What can GP data tell us about the treatment of onychomycosis in the UK?

Background: Treatment of onychomycosis is challenging, and there is much literature on optimal treatment strategies. In contrast, information on how onychomycosis is actually treated in primary care is scarce. Information on practice is important as it can reveal much, such as, to what extent national guidelines are followed and which population groups seek/receive treatment or do not do so. Objectives: To describe the pattern of onychomycosis treatment in primary care in the UK, by patient's gender and age. Methods: A population-based retrospective cross-sectional study was conducted. The Health Improvement Network (THIN) database was used to calculate incidence rates of onychomycosis in the years 2001-2017. The prescription of oral and topical anti-fungal drugs to patients with onychomycosis was reviewed. Results: THIN data showed an onychomycosis incidence rate of about 50 per 100,000. More males than females (52% vs. 48%), and more people aged 50-59 years had received treatment for onychomycosis. Oral terbinafine was the most commonly prescribed drug, followed by topical amorolfine, although terbinafine was used more commonly by men and amorolfine by women. Patients with onychomycosis were also prescribed other antifungals, including itraconazole, griseofulvin, tioconazole, ketoconazole shampoo, fluconazole and clotrimazole. A greater proportion of women, compared to men, were prescribed fluconazole. Conclusions: Onychomycosis treatment in primary care in the UK is broadly in concordance with national guidelines.

A drug-in-adhesive anti-onychomycotic nail patch: Influence of drug and adhesive nature on drug release, ungual permeation, in vivo residence in human and anti-fungal efficacy.

A nail patch is an attractive option for the topical treatment of onychomycosis, although no product is commercially available. We previously identified optimal nail patch formulations for two anti-onychomycotic drugs, based on their properties, as well as those of the other patch components. In this paper, our aim was to further investigate the potential of the patch formulations as topical nail medicines, in particular, whether the drug-in-adhesive patches release drug which then permeates into and through the nail plate and show anti-fungal efficacy, and whether and to what extent they remain adhered to the human nail plate in vivo when tested over 2 week durations. In addition, the influence of the drug (amorolfine HCl, ciclopirox olamine) and PSA (Duro-Tak 2852 or Duro-Tak 202A) on these parameters was determined. We found that both the nature of the drug and of the PSA influenced in vitro drug release. The nature of the drug, but not that of the PSA, influenced ungual drug permeation through human nail clippings, with considerably greater (almost double) permeation for ciclopirox olamine, the smaller and less lipophilic molecule. In vivo residence, tested with 3 out of the 4 patches, excluding the patch where ciclopirox olamine degraded with time, showed greater residence on toenails compared to fingernails reflecting their far lesser exposure to environmental stresses during daily activities. In vivo residence was enhanced when the patch was cut to the shape of the nail, was applied at bedtime, and when a clear colourless nail varnish was applied on top of the patch to 'seal' it into place on the nail. Comparison of the patches indicated greater residence of Duro-Tak 202A containing patches over those containing Duro-Tak 2852. Amorolfine HCl in Duro-Tak 202A based patch also showed antifungal efficacy in contrast to Duro-Tak 2852-based patch, and is particularly promising for further development as a potential toenail medicine, remaining almost fully adhered to toenails for at least two weeks.

A systematic approach to the formulation of anti-onychomycotic nail patches.

Nail patches have a potential role as drug carriers for the topical treatment of nail diseases such as onychomycosis, a common condition. Our aim was therefore to develop a systematic and novel approach to the formulation of a simple drug-in-adhesive ungual patch. Twelve pressure-sensitive adhesives (PSAs), four backing membranes, two release liners and three drugs were screened for pharmaceutical and mechanical properties. From this initial screening, two PSAs, two drugs, one backing membrane and one release liner were selected for further investigation. Patches were prepared by solvent-casting and characterised. The patches had good uniformity of thickness and of drug content, and showed minimal drug crystallisation during six months of storage. Meanwhile, the drug stability in the patch upon storage and patch adhesion to the nail was influenced by the nature of the drug, the PSA and the backing membrane. The reported methodology paves the way for a systematic formulation of ungual nail patches to add to the armamentarium of nail medicines. Further, from this work, the best patch formulation has been identified.

