Antifungal agents: An overview. Part I

Recent Advances in Pharmaceutical Approaches of Antimicrobial Agents for Selective Delivery in Various Administration Routes

Globally, the increase of pathogenic bacteria with antibiotic-resistant characteristics has become a critical challenge in medical treatment. The misuse of conventional antibiotics to treat an infectious disease often results in increased resistance and a scarcity of effective antimicrobials to be used in the future against the organisms. Here, we discuss the rise of antimicrobial resistance (AMR) and the need to combat it through the discovery of new synthetic or naturally occurring antibacterial compounds, as well as insights into the application of various drug delivery approaches delivered via various routes compared to conventional delivery systems. AMR-related infectious diseases are also discussed, as is the efficiency of various delivery systems. Future considerations in developing highly effective antimicrobial delivery devices to address antibiotic resistance are also presented here, especially on the smart delivery system of antibiotics.

Investigation on utility of some novel terpenes on transungual delivery of fluconazole for the management of onychomycosis

BACKGROUND

Onychomycosis, the most prevailing affliction of the nail, accounts for approximately 90% of the toenail infection worldwide. Owing to this infection, the affected patients experience reduced quality of their life as its awful appearance undermines their daily activities and social interactions. Onychomycosis is notoriously strenuous to cure. Systemic therapy, though effective, possess severe complication of toxicities, contra-indication, and drug-drug interaction. Albeit topical therapy is favorable to its localized effect, its potency relates to the effective concentration of the antifungal drugs achieved at the infection site. An approach to accomplish this goal would be acquiring benefits from the terpenes as penetration enhancers from natural sources. This investigation aimed to study the effectiveness of six terpenes, namely safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, as potential penetration enhancers for improved nail permeation of fluconazole through the human nail.

METHODS

Ex vivo permeation experiments were carried out by soaking the nail clippings of human volunteers in control and working solutions containing fluconazole (5 mg/ml) per se and fluconazole (5 mg/ml) with 6% of each terpene, including safranal, lavandulol, rose oxide, 3-methyl-2-butene-1-ol, linalool, and limonene, respectively, for 48 hours. The amount of fluconazole in nail clippings was quantified using an HPLC method.

RESULTS

Statistical analysis showed that fluconazole transungual permeation was influenced by the studied terpenes in the following order: safranal > lavandulol acetate > limonene > rose oxide (P-value > 0.05) while the other terpenes showed no significant difference with the control group and safranal represents as the most effective permeation enhancer for the transungual delivery of fluconazole.

CONCLUSION

It is concluded that the safranal can be successfully used as a safe and potential permeation enhancer to enhance the transungual delivery of fluconazole for the treatment of onychomycosis.

A detailed insight on the molecular and cellular mechanism of action of the antifungal drugs used in the treatment of superficial fungal infections

Background:

Dermatomycosis, a type of fungal infection that can infect human skin, hair, and nails; day by day the growth of fungal infections ranging from superficial to systemic infection is alarming. Common causative agents included are Candida, Cryptococcus, Aspergillus, and Pneumocystis species.

Objective:

The effective treatment of the fungal infection includes the use of proper antifungal drug therapy. Antifungal drugs are classified into various classes. This paper focuses on understanding and interpreting the detailed molecular and cellular mechanism of action of various classes of an anti-fungal drug along with their important characteristics along with the safety and efficacy data of individual drugs of the particular class.

Methods:

The data selection for carrying out the respective study has been done by studying the combination of review articles and research papers from different databases like Research Gate, PubMed, MDPI, Elsevier, Science Direct, and Med Crave ranging from the year 1972 to 2019 by using the keywords like “anti-fungal agents”, “dermatophytes”, “cutaneous candidiasis”, “superficial fungal infections”, “oral candidiasis”, “amphotericin”, “echinocandins”, “azoles”, “polyenes” “ketoconazole”, “terbinafine”, “griseofulvin”, “azoles”.

Result:

Based on interpretation, we have concluded that the different classes of antifungal drugs follow the different mechanisms of action and target the fungal cell membrane, and are efficient in reducing fungal disease by their respective mechanism.

Conclusion:

The prevention and cure of fungal infections can be done by oral or topical antifungal drugs that aim to destroy the fungal cell membrane. These drugs show action by their respective pathways that are either preventing the formation of ergosterol or squalene or act by inhibiting β-1,3-glucan synthase enzyme. All the drugs are effective in treating fungal infections.

Efficacy of Lasers for the Management of Dermatophyte Toenail Onychomycosis

BACKGROUND

Onychomycosis is a chronic fungal nail infection caused predominantly by dermatophytes, and less commonly by nondermatophyte molds and Candida species. Onychomycosis treatment includes oral and topical antifungals, the efficacy of which is evaluated through randomized, double-blind, controlled trials for US Food and Drug Administration approval. The primary efficacy measure is complete cure (complete mycologic and clinical cure). The secondary measures are clinical cure (usually ≤10% involvement of target nail) and mycologic cure (negative microscopy and culture). Some lasers are US Food and Drug Administration approved for the mild temporary increase in clear nail; however, some practitioners attempt to use lasers to treat and cure onychomycosis.

METHODS

A systematic review of the literature was performed in July of 2020 to evaluate the efficacy rates demonstrated by randomized controlled trials of laser monotherapy for dermatophyte onychomycosis of the great toenail.

RESULTS

Randomized controlled trials assessing the efficacy of laser monotherapy for dermatophyte toenail onychomycosis are limited. Many studies measured cure rates by means of nails instead of patients, and performed only microscopy or culture, not both. Only one included study reported mycologic cure rate in patients as negative light microscopy and culture (0%). The combined clinical cure rates in short- and long-pulsed laser studies were 13.0%-16.7% and 25.9%, respectively. There was no study that reported the complete cure rate; however, one did report treatment success (mycologic cure [negative microscopy and culture] and ≤10% clinical involvement) in nails as 16.7%.

CONCLUSIONS

The effectiveness of lasers as a therapeutic intervention for dermatophyte toenail onychomycosis is limited based on complete, mycologic, and clinical cure rates. However, it may be possible to use different treatment parameters or lasers with a different wavelength to increase the efficacy. Lasers could be a potential management option for older patients and onychomycosis patients with coexisting conditions such as diabetes, liver, and/or kidney diseases for whom systemic antifungal agents are contraindicated or have failed.

