mycoses Diagnosis,Therapy and Prophylaxis of Fungal Diseases

Original article

Therapeutic efficacy of topical OLEOZON in patients suffering from

onychomycosis

Silvia Menéndez,1 Leopoldina Falcón2 and Yordana Maqueira2

1
Ozone Research Center, National Center for Scientific Research, Havana, Cuba and 2‘‘Carlos J. Finlay’’ Hospital, Havana, Cuba

Summary The results of the use of ozonised sunflower oil (OLEOZON) in the treatment of
onychomycosis, based on its known antimycotic action and good skin tolerance, by
means of a controlled randomised phase III assay are presented. A total of 400
outpatients were randomly divided into two groups: experimental, treated with topical
OLEOZON, two times per day and control, treated also two times per day, with
ketoconazole cream 2%, for 3 months. A patient was considered cured when the sick
nails regained the normal colour, growth and thickness, with a negative mycological
study. In the experimental group, a regression of signs was achieved from the first
month of treatment, while in the control group, it was obtained after the third month
of treatment. All patients treated with OLEOZON had improvement in their condition
(9.5%) or were cured (90.5%). However, in the control group, only 13.5% of patients
were cured, 27.5% improved and 59% remained the same, with significant differences
between both the groups. After 1 year of follow-up, experimental and control groups
presented 2.8% and 44.4% of relapses, respectively. Topical OLEOZON demonstrated
effectiveness in the treatment of onychomycosis, superior to that of ketoconazole. No
side effects were observed.

Key words: Onychomycosis, OLEOZON, ozonised vegetable oils, ozone therapy, antimycotic therapy.

very expensive. Many patients can now expect a

Introduction
Onychomycosis is the infection of hand and foot nails
caused by diverse species of fungi of filamentous type
(mainly Trichophyton rubrum) and by yeast (Candida
albicans). It accounts for about 50% of all nail diseases
examined by physicians.1–4 This superficial mycosis is
resistant to medication. There are lesions that are not
cured for months, even years, and if cured, they can
relapse frequently.5–11 It can cause pain, discomfort and
disfigurement, and may produce serious physical and
occupational limitations, with a significant impact on
quality of life.12–14
The usual topical treatments cause irritation and are
less effective. With the production of new antimycotic
drugs, the effectiveness has increased, but they are still
Correspondence: Silvia Menéndez, Ozone Research Center,
National Center for Scientific Research, PO Box 6414, Havana, Cuba.
Tel.: +53 7 271 9264. Fax: +53 7 271 0233.
E-mail: silviamenendez@infomed.sld.cu
Accepted for publication 23 March 2010
complete and lasting cure; however, for up to 25% of
patients, persistent disease remains a problem, thus
presenting a particular challenge to the clinician.13–17
Griseofulvin is an effective medication, but it has to be
used for more than 6 months. It is not always well
tolerated and is contraindicated in pregnant women and
alcoholics. Imidazole derivatives (ketoconazole, itraco-
nazole and fluconazole), which are wide-spectrum
antimycotics, seem to be more effective than griseoful-
vin, but are also very expensive, as is the case with
terbinafine. A combination of long-term oral and topical
therapies, when given at the same time, yield good
clinical outcomes,6,18–23 although there remains a need
for more effective topical agents with greater nail
penetration that can avoid unnecessary use of oral
antifungal agents, thereby avoiding their side effects.
OLEOZON (ozonised sunflower oil; Ozone Research
Center, Havana City, Cuba) has a remarkable germicidal
action.24 Many studies refer to its antimicrobial effects
against virus, fungi and bacteria including multidrug-
resistant strains.25–32 In addition, toxicological studies

doi:10.1111/j.1439-0507.2010.01898.x  2010 Blackwell Verlag GmbH • Mycoses 54, e272–e277


