Onychomycosis is a common infection of the nail predominantly caused by anthropophilic dermatophytes, and to a lesser extent by yeasts (Candida species) and non-dermatophyte molds. The treatment of onychomycosis is dependent on several variables, including the type of onychomycosis and the causative organism. Various techniques have been used to accurately diagnose onychomycosis, with microscopy and culture being used most frequently. Histological examination of the distal nail plate can aid in confirming the presence of invasive nail disease, but histological examination should not be limited to the nail plate as it may also be helpful in diagnosing subungual onychomycosis. Nucleic acid-based identification techniques may also be valuable when diagnosing onychomycosis; however, multiple steps may be necessary to determine the causative species. Confocal microscopy may also be a fast and reliable method of diagnosing onychomycosis, though it has very limited ability to distinguish between dermatophyte and mold infections. Prior to treatment an accurate diagnosis can provide guidance about the choice of antifungal agent, especially since the causative organism may vary in its response to the antifungal therapies available.

Humans↗

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Seborrheic dermatitis of the scalp: etiology and treatment.

Seborrheic dermatitis is a common chronic infection of the lipid-rich areas of skin. While seborrheic dermatitis has been a recognized clinical entity for decades, its etiology is far from clear. Early investigators of the development of seborrheic dermatitis focused on the role of the Malassezia (previously Pityrosporum) yeasts. These yeasts are also normal skin commensals, thus their importance as pathogens in this disorder came to be doubted. However, it was subsequently found that treatment of seborrheic dermatitis with an antifungal agent not only resulted in clinical improvement but also reduced the number of Malassezia yeasts on the skin. This has resulted in a resurgence of interest in the Malassezia yeasts. It has been hypothesized that there is an immunological component to seborrheic dermatitis, possibly representing an abnormal host response to the Malassezia yeasts. This paper will discuss the role of Malassezia in the etiology of seborrheic dermatitis, as well as the various treatment options.

Administration, Topical↗

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The use of sulfur in dermatology.

Sulfur has antifungal, antibacterial, and keratolytic activity. In the past, its use was widespread in dermatological disorders such as acne vulgaris, rosacea, seborrheic dermatitis, dandruff, pityriasis versicolor, scabies, and warts. Adverse events associated with topically applied sulfur are rare and mainly involve mild application site reactions. Sulfur, used alone or in combination with agents such as sodium sulfacetamide or salicylic acid, has demonstrated efficacy in the treatment of many dermatological conditions.

Acne Vulgaris↗

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Prednicarbate (dermatop): a review.

Prednicarbate is a non-halogenated, double-ester derivative of prednisolone that has become of interest for the treatment of inflammatory skin diseases, for example atopic dermatitis. In the past, topical steroids have been a popular choice for treating these diseases; however, the potential for significant local and systemic adverse events, such as skin atrophy and hypothalamic-pituitary-adrenal (HPA) axis suppression have limited their use. Prednicarbate has been found to have a favorable benefit-risk ratio, with low skin atrophy potential, and a high anti-inflammatory action. Prednicarbate may be particularly advantageous when used intermittently in pediatric and elderly patients.

Aged↗

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The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence.

Terbinafine is an allylamine with fungicidal activity, first approved for the treatment of onychomycosis in the United Kingdom in the early 1990s, and in the US in 1996. Terbinafine is the most frequently prescribed oral antifungal agent in the US and Canada for onychomycosis. Its efficacy and safety in dermatophyte toenail onychomycosis in adults has been established in many studies. In fact, 18 randomized controlled trials have shown terbinafine to be highly effective, with a meta-average for mycological cure of 76% +/- 3% (mean +/- standard error). In large surveillance studies, terbinafine exhibited excellent safety profiles consistent with results obtained in pivotal studies. Additionally, terbinafine has been reported to be superior to both itraconazole and fluconazole in comparative studies in the treatment of dermatophyte toenail onychomycosis. Recent studies have reported terbinafine to be more cost effective than griseofulvin, fluconazole, or itraconazole. Terbinafine has also been used to treat onychomycosis effectively and safely in special patient populations, such as children, the elderly, immunocompromised patients, diabetics, and those with Down syndrome. Terbinafine should therefore be considered for the management of onychomycosis in adults based on its effectiveness, broad spectrum, fungicidal nature, established safety profile, and very low occurrence of drug interactions. Furthermore, the data support the use of terbinafine to treat dermatophyte onychomycosis in children and the elderly.

Adult↗

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Ciclopirox topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized, evaluator-blinded study.

This randomized, evaluator-blind, 3-arm parallel, comparator controlled, multicenter pilot study evaluated the safety and efficacy of ciclopirox nail lacquer topical solution, 8% in combination with oral terbinafine for the treatment of moderate to severe toenail onychomycosis (> or =60% disease involvement of target nail and/or lunula/matrix involvement) (N = 73). Patients were randomized to 1 of 3 treatment arms: ciclopirox nail lacquer once daily for 48 weeks plus 4 weeks of terbinafine 250 mg/day, followed by 4 weeks of rest (no terbinafine), then another 4 weeks of terbinafine 250 mg/day (PLs); ciclopirox nail lacquer once daily for 48 weeks plus terbinafine 250 mg/day for 12 weeks (PL12); or terbinafine 250 mg/day for 12 weeks (L12). At week 48, mycological cure (negative microscopy and culture) occurred in 66.7% (14/21) (PL8), 70.4% (19/27) (PL12), and 56.0% (14/25) (L12) of patients confirmed dermatophyte positive, respectively (P: not significant). At this time point, effective cure (simultaneous mycological cure and > or =90% reduction in the disease area) was observed in 40.0% (8/20), 33.3% (8/24), and 34.8% (8/23) of patients, respectively (P: not significant). The PLs regimen was well-tolerated and had high compliance. The data suggest that combination therapy (PL8) may be an alternative regimen to continuous terbinafine (L12) in the treatment of moderate to severe dermatophyte toenail onychomycosis.

Administration, Topical↗