Review of the alternative therapies for onychomycosis and superficial fungal infections: posaconazole, fosravuconazole, voriconazole, oteseconazole

Terbinafine and itraconazole are the most commonly used oral antifungals to treat onychomycosis and superficial dermatomycoses. Recently, poor response to oral terbinafine has been reported. We have summarized the most appropriate dosing regimens of posaconazole, fosravuconazole, voriconazole, and oteseconazole (VT-1161) to treat onychomycosis and superficial fungal infections. A structured search on PubMed and Google Scholar was conducted. Additionally, the bibliographies of selected articles were searched to identify relevant records. The number of records identified from the searches was 463, with 50 articles meeting the inclusion criteria for review. None of the new azoles are US FDA approved for onychomycosis treatment; however, an increasing number of studies have evaluated these agents. The efficacies (complete cure and mycologic cure) of the antifungal agents for dermatophyte great toenail onychomycosis treatment are terbinafine 250 mg/day × 12 weeks (Phase III trial) (38%, 70%), itraconazole 200 mg/day × 12 weeks (Phase III trial) (14%, 54%), posaconazole 200 mg/day × 24 weeks (Phase IIB) (54.1%, 70.3%), fosravuconazole 100 mg/day ravuconazole equivalent × 12 weeks (Phase III) (59.4%, 82.0%), and oteseconazole 300 mg/day loading dose × 2 weeks (Phase II), followed by 300 mg/week × 10 weeks (maintenance dose) (45%, 70%). Guidelines for monitoring are also presented.

Candidiasis in Birds (Galliformes, Anseriformes, Psittaciformes, Passeriformes, and Columbiformes): A Focus on Antifungal Susceptibility Pattern of Candida albicans and Non-albicans Isolates in Avian Clinical Specimens

Candidiasis is a fungal infection caused by Candida species which has been reported in most domestic and wild birds and mammals. In this study, 196 samples from different species of birds with suspected symptoms of candidiasis were examined. Pharyngeal swabs, cloacal swabs, and fecal samples were taken from the birds. The samples were cultured in sabouraud dextrose agar (SDA) containing cycloheximide and chloramphenicol and incubated at 42°C. Suspected isolates of Candida were identified using PCR. To detect the candida genus, a primer set to target the candida rDNA (ITS1-ITS4) was selected. To detect Candida albicans (C albicans), a primer set to target cytochrome P-450 lanosterol-a-demethylase (P450-LIAl) gene (DH-1558) was selected. In direct microscopic observation and culture, 28.57% of the birds were suspected of candidiasis. In the molecular study, candidiasis was confirmed in 25% of the birds, and candidiasis caused by C albicans was confirmed in 14.28% of the birds. All isolates were subjected to antibiotic susceptibility by the disk diffusion method with glucose-enriched Mueller-Hinton Agar. 78.5% of the isolates were sensitive to nystatin and amphotericin B. None of the isolates were sensitive to itraconazole and more than 50% of the isolates were resistant to fluconazole, ketoconazole, and itraconazole. According to the results, it is suggested to use nystatin and amphotericin B in the treatment of avian candidiasis in the Ahvaz region. To the authors' knowledge, this is the first report of the molecular detection and antifungal susceptibility pattern of C albicans and non- albicans from Galliformes, Anseriformes, Psittaciformes, and Passeriformes in Iran.

Fosciclopirox suppresses growth of high-grade urothelial cancer by targeting the γ-secretase complex

Ciclopirox (CPX) is an FDA-approved topical antifungal agent that has demonstrated preclinical anticancer activity in a number of solid and hematologic malignancies. Its clinical utility as an oral anticancer agent, however, is limited by poor oral bioavailability and gastrointestinal toxicity. Fosciclopirox, the phosphoryloxymethyl ester of CPX (Ciclopirox Prodrug, CPX-POM), selectively delivers the active metabolite, CPX, to the entire urinary tract following parenteral administration. We characterized the activity of CPX-POM and its major metabolites in in vitro and in vivo preclinical models of high-grade urothelial cancer. CPX inhibited cell proliferation, clonogenicity and spheroid formation, and increased cell cycle arrest at S and G0/G1 phases. Mechanistically, CPX suppressed activation of Notch signaling. Molecular modeling and cellular thermal shift assays demonstrated CPX binding to γ-secretase complex proteins Presenilin 1 and Nicastrin, which are essential for Notch activation. To establish in vivo preclinical proof of principle, we tested fosciclopirox in the validated N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) mouse bladder cancer model. Once-daily intraperitoneal administration of CPX-POM for four weeks at doses of 235 mg/kg and 470 mg/kg significantly decreased bladder weight, a surrogate for tumor volume, and resulted in a migration to lower stage tumors in CPX-POM treated animals. This was coupled with a reduction in the proliferation index. Additionally, there was a reduction in Presenilin 1 and Hes-1 expression in the bladder tissues of CPX-POM treated animals. Following the completion of the first-in-human Phase 1 trial (NCT03348514), the pharmacologic activity of fosciclopirox is currently being characterized in a Phase 1 expansion cohort study of muscle-invasive bladder cancer patients scheduled for cystectomy (NCT04608045) as well as a Phase 2 trial of newly diagnosed and recurrent urothelial cancer patients scheduled for transurethral resection of bladder tumors (NCT04525131).

Hydrogel-Based Active Substance Release Systems for Cosmetology and Dermatology Application: A Review

Hydrogels are playing an increasingly important role in medicine and pharmacy. Due to their favorable physicochemical properties, biocompatibility, and designed interaction with living surroundings, they seem to be one of the most promising groups of biomaterials. Hydrogel formulations from natural, semi, or synthetic polymeric materials have gained great attention in recent years for treating various dermatology maladies and for cosmetology procedures. The purpose of this review is to present a brief review on the basic concept of hydrogels, synthesis methods, relevant mechanisms, and applications in dermatology or cosmetology. This review discusses transdermal therapies and the recent advances that have occurred in the field.

