Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014;171:937-958. Abstract
Taheri A, Davis SA, Huang KE, Feldman SR. Onychomycosis treatment in the United States. Cutis. 2015;95:E15-E21.
Sigurgeirsson B, Baran R. The prevalence of onychomycosis in the global population: a literature study. J Eur Acad Dermatol Venereol. 2014;28:1480-1491. Abstract
Gupta AK, Daigle D, Foley KA. The prevalence of culture-confirmed toenail onychomycosis in at-risk patient populations. J Eur Acad Dermatol Venereol. 2015;29:1039-1044. Abstract
Gupta AK, Jain HC, Lynde CW, Macdonald P, Cooper EA, Summerbell RC. Prevalence and epidemiology of onychomycosis in patients visiting physicians' offices: a multicenter canadian survey of 15,000 patients. J Am Acad Dermatol. 2000;43(2 Pt 1):244-248.
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Joseph WS. Onychomycosis in patients with diabetes. Advanced Studies in Medicine. 2005;5(6D):S62-S623.
Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care. 2006;29:1202-1207. Abstract
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Pariser D. The rationale for renewed attention to onychomycosis. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S1.
Hay RJ, Baran R. Why should we care if onychomycosis is truly onychomycosis? Br J Dermatol. 2015;172:316-317. Abstract
Harada K, Oka K, Shibata A, Kaburagi H, Nakamura Y. [Relationships between foot problems, fall experience and fear of falling among Japanese community-dwelling elderly]. [Japanese Journal of Public Health] Nihon Koshu Eisei Zasshi . 2010;57:612-623.
Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. J Gerontol A Biol Sci Med Sci. 2006;61:866-870. Abstract
Walling HW. Subclinical onychomycosis is associated with tinea pedis. Br J Dermatol. 2009;161:746-749. Abstract
Szepietowski JC, Reich A, Garlowska E, Kulig M, Baran E. Factors influencing coexistence of toenail onychomycosis with tinea pedis and other dermatomycoses: a survey of 2761 patients. Arch Dermatol. 2006;142:1279-1284. Abstract
Ghannoum MA, Mukherjee PK, Warshaw EM, Evans S, Korman NJ, Tavakkol A. Molecular analysis of dermatophytes suggests spread of infection among household members. Cutis. 2013;91:237-245. Abstract
Drake LA, Patrick DL, Fleckman P, et al. The impact of onychomycosis on quality of life: development of an international onychomycosis-specific questionnaire to measure patient quality of life. J Am Acad Dermatol. 1999;41(2 Pt 1):189-196.
Szepietowski JC, Reich A, Pacan P, Garlowska E, Baran E. Evaluation of quality of life in patients with toenail onychomycosis by Polish version of an international onychomycosis-specific questionnaire. J Eur Acad Dermatol Venereol. 2007;21:491-496. Abstract
Milobratovic D, Jankovic S, Vukicevic J, Marinkovic J, Jankovic J, Railic Z. Quality of life in patients with toenail onychomycosis. Mycoses. 2013;56:543-551. Abstract
Chan HH, Wong ET, Yeung CK. Psychosocial perception of adults with onychomycosis: a blinded, controlled comparison of 1,017 adult Hong Kong residents with or without onychomycosis. Biopsychosoc Med. 2014;8:15.
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Ozkan F, Ozturk P, Ozyurt K, et al. Frequency of peripheral arterial disease and venous insufficiency in toenail onychomycosis. J Dermatol. 2013;40:107-110. Abstract
Tosti A, Hay R, Arenas-Guzman R. Patients at risk of onychomycosis--risk factor identification and active prevention. J Eur Acad Dermatol Venereol. 2005;19(Suppl 1):13-16. Abstract
Scher RK, Baran R. Onychomycosis in clinical practice: factors contributing to recurrence. Br J Dermatol. 2003;149(Suppl 65):5-9. Abstract
Sigurgeirsson B, Steingrimsson O. Risk factors associated with onychomycosis. J Eur Acad Dermatol Venereol. 2004;18(1):48-51.
Faergemann J, Correia O, Nowicki R, Ro BI. Genetic predisposition--understanding underlying mechanisms of onychomycosis. J Eur Acad Dermatol Venereol. 2005;19(Suppl 1):17-19. Abstract
Gupta AK, Simpson FC, Brintnell WC. Do genetic mutations and genotypes contribute to onychomycosis? Dermatology. 2014;228:207-210. Abstract
Carrillo-Melendrez H, Arenas R, Granados J, Ortega E. Further role of HLA-DR alleles in the genetic susceptibility to develop onychomycosis in nail psoriasis. J Am Acad Dermatol. 2015;72:AB135.
