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Presented by:
Sim Sui Theng
Hospital Miri
OUTLINE
Introduction
Anatomy of a Nail
Types of Onychomycosis
Causes
Oral Therapy
Topical Therapy
Patient Counseling
Conclusion
References
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INTRODUCTION
Definition: Infection of the nail caused by fungi
such as dermatophytes, non-dermatophyte
moulds and yeasts (mainly Candida species)
Classified as
Distal and lateral subungual onychomycosis
(DLSO)
Superficial white onychomycosis (SWO)
Proximal subungual onychomycosis (PSO)
Candidial onychomycosis
Total dystrophic onychomycosis
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ANATOMY OF A NAIL
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(1) Distal & lateral subungual
onychomycosis (DLSO)
Majority case due to dermatophyte
infection
Thickened & opacified nail plate
Subungual hyperkeratosis
Oncholysis
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(1) DLSO
Fig 1a: Distal lateral onychomycosis Fig 1b: Distal subungual onychomycosis
with surrounding erythema caused by T. rubrum.
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(2) Superficial white
onychomycosis (SWO)
Dermatophyte infection caused by: T.
mentagrophytes
Less common than DLSO; affects the surface
of nail plate rather than nail bed
Usually confined to the toenails
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(2) SWO
Fig 3a: Proximal onychomycosis Fig 3b: Chronic tinea pedis and
Proximal onychomycosis
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(4) Candidal Onychomycosis
Infected by Candida yeasts
Manifested as erythematous swelling of the
nail fold OR as separation of the nail plate
from its bed
Presented in one of the four ways:
Chronic paronychia with secondary nail dystrophy
Distal nail infection
Chronic mucocutaneous candidiasis
Secondary candidiasis
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(4) Candidal Onychomycosis
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(5) Total dystrophic
onychomycosis
Presented as a thickened, opaque and
yellow-brown nail and involves the entire nail
plate and matrix
Fig 5:Total dystrophic onychomycosis with the nail plate partially removed 13
CAUSES
Caused by 3 main classes of fungi: dermatophytes, yeasts &
nondermatophyte molds
Two major pathogens are responsible for 90% of all OM cases
Trichophyton rubrum (70%)
Trichophyton mentagrophytes (20%)
Yeasts (8%) & nondermatophyte molds (2%)
T. rubrum is the most common pathogen in DLSO and PSO
T. mentagrophytes (often) and species of nondermatophyte
molds (rare) cause SWO
Candida albicans primarily causes chronic mucocutaneous
candidiasis of the nail
Risk factors: family history, ↑ age, poor health, warm climate,
participation in fitness activities, immunosuppression (HIV, drug
induced), communal bathing, and occlusive footwear
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TREATMENT
(1) Medical care
Oral therapy
Topical therapy
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ORAL THERAPY
Antifungal drugs
Griseofulvin (Fulvicin®, Gifulvin®, Gris-Peg®)
Terbinafine (Lamisil®)
Itraconazole (Sporanox®)
Fluconazole (Diflucan®)
Disadvantages: require longer Rx period &
more side effects
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Efficacy
Newer generation (terbinafine & itraconazole) replaced
older drug (griseofulvin)
Griseofulvin has ↑ recurrence rates and ↓ clinical cure
rates Hofmann et al 1995
Volatile solvent
Gupta, 2005 20
Avner, Nir & Henri, 2005
Topical Agent: Ciclopirox
(Penlac 8%) Nail Lacquers
MOA:
Chelates with the polyvalent cations (Fe3+ & Al3+ ) that are involved in
fungal enzymatic activity interrupts intracellular energy production &
toxic peroxide degradation
Inhibits fungal nutrient uptake depletion of amino acids & nucleotides
protein synthesis ↓ (Fungicidal effect)
Dosing:
Apply once daily to affected nails can can be used up to 48 weeks
(indicated for infected nails w/o lunula involvement)
FDA
Common side effects:
Rash-related: periungual erythema, erythema of the proxymal nail fold
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Gupta, Schouten & Lynch, 2005
Topical Agent: Amorolfine
(5%) Nail Lacquers
MOA:
Inhibits sterol biosynthesis disrupts fungal cell membrane
cell death
Dosing:
Apply once or twice weekly until clinical cure is achieved
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Patient Counseling: How to
apply nail lacquer?
It should be applied evenly over the entire nail plate and 5mm of surrounding skin
preferably at bedtime
Area of application: Nail bed, hyponychium and the under surface of the nail plate
Apply daily (ciclopirox) / twice weekly (amorolfine) on previous coat
Wait 30 seconds for application to dry
Wait 8 hours after application before washing or showering
Remove previous coats with alcohol, file loose nail materials, and trim nails every
7 days
Unattached, infected part of the nail should be removed by health care
professionals periodically (at least monthly)
Contact with surrounding skin may produce mild, transient irritation (redness)
Avoid contact with eyes and other internal route
Do not remove product on daily basis
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CONCLUSION
Onychomycosis is not life-threatening, but it
can cause pain, discomfort, disfigurement
and may produce serious physical and
occupational limitations
Psychosocial & emotional effects affect
QOL
Appropriate patient education should be
enhanced in order to improve patient’s
compliance to therapy
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REFERENCES
Hofmann, H, Brautigam, M, Weidinger, G, Zaun, H. Treatment of toenail onychomycosis. A randomized, double-
blind study with terbinafine and griseofulvin. LAGOS II Study Group. Arch Dermatol 1995; 131:919.
Gupta, AK, Ryder, JE, Johnson, AM. Cumulative meta-analysis of systemic antifungal agents for the treatment of
onychomycosis. Br J Dermatol 2004; 150:537.
Gupta, AK. Ciclopirox topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized,
evaluator-blinded study. J Drugs Dermatol 2005; 4:481.
Avner, S, Nir, N, Henri, T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for
the treatment of onychomycosis. J Dermatolog Treat 2005; 16:327.
Gupta, AK, Schouten, JR, Lynch, LE. Ciclopirox nail lacquer 8% for the treatment of onychomycosis: A Canadian
perspective. Skin Ther Lett 2005;10:1-3.
Blumberg, M, Kantor, GR. Onychomycosis. eMedicine Dermatology 2007. Retrieved from:
http://emedicine.medscape.com/article/1105828-overview
Shirwaikar, AA, Thomas,T, Shirwaikar A, Lobo,R, Prabhu, KS. Treatment of Onychomycosis: An Update. Indian
Journal of Pharmaceutical Sciences 2008; Nov-Dec:710-714.
Jan, S, Bora, D, Bhise K. Preungual drug delivery systems of Terbinafine Hydrochloride Nail Lacquer. Asian
Journal of Pharmaceutics 2008; Jan:53-56.
Goldstein, AO, Goldstein BG. Onychomycosis. UpToDate database system 2007.
Lexi-Comp’s Drug Information Handbook, 13th Edition.
British National Formulary 55, March 2008. British Medical Association.
Micromedex Healthcare Series.
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THANK YOU!
Any questions?