Preclinical Pharmacokinetics of Fosciclopirox, a Novel Treatment of Urothelial Cancers, in Rats and Dogs

Pharmacokinetic studies in rats and dogs were performed to characterize the in vivo performance of a novel prodrug, fosciclopirox. Ciclopirox olamine (CPX-O) is a marketed topical antifungal agent with demonstrated in vitro and in vivo preclinical anticancer activity in several solid tumor and hematologic malignancies. The oral route of administration for CPX-O is not feasible due to low bioavailability and dose-limiting gastrointestinal toxicities. To enable parenteral administration, the phosphoryl-oxymethyl ester of ciclopirox (CPX), fosciclopirox (CPX-POM), was synthesized and formulated as an injectable drug product. In rats and dogs, intravenous CPX-POM is rapidly and completely metabolized to its active metabolite, CPX. The bioavailability of the active metabolite is complete following CPX-POM administration. CPX and its inactive metabolite, ciclopirox glucuronide (CPX-G), are excreted in urine, resulting in delivery of drug to the entire urinary tract. The absolute bioavailability of CPX following subcutaneous administration of CPX-POM is excellent in rats and dogs, demonstrating the feasibility of this route of administration. These studies confirmed the oral bioavailability of CPX-O is quite low in rats and dogs compared with intravenous CPX-POM. Given its broad-spectrum anticancer activity in several solid tumor and hematologic cancers and renal elimination, CPX-POM is being developed for the treatment of urothelial cancer. The safety, dose tolerance, pharmacokinetics, and pharmacodynamics of intravenous CPX-POM are currently being characterized in a United States multicenter first-in-human Phase 1 clinical trial in patients with advanced solid tumors (NCT03348514).

Treatment of Tinea Capitis

Tinea capitis is a common fungal infection of the hair of the scalp affecting predominately prepubertal children. In the US, griseofulvin has been considered a first-line therapy agent for tinea capitis since the 1960s. However, it has been falling out of favor due to significant treatment failure, high cost, and long duration of treatment. Other antifungal agents have been researched as an alternative to griseofulvin. This paper will review the relevant pharmacologic properties, dosing, cost, efficacy, and adverse events profile for griseofulvin, terbinafine, itraconazole, fluconazole, and some adjuvant therapy options such as selenium sulfide shampoos and topical ketoconazole.

Therapy of Skin, Hair and Nail Fungal Infections

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.

Diagnosis and treatment of dermatophytosis in dogs and cats.: Clinical Consensus Guidelines of the World Association for Veterinary Dermatology

BACKGROUND

Dermatophytosis is a superficial fungal skin disease of cats and dogs. The most common pathogens of small animals belong to the genera Microsporum and Trichophyton. It is an important skin disease because it is contagious, infectious and can be transmitted to people.

OBJECTIVES

The objective of this document is to review the existing literature and provide consensus recommendations for veterinary clinicians and lay people on the diagnosis and treatment of dermatophytosis in cats and dogs.

METHODS

The authors served as a Guideline Panel (GP) and reviewed the literature available prior to September 2016. The GP prepared a detailed literature review and made recommendations on selected topics. The World Association of Veterinary Dermatology (WAVD) provided guidance and oversight for this process. A draft of the document was presented at the 8th World Congress of Veterinary Dermatology (May 2016) and was then made available via the World Wide Web to the member organizations of the WAVD for a period of three months. Comments were solicited and posted to the GP electronically. Responses were incorporated by the GP into the final document.

CONCLUSIONS

No one diagnostic test was identified as the gold standard. Successful treatment requires concurrent use of systemic oral antifungals and topical disinfection of the hair coat. Wood's lamp and direct examinations have good positive and negative predictability, systemic antifungal drugs have a wide margin of safety and physical cleaning is most important for decontamination of the exposed environments. Finally, serious complications of animal-human transmission are exceedingly rare.

Itraconazole and Terbinafine Treatment of Some Nondermatophyte Molds Causing Onychomycosis of the Toes and a Review of the Literature

Background:

Onychomycosis may be caused by dermatophytes (which form the majority of organisms), Candida species, and nondermatophyte molds.

Objective:

To evaluate the efficacy and safety of itraconazole and terbinafine in the treatment of some nondermatophyte molds that cause toe onychomycosis and to review the literature on the treatment of nondermatophyte mold toe onychomycosis using the oral antifungal agents.

Patients and Methods:

Patients with nondermatophyte mold toe onychomycosis were treated in an open, prospective manner with either itraconazole (pulse) or terbinafine therapy. In each instance, light microscopic examination was consistent with the diagnosis of a nondermatophyte mold. For each patient, mycological evaluation of the target nail resulted in 3 or more successive cultures yielding growth of the mold alone.

Results:

All 15 patients had onychomycosis of the toes which was of the distal and lateral type. The patients were treated with itraconazole given as the standard 3 pulses with additional pulses administered depending upon the response exhibited by the toe onychomycosis in the patient. Similarly, terbinafine was given for 12 weeks with additional therapy administered as dictated by the response. Efficacy parameters were mycological cure (MC) and clinical cure (CC). Mycological cure was negative light microscopic examination (KOH) and culture. Clinical cure was the appearance of a completely normal-looking nail. At month 12 from the start of treatment, the response was as follows: Scopulariopsis brevicaulis: itraconazole (MC 4/4, CC 2/4) and terbinafine (MC 0/1, CC 0/1), Fusarium species: itraconazole (MC 1/1, CC 1/1) and terbinafine (MC 0/1, CC 0/1), Aspergillus species: itraconazole (MC 5/6, CC 3/6), Alternaría alternata: itraconazole (MC 0/1, CC 0/1), and Onychocola canadensis: itraconazole (MC 1/1, CC 0/1). There were no significant clinical or laboratory adverse effects.

Conclusions:

In the present series itraconazole demonstrated efficacy against onychomycosis of the toenails caused by 5. brevicaulis and Aspergillus species. A review of the literature confirms our experience with itraconazole and further suggests that terbinafine may also demonstrate efficacy against cases of S. brevicaulis and Aspergillus toe onychomycosis. Additionally, reports in the literature suggest that pedal onychomycosis caused by Fusarium species may also show response to itraconazole and terbinafine. For the other species, there are fewer data, making it difficult to draw conclusions.

