Overview of topical therapy for common superficial fungal infections and the role of new topical agents

Pityriasis Versicolor-A Narrative Review on the Diagnosis and Management

This narrative review presents a comprehensive overview of the diagnosis and management of pityriasis versicolor (PV), a common superficial fungal infection caused by the yeast Malassezia. PV is characterised by scaly hypopigmented or hyperpigmented patches, primarily affecting the upper trunk, neck, and upper arms. Regarding commensal interactions, Malassezia utilises nutrient sources without affecting the human host. In cases of pathogenicity, Malassezia can directly harm the host via virulence factors or toxins, or indirectly by triggering damaging host responses. The diagnosis typically relies on recognising characteristic clinical features. Due to the wide variability in its clinical presentation, recognising the differential diagnosis is critical. In this paper, we discuss the clinical differentials, with their dermatoscopic presentation, but also describe a range of helpful diagnostic techniques (microscopy, conventional and ultraviolet-induced fluorescence dermatoscopy, and confocal microscopy). Topical therapies are the primary treatment for PV, encompassing non-specific antifungal agents like sulphur with salicylic acid, selenium sulphide 2.5%, and zinc pyrithione. Additionally, specific topical antifungal medications with either fungicidal or fungistatic properties may also be incorporated into the topical treatment regimen, such as imidazoles, allylamines, and ciclopirox olamine. Systemic therapies might occasionally be used. Patient education and the promotion of good personal hygiene are pivotal to reduce the risk of recurrence. In recurrent cases, particularly during warmer and more humid periods, prolonged prophylaxis with topical agents should be considered.

Potential Inhibitory Effect of Miltefosine against Terbinafine-Resistant Trichophyton indotineae

Several prolonged and significant outbreaks of dermatophytosis caused by Trichophyton indotineae, a new emerging terbinafine-resistant species, have been ongoing in India in recent years, and have since spread to various countries outside Asia. Miltefosine, an alkylphosphocholine, is the most recently approved drug for the treatment of both visceral and cutaneous leishmaniasis. Miltefosine in vitro activity against terbinafine-resistant and susceptible T. mentagrophytes/T. interdigitale species complex, including T. indotineae, is limited. The current study aimed to assess miltefosine's in vitro activity against dermatophyte isolates, which are the most common causes of dermatophytosis. Miltefosine, terbinafine, butenafine, tolnaftate, and itraconazole susceptibility testing was performed using Clinical and Laboratory Standards Institute broth microdilution methods (CLSI M38-A3) against 40 terbinafine-resistant T. indotineae isolates and 40 terbinafine-susceptible T. mentagrophytes/T. interdigitale species complex isolates. Miltefosine had MIC ranges of 0.063-0.5 µg/mL and 0.125-0.25 µg/mL against both terbinafine-resistant and susceptible isolates. In terbinafine-resistant isolates, the MIC₅₀ and MIC₉₀ were 0.125 µg/mL and 0.25 µg/mL, respectively, and 0.25 µg/mL in susceptible isolates. Miltefosine had statistically significant differences in MIC results when compared to other antifungal agents (p-value 0.05) in terbinafine-resistant strains. Accordingly, the findings suggest that miltefosine has a potential activity for treating infections caused by terbinafine-resistant T. indotineae. However, further studies are needed to determine how well this in vitro activity translates into in vivo efficacy.

Antifungal agents commonly used in the superficial and mucosal candidiasis treatment: mode of action and resistance development

Recent progress in medical sciences and therapy resulted in an increased number of immunocompromised individuals. Candida albicans is the leading opportunistic fungal pathogen causing infections in humans, ranging from superficial mucosal lesions to disseminated or bloodstream candidiasis. Superficial candidiasis not always presents a risk to the life of the infected host, however it significantly lowers the quality of life. Superficial Candida infections are difficult to treat and their frequency of occurrence is currently rising. To implement successful treatment doctors should be up to date with better understanding of C. albicans resistance mechanisms. Despite high frequency of Candida infections there is a limited number of antimycotics available for therapy. This review focuses on current understanding of the mode of action and resistance mechanisms to conventional and emerging antifungal agents for treatment of superficial and mucosal candidiasis.