UV-curable gels as topical nail medicines:In vivo residence, anti-fungal efficacy and influence of gel components on their properties.

UV-curable gels, used as nail cosmetics for their in vivo durability, were reported to be promising as topical nail medicines. Our first aim was thus to investigate whether such durability applies to drug-loaded formulations. This was found to be true. However, ethanol inclusion in the pharmaceutical formulation (to enable drug loading) reduced the in vivo residence. The second aim was therefore to determine any other effects of ethanol, and if ethanol could be avoided by the choice of monomers. Thus, three methacrylate monomers, ethyl methacrylate, isobornyl methacrylate and 2-hydroxyethyl methacrylate (HEMA) were selected, and their influence on the formulation properties were determined. Ethanol and the methacrylate monomer influenced some (but not all) of the formulation properties. The most significant was that HEMA could dissolve drug and enable the preparation of ethanol-free, drug-loaded formulations, which would benefit in vivo residence. The absence of ethanol reduced drug loading, release and ungual flux, but had no negative impact on the in vitro anti-fungal efficacy. Thus, judicious selection of gel components enabled the exclusion of ethanol. The long in vivo residence, little residual monomers, sufficient ungual permeation and in vitro anti-fungal activity of the gels indicates their potential as anti-onychomycotic topical medicines.

An investigation of how fungal infection influences drug penetration through onychomycosis patient's nail plates.

The treatment of onychomycosis remains problematic even though there are several potent antifungal agents available for patient use. The aim of this investigation was to understand whether the structural modifications that arise when a patient's nail become infected plates influences the permeation of drugs into the nail following topical application. It was hoped that through improving understanding of the nail barrier in the diseased state, the development of more effective topical treatments for onychomycosis could be facilitated. The permeation of three compounds with differing hydrophobicities, caffeine, terbinafine and amorolfine (clogD at pH 7.4 of -0.55, 3.72 and 4.49 respectively), was assessed across both healthy and onychomycosis infected, full thickness, human nail plate sections. Transonychial water loss (TOWL) measurements performed on the healthy and diseased nails supported previous observations that the nail behaves like a porous barrier given the lack of correlation between TOWL values with the thicker, diseased nails. The flux of the more hydrophilic caffeine was twofold greater across diseased in comparison with the healthy nails, whilst the hydrophobic molecules terbinafine and amorolfine showed no statistically significant change in their nail penetration rates. Caffeine flux across the nail was found to correlate with the TOWL measurements, though no correlation existed for the more hydrophobic drugs. These data supported the notion that the nail pores, opened up by the infection, facilitated the passage of hydrophilic molecules, whilst the keratin binding of hydrophobic molecules meant that their transport through the nail plate was unchanged. Therefore, in order to exploit the structural changes induced by nail fungal infection it would be beneficial to develop a small molecular weight, hydrophilic antifungal agent, which exhibits low levels of keratin binding.

Application of Hansen Solubility Parameters to predict drug-nail interactions, which can assist the design of nail medicines.

We hypothesised that Hansen Solubility Parameters (HSPs) can be used to predict drug-nail affinities. Our aims were to: (i) determine the HSPs (δD, δP, δH) of the nail plate, the hoof membrane (a model for the nail plate), and of the drugs terbinafine HCl, amorolfine HCl, ciclopirox olamine and efinaconazole, by measuring their swelling/solubility in organic liquids, (ii) predict nail-drug interactions by comparing drug and nail HSPs, and (iii) evaluate the accuracy of these predictions using literature reports of experimentally-determined affinities of these drugs for keratin, the main constituent of the nail plate and hoof. Many solvents caused no change in the mass of nail plates, a few solvents deswelled the nail, while others swelled the nail to varying extents. Fingernail and toenail HSPs were almost the same, while hoof HSPs were similar, except for a slightly lower δP. High nail-terbinafine HCl, nail-amorolfine HCl and nail-ciclopirox olamine affinities, and low nail-efinaconazole affinities were then predicted, and found to accurately match experimental reports of these drugs' affinities to keratin. We therefore propose that drug and nail Hansen Solubility Parameters may be used to predict drug-nail interactions, and that these results can assist in the design of drugs for the treatment of nail diseases, such as onychomycosis and psoriasis. To our knowledge, this is the first report of the application of HSPs in ungual research.

Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus.

OBJECTIVES: To assess and compare the implementation of antimicrobial stewardship (AMS) interventions recommended within the national AMS toolkits, TARGET and Start Smart Then Focus, in English primary and secondary healthcare settings in 2014, to determine the prevalence of cross-sector engagement to drive AMS interventions and to propose next steps to improve implementation of AMS. METHODS: Electronic surveys were circulated to all 211 clinical commissioning groups (CCGs; primary sector) and to 146 (out of the 159) acute trusts (secondary sector) in England. Response rates were 39% and 63% for the primary and secondary sectors, respectively. RESULTS: The majority of CCGs and acute trusts reported reviewing national AMS toolkits formally or informally (60% and 87%, respectively). However, only 13% of CCGs and 46% of acute trusts had developed an action plan for the implementation of these toolkits. Only 5% of CCGs had antimicrobial pharmacists in post; however, the role of specialist antimicrobial pharmacists continued to remain embedded within acute trusts, with 83% of responding trusts having an antimicrobial pharmacist at a senior grade. CONCLUSIONS: The majority of healthcare organizations review national AMS toolkits; however, implementation of the toolkits, through the development of action plans to deliver AMS interventions, requires improvement. For the first time, we report the extent of cross-sector and multidisciplinary collaboration to deliver AMS interventions in both primary and secondary care sectors in England. Results highlight that further qualitative and quantitative work is required to explore mutual benefits and promote best practice. Antimicrobial pharmacists remain leaders for implementing AMS interventions across both primary and secondary healthcare sectors.

Human nail plate modifications induced by onychomycosis: implications for topical therapy.

PURPOSE: Through the characterisation of the human onchomycotic nail plate this study aimed to inform the design of new topical ungual formulations. METHODS: The mechanical properties of the human nail were characterised using a Lloyd tensile strength tester. The nail's density was determined via pycnometry and the nail's ultrastructure by electron microscopy. Raman spectroscopy analysed the keratin disulphide bonds within the nail and its permeability properties were assessed by quantifying water and rhodamine uptake. RESULTS: Chronic in vivo nail plate infection increased human nailplate thickness (healthy 0.49 ± 0.15 mm; diseased 1.20 ± 0.67 mm), but reduced its tensile strength (healthy 63.7 ± 13.4 MPa; diseased 41.7 ± 5.0 MPa) and density (healthy 1.34 ± 0.01 g/cm(3); diseased 1.29 ± 0.00 g/cm(3)). Onchomycosis caused cell-cell separation, without disrupting the nail disulfide bonds or desmosomes. The diseased and healthy nails showed equivalent water uptake profiles, but the rhodamine penetration was 4-fold higher in the diseased nails using a PBS vehicle and 3 -fold higher in an ethanol/PBS vehicle. CONCLUSIONS: Onchomycotic nails presented a thicker but more porous barrier, and its eroded intracellular matrix rendered the tissue more permeable to topically applied chemicals when an aqueous vehicle was used.

In vivo measurement of the surface energy of human fingernail plates.

The surface energy of the human nail plate is expected to influence the adhesion of microorganisms (and subsequent colonization and infections) as well as that of medicines (and subsequent drug permeation) and of cosmetics. The aim of the study was therefore to measure the surface energy of nail plates in vivo. The surface energy of healthy human fingernails (untreated, hydrated and abraded) and of hoof membranes (often used as a model for the nail plate) was estimated from contact angle measurements of liquids (water, formamide, diiodomethane and glycerol) on the nail plate and subsequent computation using the Lifshitz-van der Waals/acid-base (LW-AB) approach. The surface energy of untreated fingernail plates was found to be 34 mJ m(-2) . Most of this total energy was from the apolar Lifshitz-van der Waals component. When the polar component of the surface energy was analysed, the electron donor component was considerably larger than the electron acceptor one. Hydrating the nail plate had no significant influence on the surface energy. In contrast, abrasion caused a small, but statistically significant increase in the apolar surface energy component. The surface energy of bovine hoof membrane was similar to that of the fingernail plate. We conclude that the human fingernail plate is a low-energy surface and that bovine hoof membranes may be used as a substitute for the nail plate in certain experiments.