Improving Cure Rates in Onychomycosis

Background:

Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management.

Objective:

To identify ways to improve cure rates for onychomycosis.

Method:

The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates.

Results and Conclusion:

To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.

Multitherapy Approach to Onychomycosis Therapy

New medications and new formulations have provided an increase in the cure rates for onychomycosis. Many cases of infection, however, are still not cured. It is not always obvious which factors are most relevant to reduction of cure, and factors may vary with each patient. For these reasons, a multitherapy approach to onychomycosis may be needed to individualize treatment to each patient's specific condition. Different presentations and severity levels of onychomycosis may respond differently to treatment modalities and require varying amounts of intervention. Nail débridement may be used to lessen the burden of infection in cases in which drug penetration may not occur adequately otherwise, such as dermatophytoma, onycholysis, or lateral infection. Ciclopirox nail lacquer has been approved for use in conjunction with regular débridement and represents the first approved multitherapy approach. Topical antifungals may be combined with oral antifungals to provide dual fronts of drug penetration. Similarly, two oral medications may be combined to provide a wider spectrum of antifungal activity and differential mode of action against the organisms, which may increase fungistatic or fungicidal action. There is a nonclinical component of therapy, represented by patient education on onychomycosis infection and treatment, which should be used to ensure that patient expectations are realistic and to encourage patient compliance with the chosen regimens.

Vulvovaginal candidosis: contemporary challenges and the future of prophylactic and therapeutic approaches

Vulvovaginal candidosis (VVC) is a common gynaecological disorder that is delineated by the inflammation of vaginal wall and it is caused by the opportunistic fungal pathogen Candida species. In fact, three out of every four women will experience at least one occasion of VVC during some point in their lives. Although uncomplicated VVC is relatively harmless, the complicated VVC such as recurrent attack often creates restlessness and depression in the patients, thus greatly affects their quality of life. Managements of VVC are usually associated with the use of antimycotic suppositories, topical cream or oral agents. These antimycotic agents are either available over-the-counter or prescribed by the clinicians. In recent decades, the rise of clinical challenges such as the increased prevalence of resistant Candida strains, recurrent VVC infection and adverse effects of multidrug interactions have necessitated the development of novel therapeutic or prophylactic options to combat the complicated VVC in the future. In this review, we discuss the current antimycotic treatments available for Candida vaginitis and the problems that exist in these seemingly effective treatments. Besides, we attempt to contemplate some of the future and prospective strategies surrounding the development of alternative therapeutic and prophylactic options in treating and preventing complicated VVC respectively.

The Rise and Fall of Oral Ketoconazole

Background:

Ketoconazole was the first broad-spectrum oral antifungal agent available to treat systemic and superficial mycoses. Evidence of hepatotoxicity associated with its use emerged within the first few years of its approval. Growing evidence of serious side effects including endocrine dysregulation, several drug interactions, and death led to the review of oral ketoconazole in 2011.

Objective:

This article chronicles the use of oral ketoconazole from its introduction to its near replacement in medicine.

Conclusion:

Due to its hepatotoxic side effects, oral ketoconazole was withdrawn from the European and Australian markets in 2013. The United States imposed strict relabeling requirements and restrictions for prescription, with Canada issuing a risk communication echoing these concerns. Today, oral ketoconazole is only indicated for endemic mycoses, where alternatives are not available or feasible. Meanwhile, topical ketoconazole is effective, safe, and widely prescribed for superficial mycoses, particularly as the first-line treatment for tinea versicolor.

Drug safety assessment of oral formulations of ketoconazole

INTRODUCTION

Ketoconazole was the first broad-spectrum oral antifungal approved by the FDA in 1981. Post-marketing reports of drug-related hepatotoxicity, endocrine dysregulation and drug interactions resulted in market withdrawal of the drug in some countries and strict product relabeling in others.

AREAS COVERED

This drug safety review summarizes reports of oral ketoconazole-related adverse events retrieved from a search of the PubMed database using the search strategy 'ketoconazole OR Nizoral AND hepat*', references from relevant publications, and data from the FDA Adverse Event Reporting System.

EXPERT OPINION

Although oral ketoconazole is effective in treating fungal infections, the potential for drug interactions, endocrine dysregulation, and hepatotoxicity may outweigh its benefits. Newer oral antifungals have similar or greater efficacy in treating dermatologic conditions and are associated with less risk. Likewise, newer agents with specific targets and fewer drug interactions have been developed to treat systemic fungal infections. Therefore, by the time ketoconazole prescribing guidelines were amended, its use had already largely been replaced with newer antifungals. Being that ketoconazole was the first broad-spectrum oral antifungal, experience with the drug made patient safety, and especially hepatic safety, an important consideration in future antifungal development.

Resistance to antifungals that target CYP51

Fungal diseases are an increasing global burden. Fungi are now recognised to kill more people annually than malaria, whilst in agriculture, fungi threaten crop yields and food security. Azole resistance, mediated by several mechanisms including point mutations in the target enzyme (CYP51), is increasing through selection pressure as a result of widespread use of triazole fungicides in agriculture and triazole antifungal drugs in the clinic. Mutations similar to those seen in clinical isolates as long ago as the 1990s in Candida albicans and later in Aspergillus fumigatus have been identified in agriculturally important fungal species and also wider combinations of point mutations. Recently, evidence that mutations originate in the field and now appear in clinical infections has been suggested. This situation is likely to increase in prevalence as triazole fungicide use continues to rise. Here, we review the progress made in understanding azole resistance found amongst clinically and agriculturally important fungal species focussing on resistance mechanisms associated with CYP51. Biochemical characterisation of wild-type and mutant CYP51 enzymes through ligand binding studies and azole IC50 determinations is an important tool for understanding azole susceptibility and can be used in conjunction with microbiological methods (MIC50 values), molecular biological studies (site-directed mutagenesis) and protein modelling studies to inform future antifungal development with increased specificity for the target enzyme over the host homologue.