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Saunte DM, Holgersen JB, Haedersdal M, et al. Prevalence of toe nail onychomycosis in diabetic patients. Acta Derm Venereol. 2006;86:425-428. Abstract
Gupta AK, Lynde CW, Jain HC, et al. A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: a multicentre study. Br J Dermatol. 1997;136:786-789. Abstract
Gupta AK, Taborda P, Taborda V, et al. Epidemiology and prevalence of onychomycosis in HIV-positive individuals. Int. J. Dermatol. 2000;39(10):746-753.
Gupta AK, Paquet M. Management of onychomycosis in Canada in 2014. J Cutan Med Surg. 2015;19(3):260-273.
Carney C, Tosti A, Daniel R, et al. A new classification system for grading the severity of onychomycosis: Onychomycosis Severity Index. Arch Dermatol. 2011;147:1277-1282. Abstract
Scher RK, Tosti A, Joseph WS, et al. Onychomycosis diagnosis and management: perspectives from a joint dermatology-podiatry roundtable. J Drugs Dermatol. 2015;14:1016-1021. Abstract
Jung MY, Shim JH, Lee JH, et al. Comparison of diagnostic methods for onychomycosis, and proposal of a diagnostic algorithm. Clin Exp Dermatol. 2015;40:479-484. Abstract
Wilsmann-Theis D, Sareika F, Bieber T, Schmid-Wendtner MH, Wenzel J. New reasons for histopathological nail-clipping examination in the diagnosis of onychomycosis. J Eur Acad Dermatol Venereol. 2011;25:235-237. Abstract
Elewski B, Pariser D, Rich P, Scher RK. Current and emerging options in the treatment of onychomycosis. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S9-S12.
Penlac®Nail Lacquer [package insert]. Bridgewater, NJ: sanofi -aventis U.S. LLC.; 2006.
Elewski BE, Rich P, Pollak R, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: Two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2013;68:600-608. Abstract
Elewski BE, Aly R, Baldwin SL, et al. Efficacy and safety of tavaborole topical solution, 5%, a novel boron-based antifungal agent, for the treatment of toenail onychomycosis: results from 2 randomized phase-III studies. J Am Acad Dermatol. 2015;73:62-69.. Abstract
Gupta AK, Daigle D, Paquet M. Therapies for Onychomycosis A Systematic Review and Network Meta-analysis of Mycological Cure. J Am Podiatr Med Assoc. 2015;105:357-366. Abstract
Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. J Am Acad Dermatol. 2000;42(2 Pt 1):217-224.
Lamasil® [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2015.
Sporanox® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc; 2014.
Gupta AK, Drummond-Main C, Paquet M. Evidence-based optimal fluconazole dosing regimen for onychomycosis treatment. J Dermatolog Treat. 2013;24:75-80. Abstract
De Backer M, De Vroey C, Lesaffre E, Scheys I, De Keyser P. Twelve weeks of continuous oral therapy for toenail onychomycosis caused by dermatophytes: a double-blind comparative trial of terbinafine 250 mg/day versus itraconazole 200 mg/day. J Am Acad Dermatol. 1998;38(5 Pt 3):S57-S63.
Sigurgeirsson B, Billstein S, Rantanen T, et al. L.I.ON. Study: efficacy and tolerability of continuous terbinafine (Lamisil) compared to intermittent itraconazole in the treatment of toenail onychomycosis. Lamisil vs. Itraconazole in Onychomycosis. Br J Dermatol. 1999;141(Suppl 56):5-14. Abstract
Sigurgeirsson B, Olafsson JH, Steinsson JB, Paul C, Billstein S, Evans EG. Long-term effectiveness of treatment with terbinafine vs itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol. 2002;138:353-357. Abstract
Scher RK, Breneman D, Rich P, et al. Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the toenail. J Am Acad Dermatol. 1998;38(6 Pt 2):S77-S86.
Havu V, Heikkila H, Kuokkanen K, et al. A double-blind, randomized study to compare the efficacy and safety of terbinafine (Lamisil) with fluconazole (Diflucan) in the treatment of onychomycosis. Br J Dermatol. 2000;142:97-102. Abstract
Elewski B, Tavakkol A. Safety and tolerability of oral antifungal agents in the treatment of fungal nail disease: a proven reality. Ther Clin Risk Manag. 2005;1:299-306. Abstract
Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Res. 2011;4:26.
