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Toenail Onychomycosis in Diabetic Patients

Issues and Management

  • Therapy in Practice
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Abstract

Diabetes mellitus may be associated with serious sequelae, such as renal disease, retinopathy, and diabetic foot. A recent large prospective study has shown that onychomycosis is among the most significant predictors of foot ulcer. As the severity of onychomycosis may be associated with the length of time the individual has had the infection, early intervention is advisable owing to the progressive nature of the fungal infection. If left untreated, toenails can become thick, causing pressure and irritation, and thus act as a trigger for more severe complications.

In the treatment of onychomycosis, compliance and drug interactions are important considerations, as diabetic patients frequently take concomitant medications. Terbinafine and itraconazole have been investigated for the treatment of onychomycosis in diabetic patients and have been shown to have efficacy and safety profiles comparable to those in the nondiabetic population. Data from clinical trials and postmarketing surveillance suggest that drug interactions resulting in hypoglycemia may not be an important issue when itraconazole and terbinafine are used to treat diabetic patients receiving concomitant hypoglycemic medications. Patient advice and education in improved foot care are an integral part of onychomycosis management, and help achieve long-term cure and reduce the complications of diabetic foot.

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References

  1. Gupta AK, Humke S. The prevalence and management of onychomycosis in diabetic patients. Eur J Dermatol 2000; 10: 379–84

    PubMed  CAS  Google Scholar 

  2. Farkas B, Paul C, Dobozy A, et al. Terbinafine (Lamisil) treatment of toenail onychomycosis in patients with insulin-dependent and non-insulindependent diabetes mellitus: a multicentre trial. Br J Dermatol 2002; 146: 254–60

    Article  PubMed  CAS  Google Scholar 

  3. Joshi N, Caputo GM, Weitekamp MR, et al. Infections in patients with diabetes mellitus. N Engl J Med 1999; 341: 1906–12

    Article  PubMed  CAS  Google Scholar 

  4. Rich P, Hare A. Onychomycosis in a special patient population: focus on the diabetic. Int J Dermatol 1999; 38: 17–9

    Article  PubMed  Google Scholar 

  5. Boyko WL, Doyle JJ, Ryu S, et al. Onychomycosis and its impact on secondary infection development in the diabetic population. 4th Annual International Meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR); 1999 May 23-26; Arlington (VA)

    Google Scholar 

  6. Boyko EJ, Ahroni JH, Cohen V, et al. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care 2006; 6: 1202–7

    Article  Google Scholar 

  7. Effendy I, Lecha M, Feuilhade de Chauvin M, et al. Epidemiology and clinical classification of onychomycosis. J Eur Acad Dermatol Venereol 2005; 19 Suppl. 1: 8–12

    Article  PubMed  Google Scholar 

  8. Scher RK, Tavakkol A, Sigurgeirsson B, et al. Onychomycosis: diagnosis and definition of cure. J Am Acad Dermatol 2007; 56: 939–44

    Article  PubMed  Google Scholar 

  9. Baran R, Kaoukhov A. Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy. J Eur Acad Dermatol Venereol 2005; 19: 21–9

    Article  PubMed  CAS  Google Scholar 

  10. Seebacher C, Brasch J, Abeck D, et al. Onychomycosis. Mycoses 2007; 50: 321–7

    Article  PubMed  CAS  Google Scholar 

  11. Cribier B, Bakshi R. Terbinafine in the treatment of onychomycosis: a review of its efficacy in the high-risk populations and in patients with nondermatophyte infections. Br J Dermatol 2004; 150: 414–20

    Article  PubMed  CAS  Google Scholar 

  12. Gupta AK, Ryder JE, Lynch LE, et al. The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence. J Drugs Dermatol 2005; 4: 302–8

    PubMed  Google Scholar 

  13. Lange M, Roszkiewicz J, Szczerkowska-Dobosz A, et al. Onychomycosis is no longer a rare finding in children. Mycoses 2006; 49: 55–9

    Article  PubMed  CAS  Google Scholar 

  14. Mayser P, Hensel J, Thoma W, et al. Prevalence of fungal foot infections in patients with diabetes mellitus type 1: underestimation of moccasin-type tinea. Exp Clin Endocrinol Diabetes 2004; 112: 264–8

