Abstract
Onychomycosis is a common and difficult to treat infection, owing predominately to the limited penetration of topical drugs to the site of infection. Systemic drugs are not an option for all patients due to adverse events and drug-drug interactions. In this article, we review the nail penetration and clinical efficacy data of topical drugs, including older agents such as ciclopirox and amorolfine, as well as the newer agents, efinaconazole and tavaborole. Additionally, we describe some unresolved questions in the management of onychomycosis.
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Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists’ guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014;171(5):937–58.
Drake LA, Dinehart SM, Farmer ER, et al. Guidelines for the care of the superficial mycotic infections of the skin: onychomycosis. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996;34:116–21.
Stuttgen G, Bauer E. Bioavailability, skin- and nail-penetration of topically applied antimycotics. Mykosen. 1982;25:74–80.
Baran R, Hay RJ, Garduno JI. Review of antifungal therapy and the severity index for assessing onychomycosis: part I. J Dermatol Treat. 2008;19(2):72–81.
Loceryl [package insert]. Galderma (UK) Ltd; 1999.
Marty JP. Amorolfine nail lacquer: a novel formulation. J Eur Acad Dermatol Venereol. 1995;5:17–21.
Polak A. Kinetics of amorolfine in human nails. Mycoses. 1993;36(3–4):101–3.
Lauharanta J. Comparative efficacy and safety or amorolfine nail lacquer 2 % versus 5 % once weekly. Clin Exp Dermatol. 1992;17(1):41–3.
Reinel D, Clarke C. Comparative efficacy and safety or amorolfine nail lacquer 5 % in onychomycosis, once-weekly versus twice-weekly. Clin Exp Dermatol. 1992;17(1):44–9.
Penlac [package insert]. Sanofi-Aventis (USA) LLC; 2006.
Onytec [package insert]. Polichem (Switzerland); 2009.
Bohn M, Kraemer KT. Dermatopharmacology of ciclopirox nail lacquer topical solution 8 % in the treatment of onychomycosis. Am Acad Dermatol. 2000;43:S57–69.
Ceschin-Roques CG, Hanel H, Pruja-Bougaret SM, Luc J, Vandermander J, Michel G. Ciclopirox nail lacquer 8 %: in vivo penetration into and through nails and in vitro effect on pig skin. Skin Pharmacol. 1991;4(2):89–94.
Monti D, Herranz U, Dal Bo L, Subissi A. Nail penetration and predicted mycological efficacy of an innovative hydrosoluble ciclopirox nail lacquer vs. a standard amorolfine lacquer in healthy subjects. J Eur Acad Dermatol Venereol. 2013;27:e153–8. This study demonstrated the higher nail penetration and efficacy of a novel, water-soluble formulation of ciclopirox.
Monti D, Tampucci S, Chetoni P, Burgalassi S, Mailland F. Ciclopirox vs amorolfine: in vitro penetration into and permeation through human healthy nails of commercial nail lacquers. J Drugs Dermatol. 2014;13(2):143–7. Notable study that showed persistent inhibition of fungal growth and good nail penetration with ciclopirox hydrolacquer formulation.
Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8 % in the treatment of toenail onychomycosis. J Am Acad Dermatol. 2000;43(4):S70–80.
Malay DS, Yi S, Borowsky P, Downey MS, Mlodzienski AJ. Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized controlled trial. J Foot Ankle Surg. 2009;48(3):294–308.
Baran R, Tosti A, Hartmane I, Altmeyer P, Hercogova J, Koudelkova V, et al. An innovative water-soluble biopolymer improves efficacy of ciclopirox nail lacquer in the management of onychomycosis. J Eur Acad Dermatol Venereol. 2009;23(7):773–81.
Schalka S, Nunes S, Gomes NA. Comparative clinical evaluation of efficacy and safety of a formulation containing ciclopirox 8 % in the form of a therapeutic nail lacquer in two different posologies for the treatment of onychomycosis of the toes. An Bras Dermatol. 2012;87(1):19–25.
