Modern treatment of onychomycosis

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The article presents the data on onychomycosis causative agents, clinical types and forms of nails affection, describes modern methods of onychomycosis treatment with the use of highly effective antifungal drugs of systemic and external action. It is shown that the cure of onychomycosis can be achieved with the right choice of antimycotic agents, taking into account the type, form of the lesion, the extent of the process, as well as the general state of the body (related diseases, the state of the immune system).

В Over the last 20 years mycoses of feet (hands) have been the most common fungal diseases in all the countries of the world, affecting also nail plates in 40% of cases.
The causative agents of onychomycosis can be dermatophytes, yeast and mold fungi. Of the dermatophytes, the main causative agent is thought to be Trichophyton rubrum, which is isolated in 60-70% of cases by cultural examination. The fungus can affect the nail plates on the toes, hands, smooth skin on any part of the skin, as well as long and downy hair. The second pathogen-Tryxorhton mentagrophytes var. interdigitale only affects the toenails on the I and V toes and the skin of the III-IV interfinger folds, the upper third of the sole, the lateral surfaces of the foot and toes and the arch of the foot. The fungus very rarely affects the nails on the I and V toes Epidermophyton floccosum. However, it is not uncommon for onychomycosis to be caused by mixed floraDermatophytes and yeast-like or mold fungi, bacterial infection may also occur. From mold fungi The most common pathogen is the fungus Scopulariopsis brevicaulis , Generally, the toenails of the big toes are affected, and the nails turn brown. Less commonly, mold onychomycosis can be caused by fungi of the genus Aspergillus, Alternaria, Acremonium, Fusarium etc.
Nail lesions caused by dermatophytes may be distal, when the nail change begins from the free edge, lateral, and proximal.
several forms of nail damage in onychomycosis: normotrophic, in which the nails retain their normal configuration, but they become dull, with a yellowish tint at the free edge, with thickening in the corners of the nail plate due to the accumulation of horny masses; hypertrophic -nail thickening over the entire surface due to subnail hyperkeratosis, nails become dull, dirty-gray in color, loosened at the free edge; atrophic – the nails are significantly destroyed, as if corroded from the free edge, the nail bed is partially exposed, covered with a layering of loose and dry crumbly masses; affection of the type of onycholysis – The nail plates separate from the nail bed, becoming dull, sometimes dirty-gray in color; the nail retains its normal color at the base. Combined nail lesions can occur in one patient.
In recent years there have been significant advances in the study of the causes of onychomycosis, in particular, the possibility of spread Тrichorhophyton rubrum lymphohematogenous route. Trichophyton rubrum и Тrichorhton interdigitale Can cause allergic rearrangement of the body, in addition, dermatophytes and some mold fungi can have a toxic effect on the body.

Onychomycosis treatment

Currently, mycologists have at their disposal a wide range of antifungal drugs of systemic and external action in various dosage forms (ointment, cream, solution, varnish, powder). However, the problem of treatment of patients with onychomycosis is still urgent, because the disease often relapses, it is difficult to treat candida onychiasis.
The therapeutic efficacy, safety, method of application, as well as cost should be primarily considered when recommending a method of treatment to the patient.
Antimycotics with fungicidal effect on various types of pathogens, the ability to accumulate in the nail matrix and the nail bed are preferred for therapeutic effect. The method of treatment is very important.
While choosing the therapy one should take into consideration the type and form of the lesion, its spreading, duration of the disease, speed of nail growth and the patient’s general state (comorbid conditions, immune system condition, etc.).).

Currently, there are 3 highly effective systemic antimycotics (terbinafine, itraconazole, fluconazole) and a number of drugs for topical therapy (bifonazole cream in a nail treatment kit, 5% amorolfin varnish, 8% cyclopyrox varnish, 1% bifonazole cream, 1% terbinafine cream, 1% cyclopyrox cream and solution, 1% naphthifine cream, 1% econazole cream, 1% isoconazole cream, 2% ketoconazole cream, 1% clotrimazole cream and solution, etc.).

Treatment with antimycotics of systemic action

Treatment with systemic antimycotics is done without removing the nail plates.
Daily dose Terbinafine For adults, 250 mg, taken once daily or 125 mg twice daily with or after meals daily. The duration of treatment is from 6 weeks to 3 months. and depends on the patient’s age, form and area of the lesion. It is possible to reduce the duration of treatment by mechanically removing the stratum corneum, especially in the hypertrophic form.
In the first days of treatment such side effects as nausea, discomfort or discomfort in the gastrointestinal tract may occur. Contraindications to the prescription of terbinafine are pregnancy and individual sensitivity to the drug.
When onychomycosis of the feet (hands), caused by dermatophytes, mold, yeast-like fungi and mixed flora, it is possible to treat itraconazole, It is administered according to the intermittent method: 200 mg (2 capsules) 2 times a day after meals for 7 days, followed by a 3-week break. In onychomycosis caused by dermatophytes or yeasts, 3-7 days cycles are enough. 2 to 3 cycles in mould onychomycosis, and 4 cycles in elderly patients with slow nail growth. In cases of onychomycosis of the hands, especially in young patients, therapeutic effect can be achieved after 2 cycles of therapy.
Studies of itraconazole pharmacokinetics in the nail tissue showed that the drug penetrates into the nail plate through the nail matrix, as well as by diffusion from the nail bed, and persists in the nail infection for 6 months. After the end of therapy with 3 cycles. The duration of treatment depends on the area of the nail and the growth rate of the nail plate.
Itraconazole is not recommended for onychomycosis patients with liver or kidney dysfunction, pregnant and lactating women. Corrective therapy is prescribed if the stomach acidity is reduced. Tolerability of itraconazole is good. Side effects are possible, but rare (gastrointestinal disorders, itchy skin, fatigue, heaviness in the head), they pass without cancelling the drug.
Candida paronychia and onychia can be treated effectively with fluconazole. The drug is prescribed 200 mg daily after meals (on the first day, a doubled dose of 400 mg) daily for 3 to 4 months. Fluconazole therapy can be combined with external antifungal drugs: bifonazole, cyclopyrox, clotrimazole, isoconazole as a cream or solution. Bifonazole is rubbed into the roller area once in the evening, the other drugs – twice a day.

