A multicenter, randomized, open-label, controlled study comparing the efficacy, safety and cost-effectiveness of a sequential therapy with RV4104A ointment, ciclopiroxolamine cream and ciclopirox film-forming solution with amorolfine nail lacquer alone in dermatophytic onychomycosis

BACKGROUND

The efficacy of topical antifungals is controversial.

OBJECTIVE

To compare the efficacy and safety of a sequential(SEQ) treatment with chemical nail avulsion and topical antifungals to amorolfine nail lacquer in dermatophytic onychomycosis.

METHODS

This was a randomized,parallel-group, controlled study comparing a 36-week SEQ treatment with chemical nail avulsion with RV4104A ointment(class I medical device containing 40% urea) followed by ciclopirox cream for 8 weeks and ciclopirox nail lacquer for 25 weeks (SEQ group) to amorolfine nail lacquer for 36 weeks (AMO group). Patients had to have a big toenail onychomycosis,sparing the matrix. The primary efficacy criterion was complete cure at week 48. A cost-effectiveness analysis was performed.

RESULTS

A total of 142 patients were randomized. The complete cure rate at week 48 was significantly higher in the SEQ group than in the AMO group (36.6 vs. 12.7%, p = 0.001). Clinical cure at week 48 was observed in 53.5% of patients in the SEQ group versus 17% in the AMO group (p < 0.01). The cost of cure per patient was 50% lower with SEQ treatment (EUR 33) compared with amorolfine(EUR 76).

CONCLUSION

A treatment of onychomycosis comprising chemical avulsion of the pathological nail, ciclopirox cream and nail lacquer is significantly more effective than amorolfine nail lacquer.

[Lumbar panniculitis with subcutaneous abscess revealing pyonephrosis]

BACKGROUND

A clinical picture of hypodermitis in the lumbar region may reveal an abscess arising from infection due to pyonephrosis. We report a case below.

CASE REPORT

A 58 year-old woman consulted for an area of inflammation in the left lumbar region that had been present for two months. The area of inflammation appeared two days after physiotherapy sessions prescribed for lower back pain. Laboratory examinations revealed inflammation associated with moderate renal failure. A skin biopsy sample taken from around the inflamed area showed septal hypodermitis. Ultrasound examination revealed a pocket of liquid measuring 7 x 2 x 2 cm; Proteus mirabilis was isolated following ultrasound-guided needle aspiration,. Magnetic resonance imaging (MRI) and uroscan revealed pyonephrosis with suffusion into the hypodermis and left lumbar fossa.

DISCUSSION

This was a case of bacterial hypodermitis with abscesses secondary to pyonephrosis. Pyonephrosis may be transferred to the skin, causing fistulas and subcutaneous pus collection. In such rare and potentially misleading clinical settings, the diagnosis can be established by imaging.