have demonstrated that OLEOZON is not mutagenic or
genotoxic.33–38 It has been registered in Cuba for the
treatment of tinea pedis and impetigo.
Taking into account the fungicidal activity of OLEO-
ZON and the need to find more effective topical agents,
a therapeutic assay in patients suffering from onycho-
mycosis (by filamentous fungi or yeast) was performed.
Patients and methods
A controlled randomised phase III simple-blind study
involving 400 outpatients suffering from onychomyco-
sis was performed. The diagnosis was made according to
the mycological (positive culture of the nail scrapings of
the affected area in Sabouraud glucose agar–chloram-
phenicol) and clinical evaluation of the sick nail
(according to the colour, growth and thickness). Most
of the patients previously treated with antimycotic
medications, resulted in therapeutic failure. It was
considered the Ethics approval written by the institu-
tions involved in this study.
The inclusion criteria were as follows: patients with
positive clinical and microbiological diagnosis of ony-
chomycosis, aged between 21 and 70 years, including
both genders and different races, without previous
treatment or with more than 5 days without any
topical or systemic treatment. All patients wrote the
informed consent to participate in the assay.
The exclusion criteria were as follows: patients with
severe diseases (stroke, decompensated diabetes mell-
itus, hepatopathy, cancer in advanced stage, severe
septic stage and nephropathy), pregnancy, hypersensi-
tivity to medications, and use of corticoids, cytostatics,
antibiotics or immunodepressing drugs.
The number of patients was calculated using the
Medstat system (2.1 version, 1989;  ASTRA –
gruppen A ⁄ S, Copenhagen, Denmark). Patients were
divided randomly into two groups of 200 patients each:
experimental, treated topically with one drop of OLEO-
ZON, in each sick nail, two times per day; and control,
treated also two times per day with ketoconazole cream
2%. Both medications were applied for 3 months.
It was recommended to all patients to file the nail up
to the ungual bed and then, apply the medication with a
little massage.
Efficacy evaluation
The efficacy was evaluated clinically and mycologically.
A patient was considered: cured, when the sick nails
regained their normal colour, growth and thickness with
a negative mycological study (negative results on
 2010 Blackwell Verlag GmbH • Mycoses 54, e272–e277
OLEOZON against onychomycosis
microscopy and culture); improved, when a partial
recovery of the sick nails was obtained with decrease in
symptoms (itching, pain, inflammation and erythema)
and with a positive mycological examination; same,
when no variation in the sick nail was observed and with
a positive mycological study; worse, when the lesions of
the nails increased, with a positive mycological test.
The nail-healing criteria were according to: size,
when the healthy nail covered all the ungula plaque;
colour, when the nail lost the dark colour and regained
its pink, brilliant and transparent aspect; and thickness,
when the nail decreased its thickness, produced by the
cellular detritus deposit in the layer.
Results were determined by monthly evaluation.
Statistical analysis
Homogeneity between groups was taken into account
(PearsonÕs chi-square). Chi-square and FisherÕs exact
tests were applied to the comparison between the
number of cured patients in both the groups. In
addition, FisherÕs exact test was applied with regard to
the average time for the disappearance of symptoms and
for healing.
Results
The general characteristics of the sample studied (400
patients) were as follows: mean age was 35 years, 80%
were men, 65% were white people, and the mean time
for the evolution of the disease was 30 months. To
demonstrate the homogeneity between the groups,
several factors were taken into account: age, gender,
race, time of evolution of the lesions and distribution of
patients according to whether they had received previ-
ous treatment or not. No significant differences were
obtained between both the groups (Pearson chi-square
and chi-square: P > 0.05).
At the third month of treatment, in relation to colour,
growth and thickness of the sick nails, they normalised
in a higher per cent and in lower time in those patients
treated with OLEOZON, with significant differences
between both groups (P < 0.00001). In the experimen-
tal group, a regression of signs was achieved in some
patients from the first month of treatment; while in the
control group, only slight improvements were seen in
the third month of treatment (Table 1).
Patients treated with OLEOZON were cured in a
higher percentage and in less time than those of the
control group (P < 0.0001). In the first, second and
third months of treatment, 32 (16%), 44 (22%) and
105 (52.5%) patients treated with OLEOZON were
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S. Menéndez et al.

Table 1 Distribution of patients in both groups of treatment, with respect to the nail-healing criteria (according to thickness, colour and
growth) evaluated every month.

Thickness Colour Growth

Medications I NI I NI I NI

First month of treatment

OLEOZON 44a (22) 156 (78) 33a (16.5) 167 (83.5) 32a (16) 168 (84)
n = 200
Ketoconazole 0 (0) 200 (100) 0 (0) 200 (100) 0 (0) 200 (100)
n = 200
Second month of treatment
OLEOZON 63a (31.5) 137 (68.5) 53a (26.5) 147 (73.5) 50a (25) 150 (75)
n = 200
Ketoconazole 0 200 (100) 0 (0) 200 (100) 0 (0) 200 (100)
n = 200
Third month of treatment
OLEOZON 97b* (48.5) 103 (51.5) 98b& (49) 102 (51) 93b# (46.5) 107 (53.5)
n = 200
Ketoconazole 5** (2.5) 195 (97.5) 10&& (5) 190 (95) 4## (2) 196 (98)
n = 200

I, improvement; NI, no improvement; Values are given as n (%).

