infections.
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Affiliation(s)
- Feifei Chen
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Hongxia Di
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Youxin Wang
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Qiao Cao
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Bin Xu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Xue Zhang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Nana Yang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Guijie Liu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Cai-Guang Yang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Yong Xu
- Humanwell Healthcare (Group) Co. Ltd., Wuhan, China
| | - Hualiang Jiang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Fulin Lian
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Naixia Zhang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Jian Li
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Lefu Lan
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective. OBJECTIVES To assess the efficacy and safety of treatments for rosacea. SEARCH METHODS We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea. DATA COLLECTION AND ANALYSIS Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors. MAIN RESULTS We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence). AUTHORS' CONCLUSIONS There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.
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Affiliation(s)
- Esther J van Zuuren
- Leiden University Medical CenterDepartment of DermatologyPO Box 9600B1‐QLeidenNetherlands2300 RC
| | | | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & NeuroscienceBiostatistics and Health InformaticsDenmark HillLondonUK
| | | | - Lyn Charland
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
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Baltazar LM, Ray A, Santos DA, Cisalpino PS, Friedman AJ, Nosanchuk JD. Antimicrobial photodynamic therapy: an effective alternative approach to control fungal infections. Front Microbiol 2015; 6:202. [PMID: 25821448 PMCID: PMC4358220 DOI: 10.3389/fmicb.2015.00202] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/25/2015] [Indexed: 11/17/2022] Open
Abstract
Skin mycoses are caused mainly by dermatophytes, which are fungal species that primarily infect areas rich in keratin such as hair, nails, and skin. Significantly, there are increasing rates of antimicrobial resistance among dermatophytes, especially for Trichophyton rubrum, the most frequent etiologic agent worldwide. Hence, investigators have been developing new therapeutic approaches, including photodynamic treatment. Photodynamic therapy (PDT) utilizes a photosensitive substance activated by a light source of a specific wavelength. The photoactivation induces cascades of photochemicals and photobiological events that cause irreversible changes in the exposed cells. Although photodynamic approaches are well established experimentally for the treatment of certain cutaneous infections, there is limited information about its mechanism of action for specific pathogens as well as the risks to healthy tissues. In this work, we have conducted a comprehensive review of the current knowledge of PDT as it specifically applies to fungal diseases. The data to date suggests that photodynamic treatment approaches hold great promise for combating certain fungal pathogens, particularly dermatophytes.
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Affiliation(s)
- Ludmila M Baltazar
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx NY, USA ; Department of Medicine, Albert Einstein College of Medicine, Bronx NY, USA
| | - Anjana Ray
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx NY, USA ; Department of Medicine, Albert Einstein College of Medicine, Bronx NY, USA
| | - Daniel A Santos
- Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais Belo Horizonte, Brazil
| | - Patrícia S Cisalpino
- Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais Belo Horizonte, Brazil
| | - Adam J Friedman
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Bronx NY, USA ; Department of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx NY, USA
| | - Joshua D Nosanchuk
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx NY, USA ; Department of Medicine, Albert Einstein College of Medicine, Bronx NY, USA
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Baltazar LM, Santos DA. Perspective on animal models of dermatophytosis caused by Trichophyton rubrum. Virulence 2015; 6:372-5. [PMID: 26065321 PMCID: PMC4601506 DOI: 10.1080/21505594.2015.1027480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- Ludmila Matos Baltazar
- Department of Microbiology & Immunology; Albert Einstein College of Medicine; Bronx, NY USA
| | - Daniel Assis Santos
- Departamento de Microbiologia; Instituto de Ciências Biológicas; Universidade Federal de Minas Gerais; Belo Horizonte, Brazil
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Morton CO, Chau M, Stack C. In vitro combination therapy using low dose clotrimazole and photodynamic therapy leads to enhanced killing of the dermatophyte Trichophyton rubrum. BMC Microbiol 2014; 14:261. [PMID: 25316407 PMCID: PMC4210577 DOI: 10.1186/s12866-014-0261-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/01/2014] [Indexed: 12/19/2022] Open
Abstract
Background Superficial infections of the skin and mucous membranes caused by dermatophyte fungi are amongst the most common and challenging infections to treat. Previously we demonstrated the phototoxic effects of photodynamic therapy (PDT) towards Trichophyton rubrum, using a green laser to photoactivate Rose Bengal (RB). The aim of this study was to evaluate whether we could; (1) achieve a similar effect using an inexpensive light-emitting diode (LED) to photoactivate RB and (2) to evaluate whether our PDT regime could be combined with standard antifungal drug therapy and increase its effectiveness. Methods We designed and built our own inexpensive green (530 nm) LED source and tested its efficacy as part our RB-PDT regime in vitro against T. rubrum. We also examined the potential benefits of incorporating PDT as part of combination therapy and whether the order in which this was done had an impact. First we subjected spore suspensions to sub-inhibitory concentrations of a number of antifungal agents (CLT, MCZ and TRB) for 72 hours followed by RB-PDT. Secondly we subjected spore suspensions to sub-inhibitory PDT followed by drug treatment and evaluated if there were any changes to the minimum inhibitory concentrations (MICs) of the drugs tested. Results The optimal conditions for photoinactivation of T. rubrum using RB-PDT alone were 140 μM of RB and 24 J/cm2 of LED (equating to a 30-minute exposure). These parameters also caused a 100% reduction in the viability of the pathogenic yeast Candida albicans and the model fungus Saccharomyces cerevisiae. By combining our RB-PDT regime as an adjunct to antifungal drugs we were able to dramatically reduce the exposure times. Treatment of spore suspensions using a sub-inhibitory dose of clotrimazole (CLT) followed by RB-PDT, this order was critical, significantly reduced the exposure times required to achieve 100% inhibition of T. rubrum to 15 minutes as compared to RB-PDT alone. Conclusions The combination of antifungal drug and RB-PDT represents an attractive alternative to the current antifungal therapies used to treat superficial fungal diseases. Our approach has the potential to reduce treatment times and drug dosages which can also reduce drug toxicity and improve patient compliance. Electronic supplementary material The online version of this article (doi:10.1186/s12866-014-0261-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Colin Stack
- School of Science and Health, University of Western Sydney, Campbelltown Campus, Narellan Road, Campbelltown NSW 2560, Australia.
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