Candida infections and their prevention

Infections caused by Candida species have been increased dramatically worldwide due to the increase in immunocompromised patients. For the prevention and cure of candidiasis, several strategies have been adopted at clinical level. Candida infected patients are commonly treated with a variety of antifungal drugs such as fluconazole, amphotericin B, nystatin, and flucytosine. Moreover, early detection and speciation of the fungal agents will play a crucial role for administering appropriate drugs for antifungal therapy. Many modern technologies like MALDI-TOF-MS, real-time PCR, and DNA microarray are being applied for accurate and fast detection of the strains. However, during prolonged use of these drugs, many fungal pathogens become resistant and antifungal therapy suffers. In this regard, combination of two or more antifungal drugs is thought to be an alternative to counter the rising drug resistance. Also, many inhibitors of efflux pumps have been designed and tested in different models to effectively treat candidiasis. However, most of the synthetic drugs have side effects and biomedicines like antibodies and polysaccharide-peptide conjugates could be better alternatives and safe options to prevent and cure the diseases. Furthermore, availability of genome sequences of Candida   albicans and other non-albicans strains has made it feasible to analyze the genes for their roles in adherence, penetration, and establishment of diseases. Understanding the biology of Candida species by applying different modern and advanced technology will definitely help us in preventing and curing the diseases caused by fungal pathogens.

Oral treatments for fungal infections of the skin of the foot

BACKGROUND

About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re-infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed.

OBJECTIVES

To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis).

SEARCH METHODS

For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers.

SELECTION CRITERIA

Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction.

MAIN RESULTS

We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported.

AUTHORS' CONCLUSIONS

The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred.

Cytochrome P450 3A-mediated microsomal biotransformation of 1α,25-dihydroxyvitamin D3 in mouse and human liver: drug-related induction and inhibition of catabolism

The biological activities of vitamin D(3) are exerted through the dihydroxy metabolite of vitamin D(3) [1α,25(OH)(2)D(3)]. Hepatic biotransformation of 1α,25(OH)(2)D(3) by cytochrome P450 (P450) enzymes could be an important determinant of bioavailability in serum and tissues. In the present study, we investigated the comparative biotransformation of 1α,25(OH)(2)D(3) in mouse and human liver microsomes and determined the effects of commonly used drugs on the catabolism of 1α,25(OH)(2)D(3). Severe symptoms of vitamin D deficiency have historically been observed in patients who received dexamethasone. To compare the effects of clinically important glucocorticoids with hepatic biotransformation of 1α,25(OH)(2)D(3), adult male CD-1 mice were given intraperitoneal injections of either vehicle (50% ethanol), dexamethasone (80 mg/kg per day), or prednisone (80 mg/kg per day) for three consecutive days. Hydroxy metabolite formation pattern and the extent of substrate depletion were similar in mouse liver microsomes (MLM) from vehicle- or prednisone-treated mice, whereas treatment with dexamethasone led to the emergence of additional metabolites and increased substrate depletion, as determined by liquid chromatography/mass spectrometry. The metabolite formation profile in vehicle-treated mice was different from that of human liver microsomes (HLM). Selective P450 chemical inhibitors have demonstrated that CYP3A isoforms are responsible for the microsomal biotransformation of 1α,25(OH)(2)D(3) in MLM. Coincubation of 1α,25(OH)(2)D(3) with commonly used drugs led to approximately 60 to 100% inhibition of CYP3A4-mediated catabolism of 1α,25-(OH)(2)D(3) in HLM. A species-based difference was identified between CYP3A-mediated hepatic microsomal metabolism of 1α,25(OH)(2)D(3) in humans and mice. We have shown that the clinical importance of glucocorticoids differentially modulates catabolism of active vitamin D(3) and that commonly used drugs could affect vitamin D homeostasis.

Cutaneous Manifestations of Infectious Diseases

Skin infections account for a significant portion of ­dermatologic diseases. Infections of the skin and subcutaneous tissues are highly diverse in respect to incidence, ­etiologic organisms, and clinical manifestations. Most cases are potentially treatable, thus, it is vital for the clinician to become familiar with the cutaneous expression of local and systemic processes. This chapter covers the clinical presentation, diagnosis, and treatment of the most common bacterial, viral, and fungal mucocutaneous infections encountered in internal medicine.

Fatty acid profile and influence of oxythiamine on fatty acid content in Malassezia pachydermatis, Candida albicans and Saccharomyces cerevisiae

Malassezia pachydermatis and Candida albicans are fungi involved in the skin diseases and systemic infections. The therapy of such infections is difficult due to relapses and problems with pathogen identification. In our study, we compare the fatty acids profile of M. pachydermatis, C. albicans and S. cerevisiae to identify diagnostic markers and to investigate the effect of oxythiamine (OT) on the lipid composition of these species. Total fatty acid content is threefold higher in C. albicans and M. pachydermatis compared with S. cerevisiae. These two species have also increased level of polyunsaturated fatty acids (PUFA) and decreased content of monounsaturated fatty acids (MUFA). We noted differences in the content of longer chain (>18) fatty acids between studied species (for example a lack of 20 : 1 in S. cerevisiae and 22 : 0 in M. pachydermatis and C. albicans). OT reduces total fatty acids content in M. pachydermatis by 50%. In S. cerevisiae, OT increased PUFA whereas it decreased MUFA content. In C. albicans, OT decreased PUFA and increased MUFA and SFA content. The results show that the MUFA to PUFA ratio and the fatty acid profile could be useful diagnostic tests to distinguish C. albicans, M. pachydermatis and S. cerevisiae, and OT affected the lipid metabolism of the investigated species, especially M. pachydermatis.

Antifungal activity of Aegle marmelos (L.) Correa (Rutaceae) leaf extract on dermatophytes

OBJECTIVE

To evaluate the in vitro antifungal activity of Aegle marmelos leaf extracts and fractions on the clinical isolates of dermatophytic fungi like Trichophyton mentagrophytes, Trichophyton rubrum, Microsporum canis, Microsporum gypseum and Epidermophyton floccosum.

METHODS

The minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) of various extracts and fractions of the leaves of Aegle marmelos were measured using method of National Committee for Clinical Laboratory Standards (NCCLS).

RESULTS

Aegle marmelos leaf extracts and fractions were found to have fungicidal activity against various clinical isolates of dermatophytic fungi. The MIC and MFC was found to be high in water and ethyl alcohol extracts and methanol fractions (200µg/mL) against dermatophytic fungi studied.

