Superficial Fungal Infections

COMPOUNDING PHARMACY SOLUTIONS 6105 Beverly Hill, Suite 201 Houston, TX 77057

VO L U M E 1 2 N U M B E R 4 RxTriad Compliments of Superficial Fungal Infections Fungal infections (dermatomycoses) are among the most common cutaneous COMPOUNDING disorders, affecting up to 10% to 20% of the population of the U.S. They are relatively minor infections that are a significant part of modern-day society. PHARMACY Mycotic infections of the skin are generally categorized as either superficial SOLUTIONS or deep. Many skin and nail disorders have characteristic lesions that become evident upon a complete examination of the entire skin surface, including the nails, scalp, palms, soles, and mucous membranes; the examinations are conducted in bright light. The most prevalent dermatomycosis is tinea pedis 6105 Beverly Hill, (athlete’s foot), followed by tinea corporis (body ringworm), tinea cruris (jock Suite 201 itch), tinea capitis (scalp ringworm), and then other types of tinea, including onychomycosis (tinea unguium or nail infections). Houston, Texas 77057

Fungal infections generally prefer environments of ring-shaped lesion that may have an advancing scaly high temperature and high humidity; therefore, they border and central clearing, occasionally with hyper- CONTACT generally occur most frequently in tropical and sub- pigmentation. These rings spread peripherally, and the tropical areas. Pathogens generally responsible for the borders may contain vesicles or pustules. Phone: (713) 783-2836 various superficial fungal infections includeTrichophy - ton, Microsporum, and Epidermophyton. Fax: (713) 782-2644 Jock itch affects the groin area with sharply defined Email: [email protected] lesions with inflamed borders and reddish-brown Symptoms and Description centers. The itching becomes very intense and can become painful; increased skin maceration can occur may present as (1) macerated, boggy, Athlete’s foot if sweating accumulates. Jock itch can be irritated with whitened, odorous, and itching skin between the toes, tight-fitting undergarments. HOURS (2) an acute vesicular inflamed and fissuring condition also accompanied by odor and itching, or (3) a fine Monday - Friday: 9:00am - 5:00pm scale over the bottom part of the foot (moccasin-type Scalp ringworm usually presents as a circular tinea pedis). Each form may become more symptomatic patch of scaly skin accompanied by a limited area during the summer months. Especially with the empha- of alopecia. Patients may appear with (1) scaly, dry, sis on personal health and exercise, fungal infections noninflammatory dermatosis with other patchy areas of the feet have become quite common and are easily of involvement, (2) active, inflamed weeping lesions, or www.cpsrxs.com transmitted from person to person if proper precau- (3) cup-shaped crusts around several hairs that expand tions are not observed. Some individuals appear to be to involve the entire scalp. Household animals can more susceptible than others. The causative agent in transmit fungal infections to occupants in a house, as in most athlete’s foot infections is the trichophyton spe- the case of ringworm infections. DELIVERY AVAILABLE cies. Upon initial contact, patients commonly complain of, or present with, itching, burning, or stinging symp- Onychomycosis (tinea unguium, nail infections) to Home or Office toms involving the feet. changes the appearance of the nails from normal and shiny to that of being dull, opaque, and yellowing; they Body ringworm occurs over the body and ap- also become thick, brittle, and crumbly. Onychomy- pears typically as an oval, scaly patch with an inflamed cosis is a trichophyton infection of one or more (but border. The skin in the center of the lesion actually ap- rarely all) fingernails or toenails. Generally, the most FREE DELIVERY pears normal. Ringworm lesions are most often on the commonly found microorganism is Trichophyton rubrum. exposed areas of the body, such as the face and arms. The nails become lusterless, brittle, and hypertrophic; Within a 10 Mile Radius Generally, a history of exposure to an infected cat is the substance of the nail becomes friable. Patients may often involved, usually indicating a microsporum infec- become embarrassed because the nails may become tion. The most common pathogens include Trichophyton thick and unsightly due to a buildup of by-products rubrum. Symptoms may include itching and a classic from fungal growth. Nail infections are very difficult to treat because access to the causative microorganism is limited, nail cal cure. None of the patients in the debridement-only group growth is slow, and long duration of therapy is usually required. experienced mycological cure.1 Compounded Fingernail involvement generally responds more rapidly than toenail involvement. In many cases, avulsion of the nail is required Another article involved patients with diabetes and summarized Formulas for the either surgically or chemically. Urea 40% topical preparations are that onychomycosis potentially can cause severe complications in Treatment of commonly used for this procedure. these patients and should be promptly treated. The selection of an appropriate regimen may be complicated due to the existence of Fungal Infections comorbid conditions and the potential for drug-drug interactions. Treatment of Fungal Infections Terbinafine is an excellent choice to use in patients with diabetes, Outcomes of successful treatment can be aimed at symptomatic as it has a low risk of drug-drug interactions and proven efficacy Rx relief, eradicating the infection, and preventing future infections. against the typical pathogens causing onychomycosis. Itraconazole, Ciclopirox 8% Topical Gel while effective, is not a first-choice therapy due to its black-box 2 Athlete’s foot can be treated using either local or systemic cardiac warning and numerous drug interactions. Rx measures. During the “macerated stage,” local measures may include treatment with aluminum subacetate solution, topical The conclusion from another