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Take a multifaceted approach when treating onychomycosis

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Abstract

Onychomycosis is difficult to treat, particularly due to factors at the patient, organism, treatment and environmental levels that increase disease susceptibility or impact treatment. Along with taking these into consideration and addressing them as required, performing diagnostic tests is necessary when selecting the appropriate treatment and administration route, thereby maximizing the chances of successful treatment. Because onychomycosis has a high recurrence rate, preventive measures are recommended even after achieving a cure.

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References

  1. Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. Br J Dermatol. 2003;148(3):402–10.

    Article  CAS  Google Scholar 

  2. Gupta AK, Versteeg SG, Shear NH, et al. A practical guide to curing onychomycosis: how to maximize cure at the patient, organism, treatment, and environmental level. Am J Clin Dermatol. 2019;20(1):123–33.

    Article  Google Scholar 

  3. Christenson JK, Peterson GM, Naunton M, et al. Challenges and opportunities in the management of onychomycosis. J Fungi (Basel). 2018;4(3):E87. https://doi.org/10.3390/jof4030087.

    Article  Google Scholar 

  4. Shuster S, Baran R. Recurrence of fungal nail disease and the dissociation of relapse from re-infection. Acta Derm Venereol. 2001;81(2):154–5.

    Article  CAS  Google Scholar 

  5. Rodriguez DA. Efinaconazole topical solution, 10%, for the treatment of mild and moderate toenail onychomycosis. J Clin Aesthet Dermatol. 2015;8(6):24–9.

    PubMed  PubMed Central  Google Scholar 

  6. Sigurgeirsson B. Prognostic factors for cure following treatment of onychomycosis. J Eur Acad Dermatol Venereol. 2010;24(6):679–84.

    Article  CAS  Google Scholar 

  7. Gupta AK, Daigle D, Foley KA. The prevalence of culture-confirmed toenail onychomycosis in at-risk patient populations. J Eur Acad Dermatol Venereol. 2015;29(6):1039–44.

    Article  CAS  Google Scholar 

  8. Gupta AK, Korotzer A. Topical treatment of onychomycosis and clinically meaningful outcomes. J Drugs Dermatol. 2016;15(10):1260–6.

    PubMed  Google Scholar 

  9. Rich P. Efinaconazole topical solution, 10%: the benefits of treating onychomycosis early. J Drugs Dermatol. 2015;14(1):58–62.

    CAS  PubMed  Google Scholar 

  10. Center for Devices and Radiological Health US FDA. Medical devices and clinical trial design for the treatment or improvement in the appearance of fungally-infected nails: guidance for industry and Food and Drug Administration staff. Rockville: U.S. Department of Health and Human Services; 2016.

    Google Scholar 

  11. Sigurgeirsson B, Olafsson JH, Steinsson JT, et al. Efficacy of amorolfine nail lacquer for the prophylaxis of onychomycosis over 3 years. J Eur Acad Dermatol Venereol. 2010;24(8):910–5.

    Article  CAS  Google Scholar 

  12. Piraccini BM, Sisti A, Tosti A. Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. J Am Acad Dermatol. 2010;62(3):411–4.

    Article  Google Scholar 

  13. Garcia-Romero MT, Granados J, Vega-Memije ME, et al. Analysis of genetic polymorphism of the HLA-B and HLA-DR loci in patients with dermatophytic onychomycosis and in their first-degree relatives. Actas Dermosifiliogr. 2012;103(1):59–62.

    Article  Google Scholar 

  14. Asz-Sigall D, Lopez-Garcia L, Vega-Memije ME, et al. HLA-DR6 association confers increased resistance to T. rubrum onychomycosis in Mexican Mestizos. Int J Dermatol. 2010;49(12):1406–9.

    Article  Google Scholar 

  15. Shapiro LE, Shear NH. Drug interactions: proteins, pumps, and P-450s. J Am Acad Dermatol. 2002;47(4):467–84.

    Article  Google Scholar 

  16. Rosen T. Evaluation of gender as a clinically relevant outcome variable in the treatment of onychomycosis with efinaconazole topical solution 10. Cutis. 2015;96(3):197–201.

    PubMed  Google Scholar 

  17. Akkus G, Evran M, Gungor D, et al. Tinea pedis and onychomycosis frequency in diabetes mellitus patients and diabetic foot ulcers: a cross sectional–observational study. Pak J Med Sci. 2016;32(4):891–5.

    PubMed  PubMed Central  Google Scholar 

  18. Mayser P, Freund V, Budihardja D. Toenail onychomycosis in diabetic patients: issues and management. Am J Clin Dermatol. 2009;10(4):211–20.

    Article  Google Scholar 

  19. Tan JS, Joseph WS. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging. 2004;21(2):101–12.

    Article  CAS  Google Scholar 

  20. Gupta AK, Ryder JE, Skinner AR. Treatment of onychomycosis: pros and cons of antifungal agents. J Cutan Med Surg. 2004;8(1):25–30.

    Article  Google Scholar 

  21. Rigopoulos D, Papanagiotou V, Daniel R 3rd, et al. Onychomycosis in patients with nail psoriasis: a point to point discussion. Mycoses. 2017;60(1):6–10.

    Article  Google Scholar 

  22. Markinson B, Caldwell B. Efinaconazole topical solution, 10% efficacy in patients with onychomycosis and coexisting tinea pedis. J Am Podiatr Med Assoc. 2015;105(5):407–11.

