Tinea Unguium (1 of 7)

1 Patient presents w/ discolored & disﬁ gured nail suggestive of tinea unguium

2 DIAGNOSIS 3 Do clinical presentation & No ALTERNATIVE diagnostics conﬁrm DIAGNOSIS tinea unguium?

Yes

A Pharmacological therapy • Choice of therapy depends on causative organism, severity of infection, cost & patient compliance Oral Antifungals Any one of the following agents: • Itraconazole • Terbinafi ne Alternative oral agents: • Fluconazole • Griseofulvin • Ketoconazole* Topical Antifungal Any one of the following agents: • Amorolfi ne • Ciclopirox • Efi naconazole • Tavaborole • Tioconazole Combination erapy • Amorolfi ne + Itraconazole or Terbinafi ne B Non-pharmacological therapy • Patient education • Other treatment options - Surgical avulsion & debridement - Laser therapy - Photodynamic therapy (PDT) - Alternative therapies

*Serious hepatotoxicity© may occur with the use of MIMSoral Ketoconazole. Please see Dosage Guidelines for more information.

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B101 © MIMS 2019 • Microscopy started is treatment before should confi be thediagnosis thus, therapy; high-cost prolonged requires typically Onychomycosis rmed • • • Total Onychomycosis Dystrophic • • • • Onychomycosis Candidal • • • • • Onychomycosis Proximal Subungual • • • • Superfi (SWO) WhiteOnychomycosis cial • • • • • (DLSO) Onychomycosis Subungual &Lateral Distal • Subtypes Clinical • • • Presentation Clinical • FactorsPatient Risk • • • - forhyphae &arthrospores light &examined microscope, in10-15%Potassium ismounted hydroxideSpecimen (KOH) w/calcofl soln gently,uor &heated under viewed theMay end fourforms ofthe be result above Nail plate completely isalmost destroyed form advanced Most May have resistance agents some tooralantifungal - albicans sp orother Candida by Candida Usually caused Entire may tototaldystrophy nailthickens progression lead ofthe yellow-brown; &turns nails folds orhyponychium orplate directlyormay the indirectly involve invades nailbed Candida the nailthrough the nailbed, infecting More commonly aff the fiects - ngernails w/chronic mucocutaneous candidiasis foundinpatientsCommonly diagnosed Trichophyton by caused Ttonsurans be butcan &Tmentagrophytes Trubrum megnini, by Usually caused hyperkeratosis Subungual &proximal onychomycosis are usuallypresent - whiteincolorNail plate istypically untreated, the ifleft Spreads entire distallyso aff be nailplate will ected - entersInfection at the involved isalways cuticle &the proximal nailbed Toenails than are more fi commonly infected ngernails infection common inhealthy indicator anearly &may ofHIV form individuals be Least non-dermatophyte by molds caused butmayTypically be also Tmentagrophytes by caused Nailplate isnotthickened &remains attached tothe nailbed - Minimal infl w/awhite-colored rough &crumbly surface soft ammation; nailbecomes ofthe surface nailplateDorsal isinvaded 10%ofinfections type, prevalent most Second - commonMost Trichophyton cause: rubrum tomildinflSplinter secondary hemorrhages are seen ammation vessels compressing smallblood opacifiNail plate looks may away break distalportion its &hyperkeratotic, ed More commonly involves the toenails - occurs at spaceInvasion distalsubungual &at the distal lateral groove 90%ofinfections commonMost type, Onychomycosis isclassifi presentation &clinical onroute ofinfection based ed ofthe swelling nailfold(paronychia), erythematous ofthe bed as separation May nailplate manifest its from interaction social & diminished Patients may aff pain,discomfort complain ofnumbness, &mayofself-esteem manual loss cause activities ecting - &patientsUsually asymptomatic first consult forcosmetic reasons Tinea oronychomycosis pedis presence of Tinea, immunosuppression, w/ atopy, pedis to individuals (HIV), exposure virus hyperhidrosis, mellitus occlusive diabetes (DM), footwear, human immunodefi diseases, vascular male,peripheral Aging, ciency dermatophytic onychomycosis; called moreAlso commonly aff the than toenails the fiects ngernails Specifi dermatophytes by nailplate, caused orboth) c onychomycosis ofthe nailbed, infection (fungal Presence of fungal infection can be detected butthe causative organism isnotspecifi detected be can infection Presence offungal ed Calcofl results negative offalse risk uor may decrease -

superﬁcial whiteonychomycosis onychomyosis fordistalsubungual for the from nailplate &scrapings whitespots ofnailbed Scrapings © MIMS Trichophyton by: tonsurans, Trichophyton caused & be May also mentagrophytes &unilateral nailchanges onthetoenails samefoot, Onychomycosis ifthere are changes inthe 3rd issuspected or5thinvolvement toenail, ofthe 1st&5th Tinea Unguium(2of7) 1 2 TINEA UNGUIUM TINEA DIAGNOSIS B102 Epidermophyton ﬂoccosum © MIMS 2019