Transverse fingernail curvature in adults: a quantitative evaluation and the influence of gender, age, and hand size and dominance.

The nail plate's convex shape in both the longitudinal and transverse directions is thought to contribute to its mechanical rigidity, and overcurvature can be a symptom of local and/or systemic disorders. Although a number of methods to measure the longitudinal nail curvature have been proposed, evaluation of the transverse nail curvature has been largely limited to visual estimation of overcurved nail plates. The aim of this study was therefore to measure the transverse curvature of healthy adult fingernail plates and thereby provide a baseline range for 'normal curved' nail plates. In addition, the influence of gender, age, hand size and hand dominance on the transverse fingernail curvature was investigated. The transverse fingernail curvature in 92 men and 90 women (aged 21-90 years) was measured using a set of radius gauges, and the nail plate curvature was expressed as the radius of a circle whose curve most closely approximated that of the nail plate. ANOVA was used to investigate the influence of digit nature on curvature, whereas general linear model was used to assess the influence of gender, age, and hand length, breadth and dominance on transverse nail curvature. Subsequently, the influence of hand dominance and age was further examined by paired t-test and ANOVA, respectively. In this study, baseline values for the transverse nailplate curvature of the thumb, index, middle, ring and little fingers are presented. The thumbnail is the flattest, followed jointly by the index and middle fingernails, then the ring fingernail and finally the little fingernail. Transverse nail curvature is influenced by a person's gender, age, hand dominance and hand width, but not by hand length. Thus, nails are flatter in the dominant hand, in men, in older individuals and in those with wider hands.

An assessment of the human nail plate pH.

PURPOSE OF STUDY: To measure the pH of the surface of healthy nail plates. PROCEDURES: The surface pH of human fingernails and big toenails was measured in vivo using a skin pH meter. The influence of washing, anatomical site (fingers/toes), side (left/right), digit (digits 1-5) and gender was determined. The pH of the nail interior was also measured. RESULTS: The pH of the nail plate surface was around 5, with toenails having a significantly higher pH than fingernails. Immediately after hand washing, the nail surface pH increased significantly, from pH 5.1 ± 0.4 to 5.3 ± 0.5. However, this was not sustained with time, and the pH returned to prewashing levels within 20 min. Gender had an influence on unwashed, but not washed, nail plate pH. The pH of the nail plate interior was lower than that of its surface. CONCLUSIONS: It was possible to measure nail plate pH, and baseline values are provided.

Room temperature ionic liquids and their mixtures: potential pharmaceutical solvents.

Room temperature ionic liquids (RTILs) are organic salts which are liquids at ambient temperature. Composed of relatively large asymmetric organic cations and inorganic or organic anions, they have generated interest as 'green' solvents. Here we report on the solvency of alkyl imidazolium salts (PF(6)(-)Br(-)Cl(-)) for poorly water-soluble model drugs, albendazole and danazol, indicating their potential application as pharmaceutical solvents/cosolvents. The solubility of albendazole, for example, is increased by more than 10,000 times by 1-butyl-3-methylimidazolium hexafluorophosphate ([bmim]PF(6)(-)). Ionic liquids can be water-miscible or water-immiscible. The aqueous miscibility of a poorly water-miscible RTIL such as of [bmim]PF(6)(-) can be improved by the inclusion of a second more miscible RTIL (e.g. 1-hexyl-3-methylimidazolium bromide ([hmim]Br(-))). The extent of improvement in water miscibility was found to correlate with the hydrophilicity of the second RTIL. This ability to modulate RTILs' aqueous miscibility increases their usefulness as pharmaceutical solvents.

An investigation into keratinolytic enzymes to enhance ungual drug delivery.