CONCLUSIONS

Aegle marmelos leaf extracts significantly inhibites the growth of all dermatophytic fungi studied. If this activity is confirmed by in vivo studies and if the compound is isolated and identified, it could be a remedy for dermatophytosis.

Oral candidiasis and angular cheilitis

Candidiasis, an often encountered oral disease, has been increasing in frequency. Most commonly caused by the overgrowth of Candida albicans, oral candidiasis can be divided into several categories including acute and chronic forms, and angular cheilitis. Risk factors for the development of oral candidiasis include immunosuppression, wearing of dentures, pharmacotherapeutics, smoking, infancy and old age, endocrine dysfunction, and decreased salivation. Oral candidiasis may be asymptomatic. More frequently, however, it is physically uncomfortable, and the patient may complain of burning mouth, dysgeusia, dysphagia, anorexia, and weight loss, leading to nutritional deficiency and impaired quality of life. A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.

3-ketocholanoic acid is the major in vitro human hepatic microsomal metabolite of lithocholic acid

3alpha-Hydroxy-5 beta-cholan-24-oic (lithocholic) acid is a relatively minor component of hepatic bile acids in humans but is highly cytotoxic. Hepatic microsomal oxidation offers a potential mechanism for effective detoxification and elimination of bile acids. The aim of the present study was to investigate the biotransformation of lithocholic acid by human hepatic microsomes and to assess the contribution of cytochrome P450 (P450) enzymes in human hepatic microsomes using human recombinant P450 enzymes and chemical inhibitors. Metabolites were identified, and metabolite formation was quantified using a liquid chromatography/mass spectrometry-based assay. Incubation of lithocholic acid with human liver microsomes resulted in the formation of five metabolites, which are listed in order of their rates of formation: 3-oxo-5 beta-cholan-24-oic (3-ketocholanoic) acid, 3 alpha,6 alpha-dihydroxy-5 beta-cholan-24-oic (hyodeoxycholic) acid, 3 alpha,7 beta-dihydroxy-5 beta-cholan-24-oic (ursodeoxycholic) acid, 3 alpha,6 beta-dihydroxy-5 beta-cholan-24-oic (murideoxycholic) acid, and 3 alpha-hydroxy-6-oxo-5 beta-cholan-24-oic (6-ketolithocholic) acid. 3-Ketocholanoic acid was the major metabolite, exhibiting apparent K(m) and V(max) values of 22 muM and 336 pmol/min/mg protein, respectively. Incubation of lithocholic acid with a of human recombinant P450 enzymes revealed that all five metabolites were formed by recombinant CYP3A4. Chemical inhibition studies with human liver microsomes and recombinant P450 enzymes confirmed that CYP3A4 was the predominant enzyme involved in hepatic microsomal biotransformation of lithocholic acid. In summary, the results indicate that oxidation of the third carbon of the cholestane ring is the preferred position of oxidation by P450 enzymes for lithocholic acid biotransformation in humans and suggest that formation of lithocholic acid metabolites leads to enhanced hepatic detoxification and elimination.

Therapeutic options for the treatment of tinea capitis: Griseofulvin versus fluconazole

BACKGROUND

Tinea capitis is a relatively common fungal infection of childhood. Griseofulvin has been the mainstay of treatment for many years. However, newer oral antifungal agents are being used more frequently.

OBJECTIVE

Our purpose was to evaluate the therapeutic efficacy of fluconazole in comparison with griseofulvin in the treatment of tinea capitis.

METHODS

We performed a single-blind, randomized, prospective evaluation of 40 patients with a clinical and mycologic diagnosis of tinea capitis. One group received fluconazole for 4 weeks. The other group received griseofulvin for 6 weeks. Five clinical parameters were evaluated. Mycologic examinations were performed at baseline and at the end of 8 weeks.

RESULTS

Patients ranged in age from 1 to 16 years; 80% were boys and 20% were girls. Mycologic examinations disclosed Trichophyton verrucosum in 40% of patients, T. violaceum in 40% and Microsporum canis in 20%. At week 8, the griseofulvin-treated group showed a cure rate of 76%, and the fluconazole-treated group 78%. The cure rates were not statistically significant.

CONCLUSION

Fluconazole constitutes an alternative but, because of greater availability and lower cost, griseofulvin remains the treatment of choice for tinea capitis.

Evidence-based veterinary dermatology: a systematic review of interventions for Malassezia dermatitis in dogs

The aim of this systematic review was to evaluate the efficacy of antifungal treatments for Malassezia dermatitis in dogs and, when possible, to propose recommendation for or against their use. Electronic searches were carried out using PubMed MEDLINE(R), CABDirect and CONSULTANT database. The volumes of Advances in Veterinary Dermatology, the proceedings of ESVD/ECVD and AAVD/ACVD congresses were hand-searched for studies relevant to this review. All articles and book chapters discussing treatment of Malassezia dermatitis were scanned for additional citations. Lastly, a request was sent to the Vetderm Listserv to share recent clinical trials. The analysis evaluated study design, methodology quality, subject enrolment quality, type of interventions and outcome measures. The searches identified 35 articles, and 14 trials that fulfilled the following selection criteria: (i) in vivo clinical trials, (ii) dogs showing clinical lesions of Malassezia dermatitis and (iii) enrolment of at least five dogs. Among these, only eight studies fulfilled the following additional criterion: (iv) prospective in vivo clinical trials reporting clinical and mycological outcome measures. A total number of 14 different treatment protocols included four blinded, randomized and controlled trials (quality of evidence grade A), four controlled studies lacking blinding and/or randomization (grade B), five open uncontrolled trials (grade C) and one descriptive study (grade D). This systematic review allowed us to recommend, with good evidence, the use of only one topical treatment of Malassezia dermatitis (2% miconazole nitrate +2% chlorhexidine, twice a week for 3 weeks) and with fair evidence the use of two systemic treatments with azole derivatives (ketoconazole, 10 mg kg(-1) day(-1) and itraconazole, 5 mg kg(-1) day(-1) for 3 weeks).