Efficacy, tolerability and consumer acceptability of terbinafine topical spray versus terbinafine topical solution: a phase IIa, randomised, observer-blind, comparative study

INTRODUCTION

Tinea pedis is one of the world's most prevalent dermatophyte infections. MedSpray™ tinea pedis 1 % w/w (topical spray) is a novel, easy-to-use propellant-based spray formulation containing 1 % w/w terbinafine, requiring no manipulation at the site of infection. This is in contrast to the only formulation currently approved in Europe for single application (none are approved in the USA for single use), which is Lamisil(®) Once 1 % w/w (topical solution), containing 1 % w/w terbinafine hydrochloride, which requires manipulation on the affected area.

OBJECTIVE

The aim of this study was to evaluate the efficacy, tolerability and consumer acceptability of a topical spray versus a topical solution in the treatment of tinea pedis.

METHODS

This study is a phase IIa, randomised, observer-blind, non-inferiority comparative study of the topical spray compared with the topical solution over a 12-week study period. The study was conducted at Bioskin GmbH, Hamburg and Berlin. Patients (n = 120) who presented with the presence of interdigital tinea pedis caused by dermatophytes on one or both feet were enrolled in the study. Patients were randomly assigned between the two treatment groups. Either the topical spray or the topical solution was administered by the study nurse and consisted of a single application (equivalent to 20 mg of terbinafine per foot) on day 1 of the study. No further applications were made for the duration of the study. The hypothesis formulated before commencement of the study was that the topical spray would prove to be non-inferior to the topical solution. Efficacy assessments, including clinical signs and symptoms, mycology and microscopy were performed at baseline and 1, 6 and 12 weeks after treatment.

RESULTS

The rate of mycological cure at week 1 was statistically equivalent for both treatments. There was a significant reduction in the overall clinical score as assessed by the Physician's Global Assessment of signs and symptoms for both treatment groups.

CONCLUSION

The topical spray and the topical solution showed comparable anti-fungal activity. Furthermore, the non-inferiority of topical spray to the topical solution was confirmed as determined by the proportion of patients categorised as successfully treated at week 1. This confirms that a topical spray product, which can be applied once without touching the affected skin, is equally as effective in the treatment of tinea pedis and removes the risk of organism transfer associated with touching infected areas.

CLINICAL TRIAL REGISTRATION NUMBER

EudraCT-No. 2008-002399-92.

Prevalence and treatment of palmoplantar keratoderma and tinea pedis in patients with Sézary syndrome

BACKGROUND

Mycosis fungoides (MF) and the Sézary syndrome (SS) are non-Hodgkin's lymphomas that present with cutaneous lesions. Sézary syndrome is characterized by blood involvement, exfoliative eryrthroderma, lymphadenopathy, pruritus, keratoderma, and immunosuppression. This study was to estimate the prevalence of palmoplantar keratoderma and tinea pedis in Sézary syndrome and to analyze the effectiveness of anti-fungal treatment.

METHODS

We conducted a retrospective review of 1562 prospectively collected patients at the MD Anderson Cancer Center Cutaneous Lymphoma Clinic over sixteen years. All patients' palms and soles were evaluated for clinical evidence of keratoderma (hyperkeratosis) and for dermatophytosis (tinea pedis or unguum) by examining scales under 10% potassium hydroxide by light microscopy for hyphae.

RESULTS

Of 138 Sézary syndrome patients (88 men, 50 women, median age at diagnosis 64 years), 85 (61.6%) had palmoplantar keratoderma; 45 of the 85 Sézary syndrome patients (52.9%) also had coexisting tinea pedis. Only 14 (10.1%) had tinea pedis without keratoderma. Treatment for tinea pedis resulted in microscopy cure of keratoderma in 12 of 45 (26.7%) patients and clinical improvement.

CONCLUSIONS

The prevalence of palmoplantar keratoderma in Sézary syndrome is 61.6%, with co-existing tinea pedis found in 52.9%. Palmoplantar keratoderma with tinea pedis showed clinical improvement with fungicidal therapy suggesting that tinea often contributes to the pathogenesis and severity of Sézary syndrome-related keratoderma.