T. UNGUIUM T. UNGUIUM • • • • • Histology • • • Culture • • • Topical Antifungals • • • Terbinafi ne • • • Itraconazole • • Fluconazole Antifungals Oral • - ofipsilateral extremity lower cellulitis Inpatients w/history - forcellulitis &other Inpatients factors risk w/diabetes - nails Inpatients related painordiscomfort tothe experiencing infected - Treatment foronychomycosis isindicated: chronic warts viral paronychia, Other nailinfections: nail dystrophy, eczematous conditions psoriasis, Lichen planus, disorders: Dermatologic onychomycosis proximalPAS subungual nailw/culture todiagnose orremoved isrequired stainingofnailplate biopsy method diagnostic sensitive Most - debris subungual Periodic acid-Schiff ofthe edge nail&attached (PAS) distal,free ofthe exam clipped, stainingw/histologic theConsidered mainstay ofonychomycosis diagnosis Identifi organism &thees specifi agentc etiologic that so treatment individualized be can Adequate onto sample Saboraud’s isinoculated additionofantibiotics w/orwithout glucoseagar May combine nailavulsion w/surgical anadjunct tooraltherapy as forresistantUsed infections nailplate penetration ofpoor rate because response Low - distalnailplate unable & inthose totolerate treatment involving systemic very tomildcases Limited - Eff ects: spornon-dermatophyte molds Candida activeagainst Notas - Active dermatophytes which against are the ofthe ofonychomycosis cause majority infections First-line agent fortreatment dermatophyte onychomycosis ofmild,moderate tosevere Studies that have continuous shown both therapies &pulse are effective - Eff ects: broad coverage antifungal Has that includes dermatophytes, dermatophyte onychomycosisw/ severe tolerate whocannot oralTerbinafine First-line agent fortreatment ofmild to moderate dermatophyte onychomycosis; 2nd-line therapy forpatients Outcome data treatment ontoenail improvement clinical shows in72-89%ofpatients treated - cure rate w/near-total mycologic elimination Eff ects: countries inmost Notapproved foronychomycosis treatment - Offers analternative toItraconazole &Terbinafi- ne non-dermatophytic molds sp&some Candida Active common against dermatophytes, alternative oralagent Patients w/ confi onychomycosisrmed to treatment but are refractory may benefi to an For switching t from cosmetic reasons -