Advances in topical and systemic antifungals

Topical antifungal agents are generally used for the treatment of superficial fungal infections unless the infection is widespread, involves an extensive area, or is resistant to initial therapy. Systemic antifungals are often reserved for the treatment of onychomycosis, tinea capitis, superficial and systemic candidiasis, and prophylaxis and treatment of invasive fungal infections. With the development of resistant fungi strains and the increased incidence of life-threatening invasive fungal infections in immunocompromised patients, some previously effective traditional antifungal agents are subject to limitations including multidrug interactions, severe adverse effects, and their fungistatic mechanism of actions. Several new antifungal agents have demonstrated significant therapeutic benefits and have broadened clinicians' choices in the treatment of superficial and systemic invasive fungal infections.

Forty-eight-hour diagnosis of onychomycosis with subtyping of Trichophyton rubrum strains

A novel strategy for the molecular identification of fungal agents of onychomycosis (including Trichophyton rubrum) has been designed based on the use of species-specific and universal primers in conjunction with a commercial kit that allows the extraction of DNA directly from the nail specimens. The microsatellite marker T1, which is based on a (GT)n repeat, was applied for the species-specific identification of Trichophyton rubrum. To evaluate how often Scopulariopsis spp. are detected in nail specimens, a second primer pair was designed to amplify specifically a 336-bp DNA fragment of the 28S region of the nuclear rRNA gene of S. brevicaulis and closely related species. Other fungal species were identified using amplification of the internal transcribed spacer (ITS) region of the rRNA gene, followed by restriction fragment length polymorphism analysis or sequencing. In addition, polyacrylamide gel separation of the T1-PCR product allowed subtyping of T. rubrum strains. We studied 195 nail specimens (the "nail sample") and 66 previously collected etiologic strains (the "strain sample") from 261 onychomycosis patients from Bulgaria and Greece. Of the etiologic agents obtained from both samples, T. rubrum was the most common organism, confirmed to be present in 76% of all cases and serving as the sole or (rarely) mixed etiologic agent in 199 of 218 cases (91%) where the identity of the causal organism(s) was confirmed. Other agents seen included molds (6% of cases with identified etiologic agents; mainly S. brevicaulis) and other dermatophyte species (4%; most frequently Trichophyton interdigitale). Simultaneous infections with two fungal species were confirmed in a small percentage of cases (below 1%). The proportion of morphologically identified cultures revealed by molecular study to have been misidentified was 6%. Subtyping revealed that all but five T. rubrum isolates were of the common type B that is prevalent in Europe. In comparison to microscopy and culture, the molecular approach was superior. The PCR was more sensitive (84%) than culture (22%) in the nail sample and was more frequently correct in specifically identifying etiologic agents (100%) than microscopy plus routine culture in either the nail or the strain samples (correct culture identifications in 96% and 94% of cases, respectively). Using the molecular approach, the time for diagnosing the identity of fungi causing onychomycosis could be reduced to 48 h, whereas culture techniques generally require 2 to 4 weeks. The early detection and identification of the infecting species in nails will facilitate prompt and appropriate treatment and may be an aid for the development of new antifungal agents.

Pediatric tinea capitis: recognition and management

Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide. If suspected clinically, further diagnostic procedures, including direct microscopy and culture, should be performed. Other scalp alterations, such as seborrheic dermatitis, atopic eczema, psoriasis, alopecia areata, folliculitis, and pseudopelade, may mimic ringworm of the head and must be identified. A proven fungal infection of scalp skin and hairs warrants immediate initiation of systemic treatment. At present, only oral griseofulvin is approved for therapy of scalp ringworm in children by health authorities. However, the advent of several newer antifungal agents such as itraconazole, fluconazole, and terbinafine has broadened the therapeutic armamentarium in recent years. These agents offer shorter treatment intervals, and their adverse effects and drug interaction profiles appear to be well within acceptable limits. In patients with tinea capitis, systemic therapy at weight-dependent dosages for an appropriate amount of time in conjunction with topical supportive measures will help to prevent disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions, and infection of other persons.

Current use of anti-infectives in dermatology

Dermatologic diseases encompass a broad category of pathologic situations. Infection remains a significant aspect of the pathology faced in patient encounters, and it is natural to expect that anti-infectives play a major element in the armamentarium utilized by dermatologists. Aside from the treatment of the classic bacterial and fungal infections, there are now new uses for antiviral agents to help suppress recurrent disease, such as herpes simplex. There is also the novel approach of using anti-infectives, or agents that have been thought to have antimicrobial activity, to treat inflammatory diseases. This review describes anti-infectives, beginning with common antibiotics used to treat bacterial infections. The discussion will then cover the current use of antivirals. Finally, the description of antifungals will be separated, starting with the oral agents and ending with the topical antimycotics. The use of anti-infectives in tropical dermatology has been purposefully left out, and perhaps should be the subject of a separate review. Cutaneous bacterial infections consist chiefly of those microorganisms that colonize the skin, such as species of staphylococcus and streptococcus. Propionibacterium acnes and certain other anaerobes can be involved in folliculitis, pyodermas and in chronic conditions such as hidradenitis suppurativa.

Tinea capitis: a treatment update

Currently, many experts consider griseofulvin to be the drug of choice for tinea capitis. It is FDA approved for this indication, highly efficacious, and has an excellent long-term safety record. Nonetheless, there is now ample evidence documenting the efficacy and safety of other antifungal agents. Terbinafine, itraconazole, and fluconazole have been used off-label in the United States and United Kingdom for tinea capitis. Several studies have shown that short-term terbinafine, itraconazole, or fluconazole each are comparable in efficacy and safety to griseofulvin. High-dose griseofulvin is still the first-line therapy for tinea capitis in our practice, but a large-scale, multicenter trial of higher dose terbinafine is now ongoing, and positive efficacy and safety results from that study may lead to a change in our standard of care. Terbinafine, itraconazole, or fluconazole currently are used in patients who have either failed griseofulvin or developed adverse reactions to this medication. Families must be informed that these other antifungal agents are not FDA-approved for this indication when they are used. Guidelines for therapy with each of these agents are summarized in Table 5. In addition, the adjuvant use of antifungal shampoos is recommended for all patients in order to decrease the viability of fungal spores present on the hair, as well as for all household contacts to prevent infection or eliminate the carrier state.