Short-term therapy with luliconazole, a novel topical antifungal imidazole, in guinea pig models of tinea corporis and tinea pedis

Luliconazole is a novel topical antifungal imidazole with broad-spectrum and potent antifungal activity. The drug is under clinical development in the United States for management of dermatophytosis with a short-term treatment regimen. The present study was undertaken to investigate the clinical benefit of short-term therapy with luliconazole cream in guinea pig models of tinea corporis and tinea pedis induced with Trichophyton mentagrophytes. The dose-dependent therapeutic efficacy of topical luliconazole cream (0.02 to 1%), measured by macroscopic improvement of skin lesions and by fungal eradication as determined by a culture assay, was demonstrated using a tinea corporis model. The improvement in skin lesions seen with luliconazole cream was observed even at a concentration of 0.02%, and its efficacy at 0.1% was equal to that of 1% bifonazole cream. The efficacy of short-term therapy with 1% luliconazole cream, which is used for clinical management, was investigated using the tinea corporis model (4- and 8-day treatment regimens) and the tinea pedis model (7- and 14-day treatment regimens). The 1% luliconazole cream completely eradicated the fungus in half or less of the treatment time required for 1% terbinafine cream and 1% bifonazole cream, as determined by a culture assay for both models. These results clearly indicate that 1% luliconazole cream is sufficiently potent for short-term treatment for dermatophytosis compared to existing drugs. Luliconazole is expected to be useful in the clinical management of dermatophytosis.

Novel, single-dose, topical treatment of tinea pedis using terbinafine: results of a dose-finding clinical trial

Tinea pedis is the most common dermatophytosis requiring topical antifungals for at least 1-4 weeks. To determine the effectiveness of a novel topical single dose formulation of terbinafine (film forming solution-FFS) in the treatment of tinea pedis, 344 outpatients from 43 dermatological centres in France and Bulgaria suffering from tinea pedis with possible extension to soles confirmed by mycological examination (direct and culture) were evaluated for efficacy of terbinafine 1%, 5%, 10% FFS in a randomised double blind vehicle controlled parallel group dose finding study. Evaluations were carried out at baseline, 1 and 6 weeks after a single application of FFS. Effective treatment rate based on negative mycology (direct and culture) and minimal signs and symptoms (two or less with only mild recorded) was measured at week 6. Effective treatment rates at week 6 with terbinafine 1%, 5% and 10% FFS were 66%, 70%, 61% compared with 18% with placebo. All three active preparations were shown to be significantly superior to placebo (P < 0.001). Terbinafine 1% and 5% FFS were shown to be non-inferior to terbinafine 10% FFS. Terbinafine 1% FFS is an effective, safe dose for the treatment of tinea pedis. This novel product represents a significant advance with the enhanced compliance and convenience that it offers.

Short-duration topical treatment of tinea pedis using terbinafine emulsion gel: results of a dose-ranging clinical trial

BACKGROUND

In the treatment of tinea pedis, current terbinafine formulations are applied once or twice daily for 7 days. A terbinafine emulsion gel formulation has been developed to provide a 5-day treatment course for tinea pedis.

OBJECTIVE

To determine the lowest effective concentration of terbinafine (1% or 3%) emulsion gel applied once daily for 5 days for the treatment of tinea pedis.

METHODS

This double-blind, placebo-controlled study evaluated the efficacy of 1% and 3% terbinafine gel for 5 days in 84 outpatients with tinea pedis. The primary efficacy endpoint was the percentage of patients with effective treatment (negative microscopy and culture with only mild erythema/desquamation/pruritus [total score<or=2]) at study endpoint (last post-baseline observation up to and including week 6).

RESULTS

Efficacy rates with terbinafine 1% and 3% emulsion gel were significantly higher than with placebo (86% and 68% vs 11%, respectively; p<0.001). Similarly, mycological cure rates were significantly greater with terbinafine 1% and 3% gel (97% and 89%, respectively) than with placebo (22%; p<0.001).

CONCLUSIONS

Terbinafine 1% emulsion gel used once daily for 5 days was the lowest effective concentration, and was significantly superior to placebo. Both concentrations were effective and safe, providing convenient, short-duration treatment of tinea pedis.

Efficacy and safety of a new single-dose terbinafine 1% formulation in patients with tinea pedis (athlete's foot): a randomized, double-blind, placebo-controlled study

BACKGROUND

Tinea pedis is a common dermatophyte infection with frequent recurrences. Terbinafine (presently used as a 1-week topical treatment of tinea pedis) is now available in a novel topical solution (film-forming solution--FFS), developed to allow single application.

OBJECTIVES

To demonstrate the efficacy and safety of terbinafine 1% FFS in a randomized, double-blind, placebo-controlled, phase III trial, and to determine relapse or re-infection rate of tinea pedis at 12 weeks.

PATIENTS/METHODS

Fifty-four centres (27 in France; 27 in Germany) enrolled 273 evaluable patients (2 : 1 randomization). Patients applied terbinafine 1% FFS or placebo only once between, under and over the toes, soles and sides of both feet. Efficacy assessments included direct microscopy, mycological culture, and clinical signs and symptoms at baseline, and at weeks 1, 6 and 12 after the single drug application.