Paul C, Coustou D, Lahfa M, Bulai-Livideanu C, Doss N, Mokthar I, et al. A multicenter, randomized, open-label, controlled study comparing the efficacy, safety and cost-effectiveness of a sequential therapy with RV410A ointment, ciclopiroxolamine cream and ciclopirox film-forming solution with amorolfine nail lacquer alone in dermatophytic onychomycosis. Dermatology. 2013;227(2):157–64.
Elewski BE, Ghannoum MA, Mayser P, Gupta AK, Korting HC, Shouey RJ, et al. Efficacy, safety and tolerability of topical terbinafine nail solution in patients with mild-to-moderate toenail onychomycosis: results from three randomized studies using double-blind vehicle-controlled and open-label active-controlled designs. J Eur Acad Dermatol Venereol. 2013;27:284–94.
Jublia [package insert]. Valeant Pharmaceuticals North America (USA) LLC; 2015.
Jo Siu WJ, Tatsumi Y, Senda H, Pillai R, Nakamura T, Sone D, et al. Comparison of in vitro antifungal activities of efinaconazole and currently available antifungal agents against a variety of pathogenic fungi associated with onychomycosis. Antimicrob Agents Chemother. 2013;57(4):1610–6.
Sugiura K, Sugimoto N, Hosaka S, Katafuchi-Nagashima M, Arakawa Y, Tatsumi Y, et al. The low keratin affinity of efinaconazole contributes to its nail penetration and fungicidal activity in topical onychomycosis treatment. Antimicrob Agents Chemother. 2014;58(7):3837–42. In vitro and in vivo studies demonstrating efinaconzole’s lower binding affinity to keratin is related to its high nail permeability and fungicidal activity in the presence of keratin.
Zeichner JA, Stein Gold L, Korotzer A. Penetration of ((14)C)-efinaconazole topical solution, 10 %, does not appear to be influenced by nail polish. J Clin Aesthet Dermatol. 2014;7(9):34–6.
Elewski BE, Rich R, Pollak R, Pariser DM, Watanabe S, Senda H, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: two randomized phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2013;68(4):600–8. Phase III trials demonstrating efinaconazole’s clinical efficacy.
Gupta AK, Elewski BE, Sugarman JL, Ieda C, Kawabata H, Kang R, et al. The efficacy and safety of efinaconazole 10 % solution for treatment of mild to moderate onychomycosis: a pooled analysis of two phase 3 randomized trials. J Drugs Dermatol. 2014;13(7):815–20.
Jellinek NJ, Korotzer A. Prognostic factors for complete cure following treatment of mild and moderate toenail onychomycosis with efinaconazole topical solution 10 %. J Drugs Dermatol. 2015;14(8):871–5.
Lipner SR, Scher RK. Management of onychomycosis and co-existing tinea pedis. J Drugs Dermatol. 2015;14(5):492–4.
Kerydin [package insert]. Anacor Pharmaceuticals (USA), Inc; 2015.
Coronado D, Merchant T, Chanda S, Zane LT. In vitro nail penetration and antifungal activity of tavaborole, a boron-based pharmaceutical. J Drugs Dermatol. 2015;14(6):609–14. In vitro studies demonstrating tavaborole’s nail penetration and antifungal activity.
Vlahovic T, MPharm TM, Chanda S, Zane LT, Coronado D. In vitro nail penetration of tavaborole topical solution, 5 %, through nail polish on ex vivo human fingernails. J Drugs Dermatol. 2015;14(7):675–8.
Elewski BE, Aly R, Baldwin SL, Gonzalez RF, Rich P, Weisfeld M, et al. Efficacy and safety of tavaborole topical solution, 5 %, a novel boron-based antifungal agent, for the treatment of toenail onychomycosis: results from 2 randomized phase-III studies. J Am Acad Dermatol. 2015;73(1):62–9. Phase III trials demonstrating tavaborole’s clinical efficacy.
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This article is part of Topical Collection on Pharmacology and Pharmacodynamics of Antifungal Agents
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Childs-Kean, L.M., Jourjy, J. Antifungal Penetration into the Nail and New Topicals for Onychomycosis. Curr Fungal Infect Rep 10, 24–29 (2016). https://doi.org/10.1007/s12281-016-0250-9
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DOI: https://doi.org/10.1007/s12281-016-0250-9