Topical therapy

If there are contraindications to the use of systemic antimycotics, patients with onychomycosis of the feet (hands) may be prescribed bifonazole cream in a nail treatment kit in combination with 1% bifonazole cream, 5% amorolfin varnish, 8% cyclopyrox varnish.
Treatment with bifonazole cream in a nail treatment kit consists of two stages. In the first stage, the affected nails are removed with a cream consisting of bifonazole and urea. The cream is applied to the affected nail area under the occlusion bandage using a dispenser, distributed over the nail surface and left for 24 hours. Under a waterproof plaster. Before each application of the cream, the bandage is changed, a warm bath is prepared and the easily separated part of the affected nail is removed with a special file. The application of the cream is continued until the nail plate or a part of it is removed. Our results show that the nail plate can be painlessly removed in layers in 4 to 28 days (16 days on the average) with this formulation, while the nail bed is treated at the same time. The patient must be warned that the removal of the nail should only be carried out according to the specified technique and no blade should be used. Subsequent therapy consists of bed treatment with 1% bifonazole cream for 4 weeks or more, depending on the degree of nail damage. The cream is rubbed into the bed once a day, at the same time it is applied to the skin of the feet and interfinger folds in the evening after washing the feet and drying them. Clinical observation and mycological studies before treatment, after nail detachment, at the end of treatment, then after 1, 3, 6, 12 months. After the end of treatment. In distal type of lesion the growth of healthy nails is observed from 1, 5 to 4 months, in distal-proximal type from 6 to 12 months, but the cure does not come to all patients, in proximal type clinical improvement is observed. The good tolerance of bifonazole cream for nail treatment should be noted, which makes it possible to use this method in patients with onychomycosis and eczema of the feet. Treatment of eczema may be performed at the same time. Bifonazole nail cream can be widely used in elderly patients.
For onychomycosis caused by dermatophytes, yeast-like and mold fungi, with the lesion area up to 80%, intact hole and nail bed can be used 5% varnish and 0.25% amorolfin cream. Nail polish is applied to the affected finger or hand nails once every 7 days. Before application, the affected nails must be removed with the nail file supplied with the varnish. Then the nail surface must be cleaned and degreased with an alcohol swab.
If the nail polish is to be applied again, the infected parts of the nails must be removed again with a file. Before treatment remove the remnants of nail polish with a tampon moistened with alcohol.
On the skin of the feet, palms apply 0.25% amorolfin cream once a day in the evening. The treatment is continued until healthy nails have grown in. The duration of treatment depends on the degree and form of the lesion, localization of mycosis and is 6 months for onychomycosis of the hands and 9-12 months – of the feet. The treatment on the skin is carried out until clinical manifestations have resolved (at least 2-6 weeks) and for several days after clinical recovery. Tolerability of varnish and cream is satisfactory, sometimes a slight transient burning sensation of the nails may occur, and when using the cream, mild skin irritation (hyperemia, itching, burning sensation). Varnish is contraindicated in case of hypersensitivity.
For the distal type of onychomycosis, caused by dermatophytes, yeast-like and mold fungi, it is possible to use 8% cyclopyrox varnish In combination with 1% cream or 1% cyclopyrox solution. Before varnish application, most of the affected nail is removed with a file and filed to create an uneven surface. The nail polish is applied once a day in a thin layer. Remove the nail polish layer once a week with a polish remover. The treatment is carried out for 1 month. Then the nail polish is applied on the nail plate twice a week for 1 month and once a week after the 3rd month. Treatment duration depends on the form of the lesion, but should not exceed 6 months. Cyclopyrox cream or solution is applied to the skin twice a day (at least for 2 weeks).). After the resolution of clinical manifestations of the drug is used for another 1-2 weeks to prevent a relapse.
In case of distal onychomycosis the infected part of the nail may be cleaned with bifonazole cream for nail treatment, and then a broad-spectrum antimycotic for external use should be rubbed into the nail bed twice a day or applied under the occlusive dressing (exoderil, econazole, ketoconazole, terbinafine, bifonazole, clotrimazole, etc.).). Simultaneous treatment of the smooth skin of the feet or hands until clinical manifestations are resolved. The duration of the treatment is from 6 to 12 months or more, until the nails grow back.
Based on many years of experience, we believe that the therapeutic effect in the treatment of onychomycosis will depend on the right choice of antifungal agent, taking into account the type, form of nail damage and the extent of the process, as well as regular disinfection of shoes (gloves) until healthy nails grow back.