RESULTS

Effective treatment (negative mycology plus absent/minimal symptoms) at week 6 in the terbinafine 1% FFS group was 63%; vehicle was 17% (P<or=0.0001). Mycological cure was 72% in the terbinafine group and 21% in the placebo (P<or=0.0001) at week 6. Clinical signs/symptoms decreased significantly in the active group compared to the placebo. The self-assessment of itching and burning sensation by the patient showed a clear reduction in symptoms starting 15 min after treatment application (this could be attributed to the cooling effect of the FFS). Recurrence (positive culture at 3 months) occurred in 12.5% of the effectively treated patients at week 6 in the terbinafine group. FFS was well tolerated.

CONCLUSION

Terbinafine 1% FFS, single dose application is an effective, safe and convenient treatment for tinea pedis. The relapse/re-infection rate 3 months after the end of single-dose therapy is similar to that previously demonstrated in a study using terbinafine 1% cream for 7 days.

Eberconazole 1% cream is an effective and safe alternative for dermatophytosis treatment: multicenter, randomized, double-blind, comparative trial with miconazole 2% cream

BACKGROUND

Eberconazole is a topical, broad-spectrum imidazole derivative, effective in dermatophytoses, candidiasis, and pityriasis treatment. In previous trials, it showed a higher efficacy than clotrimazole in the treatment of dermatophytoses. The purpose of this trial was to evaluate the efficacy of eberconazole 1% cream compared with miconazole 2% cream in the treatment of dermatophytoses.

METHODS

A multicenter, double-blind, randomized trial was performed in 653 patients with dermatophytoses, randomized to eberconazole 1% cream every 12 h or miconazole 2% cream every 12 h for 4 weeks. Treatment efficacy was assessed on the basis of the percentage of effective response after 4 weeks through mycologic and clinical assessment.

RESULTS

Of the 653 patients included in the trial, 360 produced positive baseline mycologic cultures and were included in the efficacy assessment. Clinical efficacy was shown in 76.1% of patients receiving eberconazole and in 75.0% of patients receiving miconazole. The incidence of adverse events related to treatment was 0.91% for eberconazole and 0.92% for miconazole, none being serious, and all being local and transient.

CONCLUSIONS

Eberconazole 1% cream is an effective treatment for fungal infections produced by dermatophytes, with a good safety and tolerability profile, and can be considered a good alternative for the treatment of dermatophytoses.

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.

Evaluation of in vitro activity of ciclopirox olamine, butenafine HCl and econazole nitrate against dermatophytes, yeasts and bacteria

BACKGROUND

In many instances, a cutaneous fungal infection may exist concomitantly with bacterial involvement. In this study we compared the in vitro activity of three antifungal agents against the dermatophytes, yeasts and bacteria recovered most commonly from cutaneous mycoses and bacterial infections.

METHODS

Using a microdilution method adapted from the National Committee for Clinical Laboratory Standards (NCCLS), we determined the minimum inhibitory concentrations (MICs) of ciclopirox olamine, econazole nitrate and butenafine HCl against a panel of dermatophyte fungi and yeasts (n = 39) and bacterial isolates (n = 45).

RESULTS

All three antifungals demonstrated comparable activity against the dermatophytes tested, with a MIC range of 0.03-0.25 micro g/ml for ciclopirox, < 0.001-0.25 micro g/ml for econazole and 0.03-0.25 micro g/ml for butenafine. For yeasts, ciclopirox showed activity against all isolates, with an MIC range of 0.001-0.25 micro g/ml, whereas econazole had a broader range of 0.125-> 0.5 micro g/ml. Butenafine displayed limited activity against the yeast Candida albicans and no activity against Malassezia furfur. For the antibacterial activity studies, ciclopirox demonstrated activity against all isolates tested with a range of 0.06-2 micro g/ml, while econazole showed activity against Gram-positive bacteria only, with a MIC range of 0.004-0.25 micro g/ml. Butenafine HCl had a limited activity against bacterial isolates tested, showing activity against beta-hemolytic Streptococcus Group A and Corynebacterium only. Neither econazole nitrate nor butenafine HCl demonstrated activity against any of the Gram-negative strains evaluated in this study.

CONCLUSIONS

The data suggest that ciclopirox olamine has the broadest in vitro activity, in comparison to econazole and butenafine HCl, against bacteria, yeasts and bacteria. These findings may have implications in the use of these antimycotics in the treatment of mixed cutaneous infections where bacteria or yeasts are present in addition to dermatophytes.