Tinea capitis caused by Microsporum canis treated with terbinafine

Tinea capitis is a disease found throughout the world. It frequently affects children and only rarely adults, usually post-menopausal women. Numerous dermatophytes of the genus Microsporum and Tricophyton can cause tinea capitis and griseofulvin is still today the treatment of choice. To study the effectiveness and tolerability of terbinafine treatment in tinea capitis caused by Microsporum canis we treated 26 patients - 22 children and four women - for a period of 12 weeks. Dosage adopted was 62.5 mg day(-1) in patients weighing less than 20 kg, 125 mg day(-1) in those weighing between 20 and 40 kg, and 250 mg day(-1) in patients weighing more than 40 kg. Clinical and mycological healing was achieved in 22 patients (84.6%), tolerability was excellent and in no cases were side effects or abnormal results in blood chemistry tests observed.

Superficial fungal infections

Superficial fungal infections arise from a pathogen that is restricted to the stratum corneum, with little or no tissue reaction. In this Seminar, three types of infection will be covered: tinea versicolor, piedra, and tinea nigra. Tinea versicolor is common worldwide and is caused by Malassezia spp, which are human saprophytes that sometimes switch from yeast to pathogenic mycelial form. Malassezia furfur, Malassezia globosa, and Malassezia sympodialis are most closely linked to tinea versicolor. White and black piedra are both common in tropical regions of the world; white piedra is also endemic in temperate climates. Black piedra is caused by Piedraia hortae; white piedra is due to pathogenic species of the Trichosporon genus. Tinea nigra is also common in tropical areas and has been confused with melanoma.

Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis

BACKGROUND

Onychomycosis is a common nail disease that is often chronic, difficult to eradicate, and has a tendency to recur. The most common oral therapies for dermatophyte toenail onychomycosis include terbinafine, itraconazole and fluconazole.

OBJECTIVES

A cumulative meta-analysis of the randomized controlled trials (RCTs) for antimycotic agents was performed to determine whether the pooled estimate of the cure rates has remained consistent over the years. Furthermore, for each agent we compared the overall meta-analytical average of both mycological and clinical response rates of RCTs vs. open studies.

METHODS

We searched MEDLINE (1966 to November 2002) for relevant studies evaluating the efficacy of the oral antifungal agents terbinafine, itraconazole (pulse or continuous), fluconazole and griseofulvin for treating dermatophyte toenail onychomycosis. Studies included in this meta-analysis required a standard accepted dosage regimen, treatment duration and follow-up period. To determine the cumulative meta-analytical average, studies were sequentially pooled by adding one study at a time according to the date of publication (i.e. earliest to the most recent).

RESULTS

There were 36 studies included in the analyses. For RCTs the change in efficacy of mycological cure rates from the first trial to the overall cumulative meta-average for each drug comparator is as follows (with 95% confidence interval): terbinafine, 78 +/- 6% (n = 2 studies, 79 patients) to 76 +/- 3% (n = 18 studies, 993 patients) (P = 0.68); itraconazole pulse, 75 +/- 10% (n = 1 study, 20 patients) to 63 +/- 7% (n = 6 studies, 318 patients) (P = 0.25); itraconazole continuous, 63 +/- 5% (n = 1 study, 84 patients) to 59 +/- 5% (n = 7 studies, 1131 patients) (P = 0.47); fluconazole, 53 +/- 6% (n = 1 study, 72 patients) to 48 +/- 5% (n = 3 studies, 131 patients) (P = 0.50); and griseofulvin, 55 +/- 8% (n = 2 studies, 109 patients) to 60 +/- 6% (n = 3 studies, 167 patients) (P = 0.41). The cumulative meta-analytical average of mycological cure rates when comparing RCTs vs. open studies was: terbinafine, 76 +/- 3% (n = 18 studies, 993 patients) vs. 83 +/- 12% (n = 2 studies, 391 patients) (P = 0.0028); itraconazole pulse, 63 +/- 7% (n = 6 studies, 318 patients) vs. 84 +/- 9% (n = 3 studies, 194 patients) (P = 0.0001); and fluconazole, 48 +/- 5% (n = 3 studies, 131 patients) vs. 79 +/- 3% (n = 3 studies, 208 patients) (P = 0.0001).

CONCLUSIONS

The cumulative meta-analysis of cure rates for RCTs suggests that over time, as new RCTs have been conducted, the efficacy rates have remained consistent. The efficacy rates of open studies are substantially higher compared with RCTs and may therefore overestimate cure rates.

Ciclopirox for the treatment of superficial fungal infections: a review

Ciclopirox is a broad-spectrum antifungal agent that also exhibits anti-inflammatory and antibacterial activity. The lotion and cream formulations of ciclopirox are effective in many types of infection, including tinea corporis/cruris, tinea pedis, cutaneous candidiasis, pityriasis (tinea) versicolor, and seborrheic dermatitis. The new ciclopirox gel 0.77% formulation is also indicated for the treatment of seborrheic dermatitis of the scalp, interdigital tinea pedis and tinea corporis.

Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis

The recent advances in pityriasis versicolor, seborrheic dermatitis, tinea capitis and onychomycosis are reviewed. Some highlighted points include the new classification of Malassezia species, and the association of Malassezia species with seborrheic dermatitis. The use of terbinafine, fluconazole, and itraconazole for the treatment of tinea capitis is discussed. The management of onychomycosis, highlighting the high efficacy rates obtained with terbinafine when used to treat dermatophyte toenail onychomycosis, is discussed. The use of combination therapies in some circumstances to maximize cure rates is reviewed.

The diagnosis of onychomycosis

The prevalence of onychomycosis is increasing and the primary pathogens may be dermatophytes, nondermatophyte molds, or Candida spp. It may not be satisfactory to treat onychomycosis on the basis of clinical diagnosis alone. Laboratory diagnosis is an important component of the proper management of this fungal infection. Laboratory diagnostic methods for detecting onychomycosis include light microscopy and culture, or histopathology. Management of onychomycosis includes palliation achieved through mechanical debridement of the nail and topical or oral antifungal therapy.