A practical application of onychomycosis cure - combining patient, physician and regulatory body perspectives.

Due to the high relapse rates and the rise of predisposing factors, the need for curing onychomycosis is paramount. To effectively address onychomycosis, the definition of cure used in a clinical setting should be agreed upon and applied homogeneously across therapies (e.g. oral, topical and laser treatments). In order to determine what is or what should be used to define cure in a clinical setting, a literature search was conducted to identify methods used to evaluate treatment success. The limitations, strengths, prevalence and utility of each outcome measure were investigated. Seven ways to measure treatment success were identified; mycological cure, patient/investigator assessments, complete cure, quality of life instruments, severity indexes, clinical cure and temporary clearance. Despite its shortcomings, mycological cure is the most objective and consistent outcome measure used across onychomycosis studies. It is suggested that diagnostic goals of onychomycosis should be used to define cure in a clinical setting. Modifications to outcome measures such as incorporating molecular-based techniques could be a future avenue to explore.

Tinea capitis in children: a systematic review of management.

BACKGROUND: Tinea capitis is the most common cutaneous fungal infection in children. OBJECTIVES: This review aims to evaluate the differences that exist between medications for the treatment of tinea capitis, to determine whether there are any significant adverse effects associated and to define the usefulness of sample collection methods. METHODS: We conducted a systematic literature search of available papers using the databases PubMed, OVID, Cochrane Libraries and ClinicalTrials.gov. Twenty-one RCTs and 17 CTs were found. RESULTS: Among the different antifungal therapies (oral and combination thereof), continuous itraconazole and terbinafine had the highest mycological cure rates (79% and 81%, respectively), griseofulvin and terbinafine had the highest clinical cure rates (46% and 58%, respectively) and griseofulvin and terbinafine had the highest complete cure rate (72% and 92%, respectively). Griseofulvin more effectively treated Microsporum infections; terbinafine and itraconazole more effectively cured Trichophyton infections. Only 1.0% of children had to discontinue medication based on adverse events. T. tonsurans was the most common organism found in North America, and hairbrush collection method is the most efficient method of sample collection. Additionally, using a hairbrush, toothbrush or cotton swab to identify the infecting organism(s) is the least invasive and most efficient method of tinea capitis sample collection in children. CONCLUSIONS: Current dosing regimens of reported drugs are effective and safe for use in tinea capitis in children.

Efficacy of non-surgical treatments for androgenetic alopecia: a systematic review and network meta-analysis.

Androgenetic alopecia, or male/female pattern baldness, is the most common type of progressive hair loss disorder. The aim of this study was to review recent advances in non-surgical treatments for androgenetic alopecia and identify the most effective treatments. A network meta-analysis (NMA) was conducted of the available literature of the six most common non-surgical treatment options for treating androgenetic alopecia in both men and women; dutasteride 0.5 mg, finasteride 1 mg, low-level laser therapy (LLLT), minoxidil 2%, minoxidil 5% and platelet-rich plasma (PRP). Seventy-eight studies met the inclusion criteria, and 22 studies had the data necessary for a network meta-analysis. Relative effects show LLLT as the superior treatment. Relative effects show PRP, finasteride 1 mg (male), finasteride 1 mg (female), minoxidil 5%, minoxidil 2% and dutasteride (male) are approximately equivalent in mean change hair count following treatment. Minoxidil 5% and minoxidil 2% reported the most drug-related adverse events (n = 45 and n = 23, respectively). The quality of evidence of minoxidil 2% vs. minoxidil 5% was high; minoxidil 5% vs. placebo was moderate; dutasteride (male) vs. placebo, finasteride (female) vs. placebo, minoxidil 2% vs. placebo and minoxidil 5% vs. LLLT was low; and finasteride (male) vs. placebo, LLLT vs. sham, PRP vs. placebo and finasteride vs. minoxidil 2% was very low. Results of this NMA indicate the emergence of novel, non-hormonal therapies as effective treatments for hair loss; however, the quality of evidence is generally low. High-quality randomized controlled trials and head-to-head trials are required to support these findings and aid in the development of more standardized protocols, particularly for PRP. Regardless, this analysis may aid physicians in clinical decision-making and highlight the variety of non-surgical hair restoration options for patients.

A critical review of improvement rates for laser therapy used to treat toenail onychomycosis.

Onychomycosis is a nail infection that is primary caused by dermatophytes. Alternative treatments are needed as current therapies (oral and topical antifungals) have limited effectiveness. Lasers are currently approved by the FDA to temporarily increase the amount of clear nail in onychomycosis patients. Lasers can theoretically elicit fungicidal effects but in practice produce mixed results. This review compared laser-induced improvement rates to FDA-approved indications and traditional onychomycosis treatments. A review of the literature (PubMed, Clinicaltrials.gov, Medline and Embase) was used to locate articles for this review. RCTs, non-randomized, uncontrolled and retrospective studies that included at least one of the following measures were eligible; complete cure, mycological cure, clinical improvement and clinical cure. Mycological cure (negative culture and negative microscopy) was evaluated in two studies using patients as the unit of analysis with an average rate of 11%, increasing to 63% when nails were used as the unit of analysis (three studies). Clinical cure (100% clear nail) was evaluated in six studies with a rate of 13% using nails as the unit of analysis and 13% when patients were used as the unit of analysis (two studies). Clinical improvement (at any time point) was found in 36% of patients (five studies) and 67% of nails (nine studies). Nail clarity as measured by clear nail growth and/or nail plate/bed clearance at 12 weeks was found to be 2.6 mm across onychomycotic nails. Laser studies, to date, provide preliminary evidence of clinical improvement and clear nail growth in toenail onychomycosis, consistent with the FDA clearance for aesthetic endpoints. Laser studies however do not provide efficacy rates for medical endpoints that equate or exceed those found with traditional therapies (oral and topical treatments).