Topical formulation studies with DEET (N,N-diethyl-3-methylbenzamide) and cyclodextrins

The purpose of this study was to investigate the utility of cyclodextrins as a safer alternative to the commonly used cosolvent ethanol in topical N,N-diethyl-3-methylbenzamide (DEET) formulations. Ethanol is a known penetration enhancer and would ideally not be used in a formulation containing DEET, a compound known for its potential toxicity. DEET formulations were prepared containing up to 20% w/w gamma-cyclodextrin (GCD) or 30% w/w hydroxypropyl-beta-cyclodextrin (HPBCD). These formulations were evaluated by determining the release rate of DEET from its vehicle through a synthetic membrane into a receiver medium with a high affinity for DEET using a fully automated Franz-diffusion cell system. DEET release was measured by ultraviolet spectrophotometry at 260 nm. Both the traditional Higuchi release model and an alternate repeated measures analysis of variance with nested factors were used to analyze the data. The influence of the cyclodextrins on the volatility of DEET was determined by solid-phase microextraction. Morphological characterization of the formulations was performed by light microscopy. Physical stability of the formulations was evaluated by rheology in an accelerated study performed at 50 degrees C for 28 days. The cyclodextrins caused a decrease in the release of DEET from its vehicle compared with an ethanol-containing formulation. This effect became more pronounced as the amount of cyclodextrin in the formulation was increased. The addition of the cyclodextrins resulted in a cream-like product compared with the ethanol formulation, which was a lotion. The DEET formulations had the following rank order of volatility: ethanol < DEET = GCD < HPBCD. Examination of the formulations by light microscopy indicated that the CD-based formulations produced a smaller and more homogeneous droplet size distribution than the ethanol-based formulations. The accelerated physical stability study indicated that cyclodextrin-based formulations are both technically and commercially feasible. Cyclodextrins are a promising alternative to ethanol in DEET-containing formulations. The reduced release rate of DEET from these formulations suggests that the toxic potential of DEET may be decreased in these products, while its repellency and stability are maintained.

Experimental and conformational analyses of interactions between butenafine and lipids

Butenafine (N-4-tert-butylbenzyl-N-methyl-1-naphtalenemethylamine hydrochloride) is an antifungal agent of the benzylamine class that has excellent therapeutic efficacy and a remarkably long duration of action when applied topically to treat various mycoses. Given the lipophilic nature of the molecule, efficacy may be related to an interaction with cell membrane phospholipids and permeabilization of the fungal cell wall. Similarly, high lipophilicity could account for the long duration of action, since fixation to lipids in cutaneous tissues might allow them to act as local depots for slow release of the drug. We have therefore used computer-assisted conformational analysis to investigate the interaction of butenafine with lipids and extended these observations with experimental studies in vitro using liposomes. Conformational analysis of mixed monolayers of phospholipids with the neutral and protonated forms of butenafine highlighted a possible interaction with both the hydrophilic and hydrophobic domains of membrane phospholipids. Studies using liposomes demonstrated that butenafine increases membrane fluidity [assessed by fluorescence polarization of 1-(4-trimethylammonium-phenyl)-6-phenyl-1,3,5-hexatriene and 1,6-diphenylhexatriene] and membrane permeability (studied by release of calcein from liposomes). The results show, therefore, that butenafine readily interacts with lipids and is incorporated into membrane phospholipids. These findings may help explain the excellent antifungal efficacy and long duration of action of this drug when it is used as a topical antifungal agent in humans.

Topical treatment of dermatophytosis and cutaneous candidosis with flutrimazole 1% cream: double-blind, randomized comparative trial with ketoconazole 2% cream

In a double-blind, randomized study the efficacy and tolerance of flutrimazole 1% cream were compared with ketoconazole 2% cream, applied once daily for 4 weeks, in 60 patients with culturally proven dermatophytosis (47 patients) or cutaneous candidosis (13 patients). Both groups of patients and distribution of target lesions were similar. The sum of clinical scores had an even distribution in both groups at the end of treatment. The proportion of patients with negative microscopy and culture after 4 weeks of treatment was 70% in the flutrimazole group and 53% in the ketoconazole group; seven ketoconazole-treated patients (23%) compared with two flutrimazole-treated patients (6.6%) were asymptomatic carriers (clinically cured with positive cultures) at the end of treatment. At the assessment 6 weeks after the end of therapy the percentages of flutrimazole- and ketoconazole-treated patients with negative mycology were 57 and 70%, respectively. There were one relapse (3.3%) in the ketoconazole group and four (13.3%) in the flutrimazole group. One patient treated with ketoconazole (3%) had a premature termination due to adverse events attributable to the medication. The results of this study show that flutrimazole 1% cream is as effective and safe as ketoconazole 2% cream for Candida and dermatophyte skin infections.