Bangsgaard N, Saunte DM, Folkenberg M, Zachariae C. Serious adverse events reporting on systemic terbinafine: a Danish register-based study. Acta Derm Venereol. 2011;91:358-359. Abstract
Diflucan® [package insert]. New York, NY: Pfizer, Inc.; 2014.
Garcia Rodriguez LA, Duque A, Castellsague J, Perez-Gutthann S, Stricker BH. A cohort study on the risk of acute liver injury among users of ketoconazole and other antifungal drugs. Br J Clin Pharmacol. 1999;48:847-852. Abstract
FDA Drug Safety Communication: FDA limits usage of Nizoral (ketoconazole) oral tablets due to potentially fatal liver injury and risk of drug interactions and adrenal gland problems. http://www.fda.gov/Drugs/DrugSafety/ucm362415.htm. Accessed May 17, 2015.
Westerberg DP, Voyack MJ. Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician. 2013;88:762-770. Abstract
Gupta AK, Daigle D, Foley KA. Topical therapy for toenail onychomycosis: an evidence-based review. Am J Clin Dermatol. 2014;15:489-502. Abstract
Coronado D, Merchant T, Chanda S, Zane LT. In vitro nail penetration and antifungal activity of tavaborole, a boron-based pharmaceutical. J Drugs Dermatol. 2015;14:609-614. Abstract
Sugiura K, Sugimoto N, Hosaka S, et al. The low keratin affinity of efinaconazole contributes to its nail penetration and fungicidal activity in topical onychomycosis treatment. Antimicrob Agents Chemother. 2014;58:3837-3842. Abstract
Elewski BE, Tosti A. Tavaborole for the treatment of onychomycosis. Expert Opin Pharmacother. 2014;15:1439-1448. Abstract
Vlahovic T, TM MP, Chanda S, Zane LT, Coronado D. In vitro nail penetration of tavaborole topical solution, 5%, through nail polish on ex vivo human fingernails. J Drugs Dermatol. 2015;14:675-678. Abstract
Zeichner JA, Gold LS, Korotzer A. Penetration of ((14)C)-efinaconazole topical solution, 10%, does not appear to be influenced by nail polish. J Clin Aesthet Dermatol. 2014;7:34-36.
Jublia® [package insert]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; 2015.
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Rodriguez DA. Efinaconazole topical solution, 10%, for the treatment of mild and moderate toenail onychomycosis. J Clin Aesthet Dermatol. 2015;8:24-29.
Rich P. Efinaconazole topical solution, 10%: the benefits of treating onychomycosis early. J Drugs Dermatol. 2015;14:58-62. Abstract
Vlahovic TC, Joseph WS. Efinaconazole topical, 10% for the treatment of toenail onychomycosis in patients with diabetes. J Drugs Dermatol. 2014;13:1186-1190. Abstract
Tosti A, Elewski BE. Treatment of onychomycosis with efinaconazole 10% topical solution and quality of life. J Clin Aesthet Dermatol. 2014;7:25-30.
Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8% in the treatment of toenail onychomycosis. J Am Acad Dermatol. 2000;43(4 Suppl):S70-S80.
Gupta A, Cooper E. Examination of cure and relapse of dermatophyte toenail onychomycosis during long-term follow-up after oral therapy. J Am Acad Dermatol. 2012;66:AB119.
Piraccini BM, Sisti A, Tosti A. Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. J Am Acad Dermatol. 2010;62:411-414. Abstract
Sigurgeirsson B, Paul C, Curran D, Evans EG. Prognostic factors of mycological cure following treatment of onychomycosis with oral antifungal agents. Br J Dermatol. 2002;147:1241-1243. Abstract
Gupta AK, Cooper EA, Paquet M. Recurrences of dermatophyte toenail onychomycosis during long-term follow-up after successful treatments with mono- and combined therapy of terbinafine and itraconazole. J Cutan Med Surg. 2013;17:201-206. Abstract
Sigurgeirsson B. Prognostic factors for cure following treatment of onychomycosis. J Eur Acad Dermatol Venereol. 2010;24:679-684. Abstract
Ruiz-Lopez P, Moreno-Coutino G, Fernandez-Martinez R, Espinoza-Hernandez J, Rodriguez-Zulueta P, Reyes-Teran G. Evaluation of improvement of onychomycosis in HIV-infected patients after initiation of combined antiretroviral therapy without antifungal treatment. Mycoses. 2015;58:516-521. Abstract
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Wiederhold NP, Fothergill AW, McCarthy DI, Tavakkol A. Luliconazole demonstrates potent in vitro activity against dermatophytes recovered from patients with onychomycosis. Antimicrob Agents Chemother. 2014;58:3553-3555. Abstract