    Article  Google Scholar 

  23. Pfaller MA. Antifungal drug resistance: mechanisms, epidemiology, and consequences for treatment. Am J Med. 2012;125(1 Suppl):S3–13.

    Article  CAS  Google Scholar 

  24. Rudramurthy SM, Shankarnarayan SA, Dogra S, et al. Mutation in the squalene epoxidase gene of Trichophyton interdigitale and Trichophyton rubrum associated with allylamine resistance. Antimicrob Agents Chemother. 2018;62(5):e02522–17. https://doi.org/10.1128/aac.02522-17.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Costa-Orlandi CB, Sardi JC, Santos CT, et al. In vitro characterization of Trichophyton rubrum and T. mentagrophytes biofilms. Biofouling. 2014;30(6):719–27.

    Article  CAS  Google Scholar 

  26. Perumal P, Mekala S, Chaffin WL. Role for cell density in antifungal drug resistance in Candida albicans biofilms. Antimicrob Agents Chemother. 2007;51(7):2454–63.

    Article  CAS  Google Scholar 

  27. Gupta AK, Nakrieko KA. Trichophyton rubrum DNA strain switching increases in patients with onychomycosis failing antifungal treatments. Br J Dermatol. 2015;172(1):74–80.

    Article  CAS  Google Scholar 

  28. Jackson CJ, Barton RC, Evans EG. Species identification and strain differentiation of dermatophyte fungi by analysis of ribosomal-DNA intergenic spacer regions. J Clin Microbiol. 1999;37(4):931–6.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Gupta AK, Daigle D, Foley KA. Network meta-analysis of onychomycosis treatments. Skin Appendage Disord. 2015;1(2):74–81.

    Article  Google Scholar 

  30. Xu Y, Miao X, Zhou B, et al. Combined oral terbinafine and long-pulsed 1,064-nm Nd: YAG laser treatment is more effective for onychomycosis than either treatment alone. Dermatol Surg. 2014;40(11):1201–7.

    Article  CAS  Google Scholar 

  31. Murdan S. Drug delivery to the nail following topical application. Int J Pharm. 2002;236(1–2):1–26.

    Article  CAS  Google Scholar 

  32. Rajendran R, Williams C, Lappin DF, et al. Extracellular DNA release acts as an antifungal resistance mechanism in mature Aspergillus fumigatus biofilms. Eukaryot Cell. 2013;12(3):420–9.

    Article  CAS  Google Scholar 

  33. Shemer A, Gupta AK, Amichai B, et al. An open comparative study of nail drilling as adjunctive treatment for toenail onychomycosis. J Dermatolog Treat. 2016;27(5):480–3.

    Article  CAS  Google Scholar 

  34. Gupta AK, Nakrieko KA. Onychomycosis infections: do polymerase chain reaction and culture reports agree? J Am Podiatr Med Assoc. 2017;107(4):280–6.

    Article  Google Scholar 

  35. Sakamoto M, Sugimoto N, Kawabata H, et al. Transungual delivery of efinaconazole: its deposition in the nail of onychomycosis patients and in vitro fungicidal activity in human nails. J Drugs Dermatol. 2014;13(11):1388–92.

    CAS  PubMed  Google Scholar 

  36. Gupta AK, Simpson FC. Routes of drug delivery into the nail apparatus: implications for the efficacy of topical nail solutions in onychomycosis. J Dermatolog Treat. 2016;27(1):2–4.

    Article  CAS  Google Scholar 

  37. Elewski BE, Pollak RA, Pillai R, et al. Access of efinaconazole topical solution, 10%, to the infection site by spreading through the subungual space. J Drugs Dermatol. 2014;13(11):1394–8.

    CAS  PubMed  Google Scholar 

  38. Tavakkol A, Fellman S, Kianifard F. Safety and efficacy of oral terbinafine in the treatment of onychomycosis: analysis of the elderly subgroup in Improving Results in ONychomycosis-Concomitant Lamisil and Debridement (IRON-CLAD), an open-label, randomized trial. Am J Geriatr Pharmacother. 2006;4(1):1–13.

    Article  CAS  Google Scholar 

  39. Gupta AK. Management of toe onychomycosis: what is the potential for improving efficacy of treatment? Clin Dermatol. 2002;20(5):607–9.

    Article  Google Scholar 

  40. Salakshna N, Bunyaratavej S, Matthapan L, et al. A cohort study of risk factors, clinical presentations, and outcomes for dermatophyte, nondermatophyte, and mixed toenail infections. J Am Acad Dermatol. 2018;79(6):1145–6.

    Article  Google Scholar 

  41. Gupta AK, Elewski BE, Rosen T, et al. Onychomycosis: strategies to minimize recurrence. J Drugs Dermatol. 2016;15(3):279–82.

    CAS  PubMed  Google Scholar 

Download references

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The article was adapted from the American Journal of Clinical Dermatology 2019;20(1):123–33 [2] by employees of Adis International Ltd./Springer Nature, who are responsible for the article content and declare no conflicts of interest.

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The preparation of this review was not supported by any external funding.

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Adis Medical Writers. Take a multifaceted approach when treating onychomycosis. Drugs Ther Perspect 35, 321–325 (2019). https://doi.org/10.1007/s40267-019-00640-w

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