To prevent the spread of fungal infection to other parts of the body (eg feet, hands, groin) & to close contacts &toclose groin) To hands, (eg feet, ofthe toother body infection parts prevent the offungal spread treatment comparativeSome Terbinafi have trials shown more effne to be than otherective agents for onychomycosis Fungistatic, mycologic cure rates range cure 45-70%&clinical 35-80% from rates from Fungistatic, high-dose pulse therapy pulse Fungistatic, forfi high-dose tohave upto90%clinical shown ngernail treatment been has ©Fungicidal, mycotic cure rate cure is71-82% &clinical rate fortoenails 60-70% MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A 3 PHARMACOLOGICAL THERAPY 2 ALTERNATIVE DIAGNOSIS Tinea Unguium(3of7) DIAGNOSIS (CONT’D) B103 • • • Malignancy: Fibroma, melanoma, Bowen disease Bowen melanoma, Fibroma, Malignancy: Trauma ischemiaSenile sp & a number of non-dermatophyteCandida molds © MIMS 2019 • • Alternative erapies • Photodynamic (PDT) erapy • Laser erapy • • Avulsion &Debridement Surgical • TreatmentOther Options • • • Patient Education • • • Efi naconazole • • Ciclopirox • • • Amorolfi ne Topical (Cont’d) Antifungals • • Tavaborole • • Luliconazole • • • in: needed may be ofantifungals courses Longer • Tioconazole May help w/ symptom relief but further studies are needed to establish the therapeutic benefiMay help relief w/ symptom studies are needed but further agentst of these AgeratinaEg pichinchensis Melaleuca oil,menthol extract, (snakeroot) tree) alternifolia (tea agents &alightInvolves infection theofphotosensitizing source use totreat fungal agents together antifungal w/topical studies when used treatment are newer signifi options that lasers diode showed cant improvements innailappearance inseveral (Nd:YAG) &dual-wavelength (870&930nm)near-infrared Neodymium-doped:yttrium-aluminum-garnet Debridement interventions ororalpharmacologic anadjunct considered may totopical as be therapy antifungal topical by agents alone,followed Surgical considered may avulsion forpatients be w/single-nailonychomycosis topharmacological unresponsive the &effi toprove Further safety are studies needed management ofthe following unguium optionsfortinea cacy cure May take9-12months toassess - tothe drug’s bindingtokeratin secondary inthe tothe nail,though medication recurrence iscommon exposed patientAssure that improvement continues cessation after oforaltreatment even iscontinually since the fungus exercise, control etc quit nailsshort, DM, smoking, Eg trim regularly - Patient encouraged should be tomaintain &improve health conditions &treat Tinea pedis Recognize - throughout the day, dry feet powder Keep foot may antifungal use - ifpossible often, Change socks - Patients breathable &100%cotton should wear footwear socks - Educate patient hygiene foot proper about foronychomycosisIndicated ofthe duetoTrubrum toenails lanosterol 14α-demethylase, ofergosterol involved inthe fungal biosynthesis Inhibits forthe treatment DLSO ofmild-to-moderate developed antifungal, A triazole Treatment may take6months-1 &cure rates year range 29-47% from distalsuperfi inmild-to-moderate Indicated cial onychomycosis onychomycosis Combination forpatients therapy w/severe useful may be - incombination used w/oralTerbinafi been Has ne orItraconazole Eff ects: other fi yeasts, fungi, dimorphic Active dermatophytes, against lamentous &dematiaceous fungi Indicated foronychomycosisIndicated ofthe duetoTrubrum toenails A light-weight, water-soluble naillacquer oxaborole topical (boron-containing-compound) orEfl Trubrum by caused DLSO treatment as formoderate-to-severe used May be occosum activity &fungistatic w/fungicidal molecule An imidazole Patients whohave near-total ortotalnailplate involvement occlusion, DM) ofconditions aresult supplytothe (eg nailas vascular peripheral blood Patients whohave decreased slowly Patients nailsgrow whose Treatment optionforsuperficial &distalonychomycosis

© MIMS eff May be (lunula) involvement nailmatrix inpatients without ective w/mildinfection A Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B PHARMACOLOGICAL THERAPY (CONT’D) NON-PHARMACOLOGICAL THERAPY to prevent spread totoenails toprevent spread Tinea Unguium(4of7) B104 orTmentagrophytes orTmentagrophytes © MIMS 2019

T. UNGUIUM Ketoconazole 200-400 mg PO 200-400 mgPO Ketoconazole Itraconazole 500-1000 mgPO Griseofulvin Fluconazole 150 mg PO once wkly 150 mgPO Fluconazole Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 24 hrly x6-12mth mth 3 24hrly x 200 mgPO treatment: Continuous 3 wk 24 hrly x 200 mg PO involvement: fi ngernail Toenails w/orw/o 2 wk 12hrly x 200 mg PO only: Fingernails mth fortoenails) for fingernails or6 4mth (At least doses 24 hrly or individed replaced nailis infected Continue until & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Guidelines ANTIFUNGALS (ORAL) Tinea Unguium(5of7) • Instructions Special • Reactions Adverse • • • • • • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse • • • • Instructions Special • Reactions Adverse • • • - are nottolerated orunavailable when other infection therapies fungal Use only totreat serious rarely (highdose), gynecomastia] synthesis Other eff &adrenal [inhibitionoftestosterone steroid ects eff CNS alopecia); somnolence); dizziness, (headache, ects effDermatological rash, pruritus, angioedema, (urticaria, ects GI eff (N/V,ects hepatotoxicity); pain,serious abdominal (eg w/anacidicdrink theadministering cola) drug by improved may be absorption In patients w/hypochlorhydia, etc) oralanticoagulants, macrolides, interactions ofdrug (egMonitor forsymptoms Rifampicin, Monitor LFTs throughout ®ularly at therapy baseline impairment &renal insufficiency hepaticUse w/caution failure, inpatients at forheart risk discontinuationfollowing oftreatment the nailregrows, as evident become will response Clinical interval drug-free a3-week by treatmentsPulse are separated always treatments infections & 3pulse fortoenail Two treatment pulse are forfi recommended ngernail infections effDermatological (pruritus) ect eff CNS pyrosis); diarrhea, dizziness); (headache, ects GI eff constipation, pain,nausea, abdominal (dyspepsia, ects long term eff ifused renal function &hematopoietic monitorhepatic, ects; ofadverse duetopossibility isnotadvised use Long-term taken meals immediatelyShould after be N/V, distress urticaria, epigastric rash, Headache, diarrhea, Only eff agents ifdermatophytes are theective etiologic Treat until oracceptably nailisnormal improved interactionsdrug (LFTs) tests monitor liverPeriodically function of &forrisk Use w/cautioninpatientsrenal&hepaticimpairment levels) disturbance, liver enzyme elevated GI eff fl pain,diarrhea, (abdominal ects atulence, N/V, taste Use w/caution inpatients w/adrenal insufficiency Monitor LFTs treatment &wklyduring at baseline course inpatientsContraindicated w/acuteorchronic liver disease

