WAIKOLOA, HAWAII – Two recent studies highlight several key points regarding topical therapy for onychomycosis: Treat it early for best results, and if concomitant tinea pedis is present, be sure to treat that, too, Dr. Theodore Rosen said at the Hawaii Dermatology Seminar.
The studies were separate secondary analyses of the pooled results of two large, double blind, vehicle-controlled, 48-week, phase III randomized trials of efinaconazole 10% topical solution (Jublia) for onychomycosis. But the same lessons probably apply to any topical antifungal, according to Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.
Dr. Theodore Rosen
Early treatment: This makes a big difference in outcome, as demonstrated in Dr. Phoebe Rich’s analysis of 1,655 patients in the phase III studies. Dr. Rich, director of the nail disorders clinic at Oregon Health and Science University, Portland, divided participants into three groups based upon disease duration: less than a year, 1-5 years, or more than 5 years. The complete cure rate was much better in the group with less than 1 year of onychomycosis, even though the extent of nail involvement of the target toenail didn’t differ significantly between the three groups (J Drugs Dermatol. 2015;Jan 14:58-62).
“Now we have data: Don’t wait to treat until it has been there for 35 years. It’s easier to treat if it’s early,” Dr. Rosen commented at the seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
When onychomycosis and tinea pedis coexist, treat both: Dr. Leon H. Kircik of Indiana University, Indianapolis, and associates reported in a poster at the Hawaii Dermatology Seminar that one in five participants in the two phase III trials had tinea pedis as well as onychomycosis, and nearly half of them were treated for their athlete’s foot using their physician’s choice of topical antifungals.
The primary endpoint in the two trials was the week 53 complete cure rate, defined as no clinical involvement of the target toenail, a negative potassium hydroxide exam, and a negative fungal culture. Among subjects with concomitant onychomycosis and tinea pedis, the onychomycosis complete cure rate was 28.2% if they received efinaconazole for their onychomycosis and got treatment for their tinea pedis, compared with 20.9% if they got efinaconazole but no treatment for their tinea pedis. The complete/almost complete cure rate was 35.5% with dual therapy versus 29.6% if they only received efinaconazole. Both differences were significant.
“Doesn’t that make logical sense? If you leave the fungus on the foot or between the toes, it’s going to say, ‘Wow, that’s steak up there on the nail. That’s real food. I’m just going to crawl back onto the nail because all my brothers up there are dead and there’s wide-open space,” Dr. Rosen explained.
He added that the reverse is also true: if a patient presents seeking treatment for athlete’s foot but also has onychomycosis, the best treatment results for the tinea pedis are obtained by also treating the nail infection.
Dr. Rosen offered a money-saving tip for effective OTC therapy for tinea pedis. Two words: Lotrimin Ultra. That’s the brand name for butenafine cream 1%, not to be confused with plain old Lotrimin, which is clotrimazole.
“Clotrimazole has been around since the dawn of man, and it’s not very effective. Many of the fungi are actually resistant to it. But they’re not resistant to butenafine, which is a very good topical antifungal now available over the counter. It costs $9 or $10 dollars for a tube the size of a baseball bat. It’s a good, effective, cheap way of treating concomitant tinea pedis,” he said.
Dr. Rosen reported serving on scientific advisory boards for Anacor, Merz, and Valeant.
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