In the OLEOZON group, a and b means significant differences (FisherÕs exact test and Chi-square: P < 0.0001) within a same category,
with respect to the time of evaluation. In the ketoconazole group, only slight improvements are seen in the third month of treatment. * and
**, & and &&, # and ## correspond to significant differences (FisherÕs exact test and Chi-square: P < 0.00001) between OLEOZON and
ketoconazole, taking into account thickness, colour and growth, respectively, at the third month of treatment.

Table 2 Distribution of patients, according to each group of treatment, with respect to the healing time of the lesions.

First month Second month Third month Total

Medications C NC C NC C NC C NC
 a a a a
OLEOZON 32 (16) 168 (84) 44 (22) 156 (78) 105 (52.5) 95 (47.5) 181 (90.5) 19 (9.5)
n = 200
Ketoconazole 0b (0) 200 (100) 0b (0) 200 (100) 27b (13.5) 173 (86.5) 27b (13.5) 173 (86.5)
n = 200

C, cured; NC, not cured; Values are given as n (%).

Different letters represent significant differences (FisherÕs exact test and Chi-square: P < 0.0001) between OLEOZON and ketoconazole
groups.

cured, respectively, taking into account the healing

criteria. However, only 27 (13.5%) patients treated with Table 3 Distribution of patients, according to each group, and
after 3 months of treatment, taking into account the clinical and
ketoconazole were cured in the third month of treat- mycological healing criteria.
ment (Table 2).
After 3 months of treatment and according to the Medications Worse Same Improved Cured
evaluation criteria, 19 patients (9.5%) treated with OLEOZON 0 (0) 0a (0) 19a (9.5) 181a (90.5)
OLEOZON showed improvement in their condition and n = 200
181 patients (90.5%) were cured. However, in the Ketoconazole 0 (0) 118b (59) 55b (27.5) 27b (13.5)
control group, only 27 patients (13.5%) were cured, 55 n = 200
patients (27.5%) improved and 118 patients (59%) Values are given as n (%).
remained the same, with significant differences between Different letters represent significant differences (FisherÕs exact test
both the groups (P < 0.0001). None of the patients got and Chi-square: P < 0.0001) between OLEOZON and ketoco-
worse at the end of both treatments (Table 3). nazole groups.