T. UNGUIUM T. UNGUIUM 1 Product combinationProduct the forspecifi w/acorticosteroid latest MIMS see isavailable. Please c formulations. Clotrimazole Imidazoles Terbinafi ne T ooaoe1 ra Apply thinly 1%cream Tioconazole 2%cream, Miconazole Drug Drug 1 Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 250 mg PO 24 hrly x12 wk 250 mg PO Toenail treatment: 24 hrly x6 wk 250 mg PO Fingernail treatment: tinct cream 1% lotion, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly Available All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMSStrength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage ANTIFUNGALS (ORAL)(CONT’D) 2-4 wk 12-24 hrly x Apply 24 hrly x 2-4 wk 8-12 hrly areas Rub onaff ected Dosage ANTIFUNGALS (TOPICAL) Dosage Guidelines Tinea Unguium(6of7) • • • • Instructions Special • Reactions Adverse B106 Reduce doses inpatients w/renalReduce doses impairment Use w/caution inpatients w/psoriasis throughout ®ularly therapybaseline &LFTs countMonitor complete at blood (CBC) inpatients notuse w/hepatic &renalDo impairment eff Dermatological (headache); urticaria) (rash, ects effor disturbance CNS liver dysfunction); oftaste, ect GI eff N/V, (anorexia, pain,loss ects abdominal diarrhea, • Instructions Special • Reactions Adverse • • • Instructions Special • Reactions Adverse • • • Instructions Special • Reactions Adverse pregnant &nursing women in inpatientsContraindicated allergic toimidazoles, allergic reaction) paresthesia, dermatitis, effDermatological irritation, (mildlocal ects or foot inpatientsContraindicated skinonhand w/cracked Avoid contact w/eyes Discontinue develops &irritation ifsensitization use allergic contact dermatitis) effDermatological sensation, irritation, (burning ects infection skin &syphilitic simplex, chickenpox, herpes in patientsContraindicated w/skinTB,measles, areas w/orw/oocclusive large over dressing used May be Use w/caution inpregnant &nursing women skinirritation) urticaria, itching, sensation, blister,burning edema, skinpeeling, effDermatological or stinging (erythema, ects Remarks Remarks © MIMS 2019 Amorolfi ne Others Ciclopirox olamine) ( Ciclopiroxolamine, Ciclopirox Naftifi ne Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, are for & non-breastfeeding non-pregnant All recommendations dosage © MIMS lacquer 5% nail lacquer 8% nail %cemApply once dailyto 1% cream Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Available Strength Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please ANTIFUNGALS (TOPICAL) Dosage Guidelines are cured regenerated &areas wkly until nailis Apply once-twice alcohol once wkly coatingRemove w/ are cured regenerated &areas until nailis 3rd mth onwards then once wklyfor twice wklyx1mth, day x1mth, then other Apply every aff nail ected Tinea Unguium(7of7) Dosage B107 • Reactions Adverse • Reactions Adverse • Reactions Adverse (CONT’D) burning sensation) burning transient slight, irritation, peri-ungual effDermatological (occasional local ects scaling, burning sensation, pain) burning scaling, effDermatological redness, (pruritus, ects sensation, dryness) effDermatological burning (redness, ects Remarks © MIMS 2019

T. UNGUIUM