CME / CE

The Relevance of Clinical Data in Dermatologic Fungus: Closing the Gaps

Authors: Jeffrey M. Robbins, DPM
CME / CE Released: 1/29/2016
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 1/29/2017, 11:59 PM EST

Target Audience and Goal Statement

This activity is intended for dermatologists, podiatrists, primary care physicians, nurses, and nurse practitioners who treat patients with onychomycosis.

The goal of this activity is to review new and emerging data relating to onychomycosis and its management.

Upon completion of this activity, participants will be able to:

Summarize the latest clinical data of systemic, topical, and other treatment modalities for onychomycosis in the context of clinical decision making
Individualize treatments for onychomycosis based on clinical findings
Describe post-treatment management, including prevention of recurrent onychomycosis infection

Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Faculty

Jeffrey M. Robbins, DPM

Professor, Podiatric Medicine, Kent State University College of Podiatric Medicine; Director, Podiatry Services VACO, Independence, Ohio

Disclosures

Disclosure: Jeffrey M. Robbins, DPM, has disclosed no relevant financial relationships.

Dr Robbins does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

Dr Robbins does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Steering Committee

Boni E. Elewski, MD (Chair)

Professor, University of Alabama, Birmingham

Disclosures

Disclosure: Boni E. Elewski, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Anacor Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Pfizer Inc; Valeant Pharmaceuticals International
Received grants for clinical research from: AbbVie Inc; Amgen, Inc.; Lilly; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; Pfizer Inc; Valeant Pharmaceuticals International

Aditya K. Gupta, MD, PhD, FRCPC, FAAD, MBA

Professor, University of Toronto, Toronto, Ontario

Disclosures

Disclosure: Aditya K. Gupta, MD, PhD, FRCPC, FAAD, MBA, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Anacor Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Moberg Pharma; Valeant Pharmaceuticals International
Received grants for clinical research from: Valeant Pharmaceuticals International
Clinical trials investigator: Lilly; Merck & Co., Inc.; UCB Pharma, Inc.

Jeffrey M. Robbins, DPM

Disclosures

As seen above.

Antonella Tosti, MD

Professor, Department of Dermatology & Cutaneous Surgery, University of Miami, Miami, Florida

Disclosures

Disclosure: Antonella Tosti, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Anacor Pharmaceuticals, Inc.; PharmaDerm; Polichem; Valeant Pharmaceuticals International; Viamet Pharmaceuticals Holdings, LLC
Served as a speaker or a member of a speakers bureau for: PharmDerm; Sandoz

Tracey C. Vlahovic, DPM, FFPM RCPS (Glasg)

Associate Professor, Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania

Disclosures

Disclosure: Tracey C. Vlahovic, DPM, FFPM, RCPS (Glasg), has disclosed the following relevant financial relationships:
Served as a speaker or a member of a speakers bureau for: Pharmaderm; Valeant Pharmaceuticals International

Dyanne P. Westerberg, DO

Associate Professor, Cooper Medical School of Rowan University, Camden, New Jersey

Disclosures

Disclosure: Dyanne P. Westerberg, DO, has disclosed no relevant financial relationships.

