Current Trends In Antifungal Therapy

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New Study Highlights Long-Term Efficacy Of Lamisil

If you would like to give your onychomycosis patients long-term treatment results, you may want to consider Lamisil, according to a recent study published in the March issue of Archives of Dermatology.

In reportedly the longest follow-up study of patients with toenail onychomycosis, researchers found that nearly half of the patients treated with Lamisil (terbinafine) remained mycologically cured five years after their initial treatment without any subsequent treatment.

“These findings offer patients and physicians evidence that toenail fungus can be effectively treated with 12 weeks of treatment with Lamisil,” notes Bardur Sigurgeirsson, MD, PhD, the lead author of the study and an Assistant Professor of Dermatology at the University of Iceland.

This actively controlled follow-up study tracked patients at six-month intervals for an average of 54 months. It included 74 Lamisil-treated patients (from three centers in Iceland) who participated in a previous study of onychomycosis patients. In the previous study (documented in the April 1999 issue of the British Medical Journal), 76 percent of Lamisil-treated patients achieved mycological cure at the end of an 18-month follow-up period.

Richard Pollak, DPM, uses Lamisil “extensively” and says his patients are “very satisfied” with it. While some of his patients have experienced recurrence after taking Lamisil, Dr. Pollak says the majority of his patients with onychomycosis see improvement three months after they start to take Lamisil. In 10 months to a year, they will see growth of the nail, according to Dr. Pollak.

Dr. Pollak feels Lamisil is safe and has few drug-to-drug interactions. He points out that he has only had to take one patient off the drug. A drawback to Lamisil is its cost, since many insurance companies do not cover oral agents, according to Dr. Pollak.

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On the top photo, you can see the onychomycotic toenail prior to treatment. The middle photo offers a view of the same toenail after a 12-week course of Lamisil. The bottom photo shows the cured nail 36 weeks after the Lamisil treatment had been completed
Dr. Joseph has been impressed with the ability of ciclopirox cream to treat moccasin tinea.
Dr. Overley has had “great success” using the topical Penlac solution (see above) in combination with oral therapy to treat recalcitrant onychomycosis.
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Author(s): 
Panelists: Warren Joseph, DPM, Aditya Gupta, MD, PhD, Benjamin Overley, DPM, Richard Pollak, DPM and Jack Rubinlicht, DPM

Should you use a topical, an oral therapy or a combination of both? This is one of many questions that came up during an intriguing discussion of antifungals. Drawing upon their clinical experience, the panelists discuss their approaches to treating tinea pedis and onychomycosis, indications and contraindications for oral drugs, and other important aspects of prescribing appropriate, effective therapy.

Q: What do you use to treat different presentations of tinea pedis, including moccasin variety, acute vesicular and dermatophytosis complex (severe interdigital tinea)?
Warren Joseph, DPM, says moccasin variety tinea pedis has always been difficult to treat, due to the chronic nature of the condition. He also points out that the body has a blunted immune response to the fungus (almost always T. Rubrum), which causes the chronicity and prevents the natural immune defenses from helping to eliminate the infection.

Traditionally, doctors could only treat this condition with systemic medications but Dr. Joseph notes that with the advent of terbinafine cream (Lamisil), he had his “first real successes in treating the condition topically.” However, lately with the terbinafine cream only being available OTC, Dr. Joseph says he has reverted back to using ciclopirox cream or gel (Loprox) and has been impressed with its ability to treat moccasin tinea. Richard Pollak, DPM, also prescribes Loprox gel bid for two months while Benjamin Overley, DPM, uses Oxistat 1% cream and may also use a topical steroid cream to treat this condition.
In his opinion, Dr. Joseph believes terbinafine and ciclopirox creams are effective for moccasin tinea because, unlike the azoles, they are fungicidal. Due to the fact that the skin needs time to completely turn over and shed the fungus, Drs. Joseph and Pollak note that it usually takes at least a month before you see results.
When it comes to treating acute vesicular tinea, Dr. Joseph says combining a short course of oral therapy with aggressive topical therapy seems to be the best course. Aditya Gupta, MD, PhD, notes that he leans toward using oral antifungals for this condition. Dr. Pollak says he initially uses Domeboro soaks bid, Spectazole cream or Loprox gel, and tinactin powder in the shoes.
If the tinea is acute and aggressive, Jack Rubinlicht, DPM, says he will use a topical, such as Spectazole, and add either Lamisil (250mg 1qd) or one Sporanox pulse pack. If the condition is severe, Dr. Pollak may consider prescribing an oral antifungal for two weeks in addition to Domeboro soaks. If there is a secondary bacterial infection, Dr. Pollak says he does not hesitate to consider an appropriate oral antibiotic.
Given the intense inflammatory response generated by T. mentagrophytes, the usual cause of acute vesicular tinea, topical steroids can also be useful, according to Dr. Joseph. Dr. Overley concurs, noting that he uses Oxistat 1% lotion and may also opt for a topical steroid cream.

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