The topical therapy of nail diseases is limited by the low permeability of drugs through the nail plate. To increase drug penetration, the integrity of the nail plate must be compromised to a certain extent. We hypothesised that keratinolytic enzymes might decrease the barrier properties of the nail plate by hydrolysing the nail keratins, and thereby enhance ungual drug permeation. To determine enzyme action on nail plates, nail clippings were incubated at 35 degrees C, in the presence of keratinase at optimal pH for 48h, after which the nail plates were examined using scanning electron microscopy. It was found that the enzyme acted on the intercellular matrix which holds nail cells together, such that corneocytes on the dorsal surface separated from one another and 'lifted off' the nail plate. In addition, the surface of the corneocytes was corroded. Permeation studies using modified Franz diffusion cells and bovine hoof membranes as a model for the nail plate showed that the enzyme enhanced drug permeation through the hoof membrane. The permeability and partition coefficients, and the drug flux were found to be significantly increased in the presence of the enzyme. We can conclude that the enzyme, via its hydrolytic action on nail plate proteins, could increase ungual drug delivery.

Fast-dissolving microparticles fail to show improved oral bioavailability.

Oral dosage forms are the preferred means of delivering drugs for systemic absorption. However, development problems occur for drugs with poor water solubility and/or gastrointestinal permeability. It is generally believed that the in-vivo bioavailability of poorly water-soluble drugs from Class II of the Biopharmaceutics Classification System can be improved by increasing the dissolution rate. We have attempted to increase the in-vivo oral bioavailability of a model Class II drug (griseofulvin) by preparing rapidly-dissolving particles. The solvent-diffusion method was used to prepare particles with hydrophilic surfactants (Brij 76/Tween 80 surfactant blend) and in-vivo studies were conducted in rats. The griseofulvin particles produced were bipyramidal in habit with a particle size of 2.18 +/- 0.12 microm; they contained crystalline drug and a relatively large proportion (12% w/w) of hydrophilic surfactant. The latter and the small particle size ensured rapid particle dispersion and dissolution in-vitro. Thus, within 30 min of the in-vitro dissolution test, the bipyramidal particles had released approximately 70% of drug compared with approximately 10% from the starting material (particle size 12.61 +/- 1.11 microm). However, the rapid and increased drug dissolution in-vitro was not translated to rapid and enhanced absorption in-vivo, and the oral bioavailability of the model drug was found to be the same from the control and from the bipyramidal particles. The poor in-vivo performance of the bipyramidal particles showed that although the dissolution rate of a Class II drug is thought to be a good indicator of its in-vivo bioavailability, this is not always the case.

Enhancement of the dissolution rate and oral absorption of a poorly water soluble drug by formation of surfactant-containing microparticles.

The slow dissolution rate exhibited by poorly water-soluble drugs is a major challenge in the drug development process. Following oral administration, drugs with slow dissolution rates generally show erratic and incomplete absorption which may lead to therapeutic failure. The aim of this study was to improve the dissolution rate and subsequently the oral absorption and bioavailability of a model poorly water-soluble drug. Microparticles containing the model drug (griseofulvin) were produced by spray drying the drug in the absence/presence of a hydrophilic surfactant. Poloxamer 407 was chosen as the hydrophilic surfactant to improve the particle wetting and hence the dissolution rate. The spray dried particles were characterized and in vitro dissolution studies and in vivo absorption studies were carried out. The results obtained showed that the dissolution rate and absolute oral bioavailability of the spray dried griseofulvin/Poloxamer 407 particles were significantly increased compared to the control. Although spray drying griseofulvin alone increased the drug's in vitro dissolution rate, no significant improvement was seen in the absolute oral bioavailability when compared to the control. Therefore, it is believed that the better wetting characteristics conferred by the hydrophilic surfactant was responsible for the enhanced dissolution rate and absolute oral bioavailability of the model drug.

WITHDRAWN: Actions of a fungal keratinase and reducing agents on the nail plate.

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Immobilisation of vaccines onto micro-crystals for enhanced thermal stability.

