Treatment

Fungus Protocol

Natural Fungal Toenails Treatment

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Treatment of tinea capitis is oral griseofulvin, 10 to 30 mg/kg/day (20-25 mg of the micronized form and 15-20 mg of the ultramicronized) for 2-3 months. A practical regimen is to administer 125 mg in children younger than 3 years old, 250 mg in children 4 to 7 years old, 375 mg in 8 to 12 years of age and 500-1000 mg/day in adults. The main side effects are nausea, headache, and photosensitiv-ity. In kerion, some authors recommend 0.5 mg/kg/day of prednisone for two weeks along with an antimycotic (Pediatr Dermatol 1994; 11:69-71). In tinea capitis, terbinafin is also effective, 3-6 or even 10 mg/kg/day for 4-8 weeks. A practical regimen consists in 62.5 mg/day in children weighing less than 20 kg, or 125 mg/ day in children that weigh 20-40 kg or are older than 5 years, respectively. In individuals of 40 kg and in adults, 250 mg/day is recommended (Br J Dermatol 1995:132:683-89; Br J Dermatol 1995: 132:98-105). In children who are able to ingest capsules, itraconazole is administrated, 5 mg/kg/day (Int J Dermatol 1994; 33:743-47); it is being tested as pulse-therapy for one week per month. There is some experience with weekly doses of fluconazole, although it has the advantage of being in an oral suspension. It is considered that an ideal antimycotic for children should be a liquid with a secure cap and a pleasant flavor; it must be effective and have few drugs interactions.

On the head, lightly rubbing the affected areas while bathing eliminates the parasitized hair. As an adjuvant, shampoos with 2.5% selenium sulfide, 2% ketoconazole or iodide-povidone, are used.

In tinea corporis the following topical compounds can be applied locally for 1-2 months: 0.5-1% iodide solution, Whitfield ointment (vaseline with 3% salicylic acid and 6% benzoic acid), tolnaftate 1% solution, cream or powder, tolciclate, pyrolnitrine or undecylenic acid, 1%-2% imidazolic cream or solutions of omoconazole, clotrimazole, or isoconazole twice a day, or ketoconazole, sertaconazole, oxiconazole, flutrimazole, tioconazole, croconazole, eberconazole or bifonazole once a day. Sometimes the following are administered: oral or topical griseofulvin, alillamines as naphtifin and terbinafin lotions (J Am Acad Dermatl 1992;26:956-90). In children > 40 kg or in adults, terbinafin 250 mg/day for two weeks if tinea corporis, or four weeks if tinea pedis is recommended. In tinea imbricata oral griseofluvin is effective.

In tinea cruris the predisposing factors, such as the use of synthetic and tight clothing and excessive sweating, should be avoided. In tinea pedis if secondary infection is present, it must be treated with topical antiseptics or topical and systemic antibiotics. Feet should be kept dry and patients should avoid the use of plastic, unventilated shoes. Antimycotic powders may help prevent relapse. Preventive measures should be taken as reinfection is observed.

Onychomycosis responds partially to topical treatments. Occlusion increases drug penetration and the infected nail keratin can be eliminated through partial surgical or chemical removal with 40% urea (25 g vaseline, 25 g lanolin, 10 g white wax and 40 g urea), also available as bifonazole 2% and urea 40%. This treatment is recommended when just a few nails are affected, or in children and pregnant women. The first, occlusive phase lasts 1-4 weeks, until the infected portion of the nail falls. The second phase, until complete cure (usually several months), involves the daily application of 1% bifonazole cream. Also, ticonazole 28%, cyclopirox 8%, or amorolfin 5% (nail polish) once or twice a week can be applied. The cyclopirox and amorolfin penetrate well. They are water resistent and are es-thetically acceptable. Before each new application, the nail should be cleaned with acetone. Nail polish is useful for distal, superficial forms after complete cure as prophylaxis.

The oral treatment of onychomycosis with griseofulvin 50-100 mg/day for 612 months has a low cure rate and is more effective in fingernails than in toenails (simultaneous use of vitamin E enhances its absorption). Itraconazole 200 mg/ day (JAm Acad Dermatol 1996; 35(1): 110-11) or terbinafin 250 mg/day for three months are used. Itraconazole 400mg or terbinafin 500 mg/day can be administered as pulse-therapy one week per month until cure. Fluconazole, 150 mg, is recommended weekly for eight months or 300 mg for a shorter length of time. Sometimes it is necessary to combine local and systemic treatments.

For inflammatory dermatophytosis, trichophytic granuloma, or tinea in immunocompromised patients, ketoconazole can be used orally 200 mg/day in adults, and 5 mg/kg/day in children. Prolonged therapy required for onychohomycosis has a risk of hepatotoxicity.

Tinea Imbricata

Fig. 1.9. Tinea imbricata (Tokelau).

Resistance to antimycotics is rare; it is usually relative, and it disappears by increasing the oral dose or the topical frequency. Therapeutic failures are due to incorrect diagnosis, the wrong dose, short duration of treatment, poor absorption, drug interactions or poor compliance.

Selected Readings

1 Arenas R. Tinea manuum. Datos epidemiologicos and micologicos en 366 casos. Gac Med Mex 1991; 127(5):435-38.

2 Chang P, Logeman H. Onychomycosis in children. Int J Derm 1994: 33(8):550-51.

3 Elweski BE. Cutaneous mycoses in children. Br J Dermatol 1996: 134(Suppl 46):7-11.

4 Frieden IJ, Howard R. Tinea capitis: Epidemiology, diagnosis, and control. J Am Acad Dermatol 1994; 31:S42-S46.

5 Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part I and II. J Am Acad Dermatol 1994; 30:677-98, 911-33.

6 Kemna ME, Elewski BE. A U.S. epidemiologic survey of superficial fungal diseases. J Am Acad Dermatol 1996; 35:539-42.

7 Schwartz RA, Janniger CK. Tinea capitis. Pediatr Dermatol 1995; 55:29-33.

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