The antifungal agent butenafine manifests anti-inflammatory activity in vivo

BACKGROUND

Dermatophyte infections are often accompanied by a striking inflammatory reaction, alleviation of which has often been achieved by the concomitant but controversial use of topical steroidal agents. Recent investigations have suggested the presence of inherent anti-inflammatory properties associated with certain antifungal agents, particularly those within the allylamine class. Butenafine, the first and only approved representative of the benzylamine antifungals, possesses a chemical structure and antifungal activity similar to the allylamines. Although several studies have demonstrated excellent antimycotic efficacy, none has addressed anti-inflammatory properties associated with butenafine.

OBJECTIVE

This study was designed to determine whether butenafine, a benzylamine antifungal, expresses anti-inflammatory activity in vivo.

METHODS

A randomized single-blinded control investigation comparing the attenuation of UVB irradiation-induced erythema by butenafine, its proprietary base cream, and no application (negative control) was performed in humans.

RESULTS

Butenafine demonstrated a significant and marked decrease in UVB-induced erythema as compared with both the base cream and the unaltered control.

CONCLUSION

The benzylamine antifungal agent butenafine demonstrates inherent anti-inflammatory properties, in vivo, as demonstrated by reduced cutaneous erythema response after UVB irradiation.

Treatment of toenail onychomycosis with 2% butenafine and 5% Melaleuca alternifolia (tea tree) oil in cream

The prevalence of onychomycosis, a superficial fungal infection that destroys the entire nail unit, is rising, with no satisfactory cure. The objective of this randomized, double-blind, placebo-controlled study was to examine the clinical efficacy and tolerability of 2% butenafine hydrochloride and 5% Melaleuca alternifolia oil incorporated in a cream to manage toenail onychomycosis in a cohort. Sixty outpatients (39 M, 21 F) aged 18-80 years (mean 29.6) with 6-36 months duration of disease were randomized to two groups (40 and 20), active and placebo. After 16 weeks, 80% of patients using medicated cream were cured, as opposed to none in the placebo group. Four patients in the active treatment group experienced subjective mild inflammation without discontinuing treatment. During follow-up, no relapse occurred in cured patients and no improvement was seen in medication-resistant and placebo participants.

Management of toenail onychomycosis with 2% butenafine and 20% urea cream: a placebo-controlled, double-blind study

Onychomycosis is an increasingly common and recalcitrant fungal nail infection world-wide. The purpose of this placebo-controlled, double-blind study was to determine the clinical efficacy, chemical avulsion, and tolerability of 2% butenafine hydrochloride and 20% urea incorporated in a cream to cure toenail onychomycosis in a preselected population. Sixty patients (38M, 22F), ranging between 18 and 60 years (mean 27.4), with more than 25% involvement of the big toenail were enrolled in the study. The diagnosis of onychomycosis was established by mycologic identification and reconfirmed by positive fungal culture. A precoded 25-g tube was randomly assigned to each patient (50 active and 10 placebo) with instructions to apply the trial medication to their infected toenail twice daily with an occlusive dressing for one week. The affected nail was removed with a nail clipper. No occlusive dressing was maintained after the initial one week regimen. To assess the chemical avulsion of the infected toenail, mycologic cure, clinical effectiveness of the treatment, and overall success, patients were examined twice a week for 16 weeks and thereafter on a weekly basis for a further 36 weeks. The treatment was well tolerated by all the patients throughout the study, with no dropouts. Marked improvement was seen in 73.3% patients after weeks 8, 16 and 24 with clinically and mycologically confirmed negative fungal culture. Code disclosure revealed that active butenafine and urea cream cured significantly more patients than placebo (88% versus 0%; p < 0.0001). Of the 60 patients 91.6% reported no drug-related adverse symptoms. Five patients reported non-objective mild inflammation without discontinuation of the treatment. During one year follow-up of the study phase, none of the cured patients had a relapse. In conclusion, the mycologic and overall assessment of this study demonstrate that 2% butenafine HCl and 20% urea incorporated in a cream for keratinolysis is safe to use and significantly more effective than placebo in curing big toenail onychomycosis.