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(a)
Figure 1 Representative results of
onychomycosis treatment with
OLEOZON. (a) Before treatment; (b) after
3 months of treatment.
After 1 year of follow-up assessment, in the patients
who were cured, experimental and control groups
presented 5 (2.8%) and 10 patients (37.0%) with
relapses, respectively. Trichophyton rubrum and C. albi-
cans (in less proportion) were again present in those
patients, and no reinfection by bacteria was observed.
Figure 1 shows the results obtained after 3 months of
treatment with OLEOZON.
Discussion
Patients with onychomycosis may report paraesthesia,
pain, discomfort and loss of dexterity that may interfere
with standing, walking and exercising. They also may
report loss of self-esteem and lack of social interac-
tion.2,12,14,15 The incidence of onychomycosis has been
reported to be 2–13% in North America and studies in
the United Kingdom, Spain and Finland found preva-
lence rates of 3–8%.39,40 Taking into account the
symptoms that this disease produces and its prevalence,
the need for more effective antifungal agents is still
present. Generally, topical treatment for this disease is
not effective; therefore, a combination of long-period
oral and topical therapies, given at the same time, has to
be used to obtain good clinical outcomes. However,
most of these medications, when administered in a long-
period oral treatment, can lead to severe systemic
adverse effects or interactions with other systemic drugs
being taken by the patient, causing the interruption of
the therapy.6–8,15,41,42
This study represents a big challenge for both
medications (OLEOZON and ketoconazole), because it
evaluates in chronic patients the effectiveness of their
topical use only.
This assay demonstrated the fungicidal activity of
topical OLEOZON, better than others reported in
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OLEOZON against onychomycosis
(b)
literature, even oral treatments.18–23 This product has
a great action spectrum, does not create pathogen
resistance, has a good tissue diffusion and is well
tolerated by patients without any adverse reac-
tions.25–32 In comparison, topical ketoconazole failed
to reduce the fungal burden in the affected nails with
only slight improvements in the third month of
treatment.
Moreover, the proven bactericidal effect of OLEOZON
results in the possibility to treat super infected lesion
caused by bacteria.25–30 It is important to take into
account that the faster the therapy begins the more
effective the results will be.
The homogeneity between the two groups guaran-
teed that age, gender, race and time of evolution of the
lesions were in equal proportion in both the groups.
The low number of relapses in the cured patients,
who had been treated with OLEOZON (2.8%), during
the 1 year of follow-up, is encouraging. Some authors
suggest that this product is superior to other commonly
used topical or oral antimycotics6,9–11,21 and acts as a
great fungicide against T. rubrum and C. albicans.
Conclusions
Topical OLEOZON can be considered an antifungal
medication in the treatment of onychomycosis with
better therapeutic effect than topical ketoconazole. It
yields no risk of systemic adverse effects and drug
interactions, unlike oral antifungal drugs, and it is a
low-cost therapy.
Acknowledgments
This study was sponsored by the Ozone Research Center
and the Health Ministry of Cuba.
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S. Menéndez et al.
References
1 Dismukes WE. Introduction to antifungal drugs. Clin Infect
Dis 2000; 30: 653–8.
2 Faergemann J, Baran R. Epidemiology, clinical presenta-
tion and diagnosis of onychomycosis. Br J Dermatol 2003;
149(Suppl. 65): 1–4.
3 Midgley G, Moore MK. Nail infections. Dermatol Clin 1996;
14: 41–49.
4 Simón RD. Micosis cutáneas. In: Colectivo de autores (ed),
Dermatologı́a. La Habana: editorial Ciencias Médicas,
2002: 233–61.
5 Restrepo A. Treatment of tropical mycoses. J Am Acad
Dermatol 1994; 31: S91–S98.
6 Scher RK, Baran R. Onychomycosis in clinical practice:
factors contributing to recurrence. Br J Dermatol 2003;
149(Suppl. 65): 5–9.
7 Crawford F, Young P, Godfrey C et al. Oral treatments for
toenail onychomycosis: a systematic review. Arch Derma-
tol 2002; 138: 811–6.
8 Evans EG. Causative pathogens in onychomycosis and the
possibility of treatment resistance: a review. J Am Acad
Dermatol 1998; 38: S32–S56.
9 Hull PR. Onychomycosis – treatment, relapse and re-
infection. Dermatology 1997; 194(Suppl. 1): 7–9.
10 Tosti A, Piraccini BM, Stinchi C, Colombo MD. Relapses of
onychomycosis after successful treatment with systemic
antifungals: a three-year follow-up. Dermatology 1998;
197: 162–6.
11 Tosti A, Piraccini BM, Stinchi C, Venturo N, Colombo
MD. Relapse rate of onychomycosis after systemic
treatment with terbinafine or itraconazole: a 2-year
follow-up. J Eur Acad Dermatol Venereol 1996;
7(Suppl. 2): 157–61.
12 Lubeck DP. Measuring health-related quality of life in
onychomycosis. J Am Acad Dermatol 1998; 38: S64–
S68.
13 Gupta AK, Scher RK, De Doncker P. Current management
of onychomycosis. An overview. Dermatol Clin 1997; 15:
121–35.
14 Gupta AK, Palese CS, Scher RK. How to treat special
populations suffering from onychomycosis. Skin Aging
1999; 7: 54–58.
15 Gupta AK, Shear NH. A risk-benefit assessment of the
newer oral antifungal agents used to treat onychomycosis.
Drug Saf 2000; 22: 33–52.
16 Gupta AK, Cooper EA, Ryder JE, Nicol KA, Chow M,
Chaudhry MM. Optimal management of fungal infections
of the skin, hair, and nails. Am J Clin Dermatol 2004; 5:
225–37.
17 Roberts DT. Onychomycosis: current treatment and future
challenges. Br J Dermatol 1999; 141: 1–4.
18 Sigurgeirsson B, Olafsson JH, Steinsson JB et al. Long-term
effectiveness of treatment with terbinafine vs itraconazole
in onychomycosis: a 5-year blinded prospective follow-up
study. Arch Dermatol 2002; 138: 353–7.
e276
19 Bräutigam M, Weidinger G, Nolting S. Successful treat-
ment of toenail mycosis with terbinafine and itraconazole
gives long term benefits. BMJ 1998; 317: 1084–9.
20 Zaias N, Rebell G. The successful treatment of Trichophyton
rubrum nail bed (distal subungual) onychomycosis with
intermittent pulse-dosed terbinafine. Arch Dermatol 2004;
140: 691–5.
21 Cribier BJ, Paul C. Long-term efficacy of antifungals in
toenail onychomycosis: a critical review. Br J Dermatol
2001; 145: 446–52.
22 Cohen AD, Medvesovsky E, Shalev R et al. An independent
comparison of terbinafine and itraconazole in the treat-
ment of toenail onychomycosis. J Dermatolog Treat 2003;
14: 237–42.
23 Jain S, Sehgal VN. Itraconazole: an effective oral anti-
fungal for onychomycosis. Int J Dermatol 2001; 40: 1–5.
24 Dı́az M, Lezcano I, Molerio J, Hernández F. Spectroscopic
characterization of ozonides with biological activity. Ozone
Sci Eng 2001; 23: 35–40.
25 Lezcano I, Núñez N, Espino M, Gómez M. Antibacterial
activity of ozonized sunflower oil, Oleozon, against Staph-
ylococcus aureus and Staphylococcus epidermidis. Ozone Sci
Eng 2000; 22: 207–14.
26 Lezcano I, Molerio J, Gómez M, Contreras R, Roura G, Dı́az
W. Actividad in vitro del OLEOZON frente a agentes eti-
ológicos de infecciones de la piel. Rev CENIC Ciencias
Biológicas (Cuba) 1998; 29: 209–12.
27 Sechi LA, Lezcano I, Nuñez N et al. Antibacterial activity
of ozonized sunflower oil (Oleozon). J Appl Microbiol 2001;
90: 279–84.
28 Vigna I, Menéndez S. Eficacia de la ozonoterapia en gatos
con diferentes enfermedades oftalmológicas. RECVET
[WWW document], Nov 2007; II(11). URL http://
www.veterinaria.org/revistas/recvet/n111107.html
[accessed on 1 November 2007]
29 Falcón L, Menéndez S, Simón RD, Garballo E, Moya S,
Abreu M. Aceite Ozonizado en Dermatologı́a. Experiencia
de 9 años. Rev CENIC Ciencias Biológicas (Cuba) 1998; 29:
192–5.
30 Menéndez S, Fernández M, Amoroto M et al. Eficacia y
seguridad del OLEOZON tópico en el tratamiento de
pacientes con impétigo. Rev Panam de Infectol 2007; 9:
23–29.
31 Menéndez S, Falcón L, Simón R, Landa N. Ozonized sun-
flower oil in the treatment of tinea pedis. Mycoses 2002;
45: 329–32.
32 Menéndez S, Re L, Falcón L et al. Safety of topical OLEO-
ZON in the treatment of tinea pedis: phase IV clinical
trial. Int J Ozone Therapy 2008; 7: 55–59.
33 Acevedo F, González J, Moleiro J et al. Ensayo de toxicidad
dérmica de 120 dı́as del aceite ozonizado, OLEOZON, en
ratas Cenp. SPRD. Avances en Biotecnologı́a Moderna (Cuba)
1997; 4: T4–10.
34 Arteaga ME, Molerio J, Bada A, González B, Zamora Z,
Remigio AC. Clasificación toxicológica del OLEOZON. Rev
CENIC Cienc Biol (Cuba) 2001; 32: 57–59.
 2010 Blackwell Verlag GmbH • Mycoses 54, e272–e277

