Treating Fungal Infections In Patients With Wounds
Dr. Markinson treats most fungal infections empirically. If the patient does not respond to topical therapy, he believes a skin biopsy is the best diagnostic procedure. As he notes, one can get a PAS stain on the tissue as well as determine if the patient has a steroid responsive dermatitis, which is very common with venous disease. If Dr. Markinson is treating nail disease, he mostly uses oral terbinafine (Lamisil, Novartis) and never treats nail disease before obtaining a confirmatory culture or positive PAS stain.
What is your fungal treatment of choice (topical/oral) in patients with wounds?
Drs. Suzuki, Markinson and Haverstock use various iterations of terbinafine. For nail treatment, Dr. Markinson will use oral terbinafine, 250 mg daily for seven days, which patients repeat every three months for a total of four pulses.2 He says his results have shown the same success as in the study by Zaias and Rebell. In between pulses, the patient has a two-month and three-week drug holiday, which he says virtually eliminates hepatotoxicity concerns. This also eliminates the need for a hepatic profile during therapy, which he would normally do. Dr. Markinson always gets a liver profile and blood count before therapy begins.
For topical antifungal treatment of skin and nail disease, Dr. Suzuki recommends QD to BID applications of over-the-counter terbinafine spray, calling it easier to apply in comparison to creams and citing its ready availability. If the patient does not respond clinically to terbinafine after a few weeks, he may prescribe other antifungal medications such as ciclopirox (Loprox, Medicis) or sertaconazole (Ertaczo, OrthoDermatologics).
Clinically, if Dr. Haverstock suspects a fungal infection of the skin, he starts the patient on a topical medication such as terbinafine hydrochloride. If the patient has a positive response, he continues using terbinafine until the infection has resolved. If a wound culture demonstrates a fungal infection, Dr. Haverstock consults infectious disease specialists to assist in treating the infection. He relies heavily on infectious disease consultants when managing these infections.
As for oral antifungal medications, Dr. Suzuki prefers terbinafine, 250 mg QD for two weeks for skin disease and three months for nail disease. He obtains a liver function panel and complete blood count prior to prescribing three-month oral therapy in order to rule out any liver dysfunction. Itraconazole (Sporanox, Janssen Pharmaceuticals) 200 mg PO QD for three months is another choice for onychomycosis treatment. However, he notes it is less preferable because of the drug interaction and the black box warning for patients with congestive heart failure.
Drs. Markinson and Haverstock cite the use of ciclopirox. For tinea pedis, Dr. Markinson typically uses ciclopirox cream 0.77%. His patients get a 90 gram tube with six refills and instructions to use it daily after showering. He will also introduce to the patient the concept of lifelong prophylaxis with this regimen. Dr. Markinson rarely uses an oral agent for tinea pedis. For nail infections, Dr. Haverstock uses topical ciclopirox 8% nail lacquer.
Dr. Mozena offers each patient all options for fungal treatment. He will also discuss the range of success rates noted in the literature for each modality. As he points out, topicals are 5 to 50 percent effective depending on the study and the definition of success.3 He also notes that orals have a 14 to 75 percent success rate for onychomycosis and laser studies have shown a 65 to 85 percent clinical response rate for onychomycosis.4,5 He explains to patients that a response rate means their condition can have a response from 1 to 100 percent, depending on many factors.
What is your opinion on laser therapy for fungal nails?
In the future, Dr. Mozena feels laser treatment will be the standard of care for tinea unguium. He acknowledges that there are several ongoing studies for lasers and more are needed. Drs. Haverstock and Markinson also cite a need for more research.
Although lasers for onychomycosis show “exciting promise,” Dr. Markinson notes a paucity of data. He feels the laser has a rightful place in the long-term management of onychomycosis.