The thermal instability of many vaccines leads to the wastage of half of all supplied vaccines. In this note, we report the application of a novel technology: protein-coated micro-crystals (PCMC) to improve the thermostability of a model vaccine (diphtheria toxoid, DT). The latter was immobilised onto the surface of a crystalline material (L-glutamine) via a rapid dehydration method, resulting in the production of a fine free-flowing powder. The PCMC consisted of thin, flat crystals with an antigen loading of 3.95% (w/w). The DT-coated glutamine crystals and free DT (the controls) were incubated at different temperatures for a defined time period (4 degrees C, RT and 37 degrees C for 2 weeks and 45 degrees C for 2 days), after which the crystals were suspended in buffer and intramuscularly administered to mice. Incubation of DT (free and crystal-coated) at room temperature and at 37 degrees C for 2 weeks did not result in any change in the antibody response compared to DT that had always been stored properly (i.e. in the refrigerator). In contrast, incubation of free DT at 45 degrees C resulted in a reduced IgG response, indicating thermal instability of free DT at that temperature. The antibody response was not reduced, however, with the crystal-coated DT. These preliminary studies show that PCMC is a promising technology for the thermal stabilisation of vaccines.

Sorbitan monostearate/polysorbate 20 organogels containing niosomes: a delivery vehicle for antigens?

Multi-component organogels formed using the non-ionic surfactant sorbitan monostearate as gelator have been formulated to contain niosomes. The purpose of this study was to evaluate the potential of these vesicle-in-water-in-oil (v/w/o) gels as delivery vehicles for vaccines. Bovine serum albumin (BSA) and haemagglutinin (HA) were used as model antigens in depot and immunogenicity studies respectively. The complex gels were prepared by the addition of a hot (60 degrees C) aqueous niosome suspension (v/w) to the sol phase (o, an organic solution of the gelator); a vesicle-in-water-in-oil (v/w/o) emulsion was produced which cools to an opaque, semi-solid, thermoreversible v/w/o gel. Light microscopy of the organogel revealed that the microstructure consists of a tubular network of surfactant aggregates in the organic medium, the niosome suspension being dispersed in these surfactant tubules. Therefore, in such gels, the vaccine is thought to be entrapped in the niosomes, themselves located within the sorbitan monostearate tubular network in the organic medium. In vivo, a depot effect was observed following intramuscular administration of the gel containing the entrapped bovine serum albumin, cleared from the injection site over a period of days. The relatively short-lived nature of the depot was thought to arise due to interactions between the gel and the local interstitial fluid which results in gel disintegration in situ. Thus, the niosomes containing antigens are believed to be released from the organic gel. Immunogenicity studies showed that the v/w/o gel as well as one of the controls, the water-in-oil (w/o) gel, possess immunoadjuvant properties and enhance the primary and secondary antibody titres (of total IgG, IgG1, IgG2a and IgG2b) to haemagglutinin antigen. As far as humoral immunity is concerned, the w/o gel showed stronger immunoadjuvant properties compared to the v/w/o gel, being effective at a lower antigen dose i.e 0.1 microg HA.

Interaction of a nonionic surfactant-based organogel with aqueous media.

In an attempt to explain the rather short half-life of molecules at the injection site after their intra-muscular administration in a sorbitan monostearate organogel, in vitro studies were carried out to study the effects of an aqueous medium (simulating interstitial fluid at injection site) on the physical form of the organogel. When the gel mass comes in contact with an aqueous phase, the latter penetrates into the organic gel via the sorbitan monostearate tubular network, resulting in gel breakdown into smaller fragments. The surfactant tubular network act as a conduit for water penetration into the gel. Meanwhile, emulsification, aided by the surfactants present in the gel, also occurs at the gel surface between the organogel and the aqueous phase. This leads to a gradual erosion of the gel as oil droplets bud off from the gel mass. From these in vitro observations, we speculate that after gel administration in vivo, dynamic interactions occur between the local interstitial fluid and the gel mass: fluid penetration into the gel and emulsification at the gel surface is thus responsible for gel breakdown and so a relatively short duration of drug at the injection site.