35 Llerena C, Garcı́a G, Molerio J, Menéndez S. Irritabilidad
dérmica del Oleozon. Rev CENIC Cienc Biol (Cuba) 1995;
26: 104–9.
36 Martı́nez G, Merino N, Sam S, Cenarega T. Efecto histol-
ógico y bioquı́mico del OLEOZON en el modelo de la cola
de ratón. Rev CENIC Cienc Biol (Cuba) 1997; 28: 31–34.
37 Zamora Z, González R, Guanche D et al. Ozonized sunflower
oil reduces oxidative damage induced by indomethacin
in rat gastric mucosa. Inflamm Res 2008; 57: 39–43.
38 Remigia A, González Y, Zamora Z, Molerio J. Evaluación
genotóxica del Oleozon. Rev CENIC Cienc Biol (Cuba)
1998; 28: 100–4.
 2010 Blackwell Verlag GmbH • Mycoses 54, e272–e277
OLEOZON against onychomycosis
39 Kemna ME, Elewski BE. A U.S. epidemiologic survey of
superficial fungal diseases. J Am Acad Dermatol 1996; 35:
539–42.
40 Summerbell RC. Epidemiology and ecology of onycho-
mycosis. Dermatology 1997; 194(Suppl. 1): 32–36.
41 Gupta AK, Katz HI, Shear NH. Drug interactions with
itraconazole, fluconazole, and terbinafine and their
management. J Am Acad Dermatol 1999; 41: 237–49.
42 Katz HI, Gupta AK. Oral antifungal drug interactions.
Dermatol Clin 1997; 15: 535–44.
e277