Editors

Shari J. Dermer, PhD

Scientific Director, Medscape, LLC

Disclosures

Disclosure: Shari J. Dermer, PhD, has disclosed no relevant financial relationships.

Eileen A. McCaffrey, MA

Freelance Medical Writer, Whippany, New Jersey

Disclosures

Disclosure: Eileen A. McCaffrey, MA, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

Amy Bernard, MS, BSN, RN-BC

Lead Nurse Planner, Medscape, LLC

Disclosures

Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

CME Reviewer

Robert Eckles, DPM, MPH

Dean, Clinical and Graduate Medical Education Associate Professor, Department of Orthopedic Sciences, New York College of Podiatric Medicine

Disclosures

Disclosure: Robert Eckles, DPM, MPH, has disclosed no relevant financial relationships.

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From Medscape Education Dermatology

CME / CE

The Relevance of Clinical Data in Dermatologic Fungus: Closing the Gaps

Authors: Jeffrey M. Robbins, DPMFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / CE Released: 1/29/2016

Valid for credit through: 1/29/2017, 11:59 PM EST

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Introduction

Onychomycosis is a fungal infection of the nails that is common, communicable, frequently relapsing and recurring, and difficult to cure. Some clinicians incorrectly view the infection as not worthy of treatment. Yet onychomycosis can lead to serious consequences, especially in certain populations. Many factors that predispose to risk of infection also can reduce the likelihood of treatment response. Accumulating evidence suggests that genetic mutations along with older age, male sex, and various other comorbidities are associated with susceptibility to infection.

Two topical treatments have been recently introduced. The choice of pharmacologic therapy should consider infection severity, presence of comorbid conditions, potential drug-drug interactions, history of prior nail infection, factors predicting treatment response, and patient viewpoint. A sometimes neglected aspect of management is the careful follow-up and patient education needed to reduce the risk of reinfection and recurrence.

Educational Impact Challenge

Assess your clinical knowledge by completing this brief survey. Answering these questions again after the activity will allow you to see what you learned and to compare your answers with those of your peers.

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Disclaimer

The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on medscape.org. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

References

Faculty and Disclosures

Faculty

Jeffrey M. Robbins, DPM

Steering Committee

Boni E. Elewski, MD (Chair)

Aditya K. Gupta, MD, PhD, FRCPC, FAAD, MBA

Jeffrey M. Robbins, DPM

Antonella Tosti, MD

Tracey C. Vlahovic, DPM, FFPM RCPS (Glasg)

Dyanne P. Westerberg, DO

Editors

Shari J. Dermer, PhD

Eileen A. McCaffrey, MA

CME Reviewer/Nurse Planner

Amy Bernard, MS, BSN, RN-BC

CME Reviewer

Robert Eckles, DPM, MPH

CME / CE

The Relevance of Clinical Data in Dermatologic Fungus: Closing the Gaps

Target Audience and Goal Statement

Disclosures

Faculty

Jeffrey M. Robbins, DPM

Steering Committee

Boni E. Elewski, MD (Chair)

Aditya K. Gupta, MD, PhD, FRCPC, FAAD, MBA

Jeffrey M. Robbins, DPM

Antonella Tosti, MD

Tracey C. Vlahovic, DPM, FFPM RCPS (Glasg)

Dyanne P. Westerberg, DO

Editors

Shari J. Dermer, PhD

Eileen A. McCaffrey, MA

CME Reviewer/Nurse Planner

Amy Bernard, MS, BSN, RN-BC

CME Reviewer

Robert Eckles, DPM, MPH

Accreditation Statements

For Physicians

For Nurses

For Podiatrists

Instructions for Participation and Credit

The Relevance of Clinical Data in Dermatologic Fungus: Closing the Gaps

Introduction

Educational Impact Challenge

PDF Downloads