study is that once-weekly micon- Fluconazole in DMSO imidazoles, or ciclopirox, terbinafine, or butenafine. During the azole cream applied to the toenail and webspaces of the foot are 3 Topical Liquid “dry and scaly stage,” the addition of urea 10% preparations under effective in preventing long-term relapsing tinea unguium. an occlusive dressing may enhance the efficacy of the topical treatments. Systemic measures may include itraconazole or terbinafine; Rx griseofulvin should only be used in severe cases. Dosage Forms Used and Their Fluconazole 10% Topical Application Cream Ringworm (body and scalp) treatment can include local and Numerous dosage forms are used in the topical treatment of these systemic measures. Locally, miconazole, clotrimazole, ketocon- superficial fungal infections, including creams, liquids, gels, oint- azole, econazole, sulconazole, oxiconazole, ciclopirox, and terbi- ments, lacquers, and others. The treatment of athlete’s foot and Rx nafine have been used. Systemic measures have included orally ringworm can easily be accomplished with creams, liquids, gels, Itraconazole in DMSO administered griseofulvin, itraconazole, and terbinafine. and ointments. Nail Liquid Treatment of nail infections is somewhat more difficult. The Onychomycosis can be treated either locally or systemically, causative agent is actually residing beneath the nail, and access Rx but local treatment has relatively low efficacy (10% or less). If is limited. Nail softening agents, such as salicylic acid and urea, Iodochlorhydroxyquin the involvement is minimal and if the patient is motivated, local have been used to assist in chemical debridement of the hypertro- (topical) treatment may be effective. Another approach is to use a phic nail, generally in a cream or a gel vehicle. In some cases, the 3% Ointment 40% urea topical preparation for nail avulsion, prior to beginning antifungal agent may be applied simultaneously with the softening treatment with an antifungal agent. In some cases, the antifungal agent, or it can be applied after the nail has been removed. Gener- Rx treatment may begin after a few weeks of urea 40% treatment. The ally, occlusive dressings are employed in this method of treatment. 40% urea will soften the nail and enable it to be removed over a This may be in the form of a plastic wrap, a bandage, or the tip of Iodochlorhydroxyquin period of time. Also, surgical or mechanical removal of the nail can a latex glove that has been cut off to the proper size. It is common 3% Cream be used. Drugs commonly used include ciclopirox and naftifine. practice to protect the healthy tissue using a barrier of white pet- Systemic treatment may involve griseofulvin, itraconazole, terbin- rolatum. In any case, nail infections require months of treatment afine, or ketoconazole. In some cases, local and systemic treatments (approximately up to about 6 months for fingernails and up to a Rx have been combined. year for toenails). Ketoconazole 1% Topical Solution Recent Research Involving Penetration Enhancing Vehicles Rx Onychomycosis for Transporting the Antifungal In one study, 55 patients were allocated to nail debridement only Ketoconazole 1% and or debridement plus application of a topical antifungal nail lacquer. Agents Salicylic acid 10% in After about 10 months, statistically, patients in the antifungal nail Antifungals are commonly incorporated in various dosage forms lacquer group improved significantly more than did those in the containing different solvents for delivery vehicles. Penetration Flexible Collodion debridement-only group and exhibited a 76.74% rate of mycologi- enhancers that may be a part of a dosage form include propylene glycol, glycerin, dimethyl sulfoxide, polyethylene glycol 300, Rx alcohol, and others. Flexible collodion can assist in enhancing efficacy by prolonging contact time of the antifungal agent with the Miconazole 2% Topical affected area. Upon evaporation of the solvent system in flexible Cream collodion, the active agent is kept in direct and prolonged contact with the skin within the “plastic” film. Rx Miconazole 2% and References Tolnaftate 1% Topical 1. Malay DS, Yi S, Borowsky P, Downey MS, Mlodzienski AJ. Efficacy of debridement alone versus debridement combined Liquid with topical antifungal nail lacquer for the treatment of pedal onychomycosis: A randomized, controlled trial. J Foot Ankle Surg Rx 2009; 48(3): 294–308. 2. Cathcart S, Cantrell W, Elewski B. Onychomycosis and diabe- Terbinafine 1% in DMSO tes. J Eur Acad Dermatol Venereol 2009; [In print]. Nail Liquid 3. Arroll B, Oakley A. Preventing long term relapsing tinea unguium with topical anti-fungal cream: A case report. Cases J 2009; 2(1): 70. Rx Thymol 4% in Isopropyl WRITTEN BY Alcohol Loyd V. Allen, Jr., PhD, RPh International Journal of Pharmaceutical Compounding Rx Edmond, OK 73034 Tolnaftate 1% Cream E-mail: [email protected] Rx Observations Regarding Onychomycosis Triacetin 25% Topical 1. Toenails are primarily affected. Liquid 2. Antifungal lacquers (5% amorolfine; 8% ciclopirox) cure about 30% of fungal infections and sometimes cause mild irritation. Rx 3. There is no firm evidence that daily applications of lacquers are any more effective than other topical antifungals. Triacetin 25% Ointment 4. Trimming, filing, or grinding of the nail, in addition to the drug treatments, is likely to be beneficial but has not been evaluated. Rx 5. Chemical nail destruction (urea and bifonazole) followed with an antifungal ointment can be used when the Undecylenic Acid 10% nail is markedly thickened. Topical Liquid 6. Surgical nail avulsion may result in local infection and permanent nail dystrophy. 7. Oral terbinafine is effective in >50% of cases but may have adverse effects. Rx 8. Candida is better treated with oral azoles than with terbinafine. Compound Undecylenic 9. It is better not to treat fungal nail infections if the risks outweigh the expected benefits. Acid Ointment Source: [No author listed.] Fungal nail infections: Diagnosis and management. Prescrire Int 2009; 18(99): 26–30.