ONYCHOMYCOSIS ==================== From: WHWoodII@aol.com I have a 50 yo patient who desires an effective topical treatment for his chronic tinea unguium. He is unwilling to use oral Sporanox, or any other oral antifungal agent, because he fears drug interactions and risks of adverse reactions. I advised that he should "make friends with his fungus" and use Loprox lotion BID, to help prevent spread. After about six months he wanted something "more effective." I told him that there had been reports in the Schoch Letter of topical use of Diflucan mixed in a solution of 50% w/w aqueous DMSO, but that I could not assure him of results, and that such treatment was innovative and not approved by the FDA. He tried it using a 40mg/ml concentration BID for a year, without response. I have explained that the topical treatments fail to deliver the antifungal agent into the nail matrix, and that if he really does want to get rid of his nail fungus, he may have to risk the oral Sporanox. He now wants to attempt to dissolve Sporanox into a liquid. I told him that to my knowledge this has not been done, but that there would be problems because itraconazole is not water soluble, etc., and that it is very unlikely that Janssen would not have looked into this possibility. Does anyone have any other topical suggestions, or success stories, with tinea unguium? Walter H. Wood, M.D. ========================= From: GenadijS@aol.com If only one or a few nails are involved, I would suggest total avulsion of these, without matrixectomy. The hyperkeratotic infected nailbeds may be curetted or superficially lased with the CO2 laser using Silktouch or Ultralpulse technique to avoid excessive thermal damage. After initial healing and reepithelialization the nailbeds may then be treated q. h.s. under occlusion with an allylamine (fungicidal) topical such as Naftin or Lamisil Cream. This should continue until outgrowth of healthy nail is >50% complete. Still, sometimes it fails... ========================= From: KSmithDerm@aol.com I have had success with 20% tioconazole [Trosyd] nail polish for 6-12 months, but Pfizer has run out. It never was licensed in Canada, but I got it from the federal government. The product is available in Europe. I suppose you might mix 20% Trosyd vaginal cream [which we can get]with 10% urea and try that, maybe under occlusion. Or maybe pull his nails out and then have him apply the vag cream straight out of the tube to the nailbeds [maybe a psych consult would be in order if he prefers this to pills]. 5% amilorfine nail polish is being experimented with -- maybe you can get some of that. Kevin C. Smith, MD, FRCPC ================================= From: Daniel F Mitchell We have been using the Diflucan in DMSO for about 2 yrs with about an 80% success rate, and no side effects at all. Great for military flierswho don't want to be grounded. Of course, 20% fail. I took some Sporanox caps down to our compounder, who emptied them into some DMSO. Itdidn't dissolve at all. There may be a way to make it dissolve in some vehicle for topical use, but I'm not aware of it. ============================= From: "MARK NAYLOR" My understanding is that some podiatrists claim a significant cure rate by using aggressive debridement with topical antifungals such as Loprox lotion. I presume that means grinding off as much nail as possible with a high speed hand-held grinder several times a month combined with bid application of the Loprox lotion. The cure rate may approach that of oral griseofulvin if done by someone experienced (or aggressive) enough. Removal of the nail with keratolytics under occlusion (40% urea) for a week followed by debridement and bid use of Loprox might also be something you would like to try yourself. I am not aware of anything else worth trying. Hope this helps. Mark Naylor, M.D. ================================= From: Haines Ely I have compounded Sporonox in chloroform with good results. I'll have to look for the method but as I remember it was about 400mg sporonox in 2oz chloroform. Haines Ely