    Article  PubMed  CAS  Google Scholar 

  15. Szepietowski JC, Reich A, Garlowska E. Factors influencing coexistence of toenail onychomycosis with tinea pedis and other dermatomycoses: a survey of 2761 patients. Arch Dermatol 2006; 142: 1279–84

    Article  PubMed  Google Scholar 

  16. Alteras I, Saryt E. Prevalence of pathogenic fungi in the toenails of diabetic patients. Mycopathologica 1979; 67: 157–9

    Article  CAS  Google Scholar 

  17. Lugo-Somolinos A, Sanchez JL. Prevalence of dermatophytosis in patients with diabetes. J Am Acad Dermatol 1992; 26: 408–10

    Article  PubMed  CAS  Google Scholar 

  18. Buxton PK, Milne LJ, Prescott RJ, et al. The prevalence of dermatophyte infection in well-controlled diabetics and the response to Trichophyton antigen. Br J Dermatol 1996; 134: 900–3

    Article  PubMed  CAS  Google Scholar 

  19. Romano C, Massai L, Asta F, et al. Prevalence of dermatophytic skin and nail infections in diabetic patients. Mycoses 2001; 44: 83–6

    Article  PubMed  CAS  Google Scholar 

  20. Dogra S, Kumar B, Bhansali A, et al. Epidemiology of onychomycosis in patients with diabetes mellitus in India. Int J Dermatol 2002; 41: 647–51

    Article  PubMed  Google Scholar 

  21. Piérard GE, Piérard-Franchimont C. The nail under fungal siege in patients with type II diabetes mellitus. Mycoses 2005; 48: 339–42

    Article  PubMed  Google Scholar 

  22. Gupta AK, Konnikov N, MacDonald P, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol 1998; 139: 665–71

    Article  PubMed  CAS  Google Scholar 

  23. Saunte DM, Holgersen JB, Haedersdal M, et al. Prevalence of toe nail onychomycosis in diabetic patients. Acta Dermatol Venereol 2006; 86: 425–8

    Article  Google Scholar 

  24. Manzano-Gayosso P, Hernández-Hernández F, Méndez-Tovar LJ, et al. Onychomycosis incidence in type 2 diabetes mellitus patients. Mycopathologia 2008; 166: 41–5

    Article  PubMed  Google Scholar 

  25. Chang SJ, Hsu SC, Tien KJ, et al. Metabolic syndrome associated with toenail onychomycosis in Taiwanese with diabetes mellitus. Int J Dermatol 2008; 47: 467–72

    Article  PubMed  CAS  Google Scholar 

  26. Finch J, Warshaw E. Toenail onychomycosis: current and future treatment options. Dermatol Ther 2007; 20: 31–46

    Article  PubMed  Google Scholar 

  27. Gupta AK, Ryder JE, Baran R, et al. Non-dermatophyte onychomycosis. Dermatol Clin 2003; 21: 257–68

    Article  PubMed  Google Scholar 

  28. Iorizzo M, Piraccini BM, Tosti A. New fungal nail infections. Curr Opin Infect Dis 2007; 20: 142–5

    Article  PubMed  Google Scholar 

  29. Winston JA, Miller JL. Treatment of onychomycosis in diabetic patients. Clin Diabetes 2006; 24: 160–6

    Article  Google Scholar 

  30. Seebacher C, Nietsch KH, Ulbricht HM. A multicenter, open-label study of the efficacy and safety of ciclopirox nail lacquer solution 8% for the treatment of onychomycosis in patients with diabetes. Cutis 2001; 68 (2 Suppl.): 17–22

    PubMed  CAS  Google Scholar 

  31. Baran R, Kaoukhov A. Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy. J Eur Acad Dermatol Venereol 2005; 19: 21–9

    Article  PubMed  CAS  Google Scholar 

  32. Brenner MA, Harkless LB, Mendicino RW, et al. Ciclopirox 8% nail lacquer topical solution for the treatment of onychomycosis in patients with diabetes: a multicenter, open-label study. J Am Podiatr Med Assoc 2007; 97: 195–202

    PubMed  Google Scholar 

  33. Watanabe D, Kawamura C, Masuda Y, et al. Successful treatment of toenail onychomycosis with photodynamic therapy. Arch Dermatol 2008; 144: 19–21

    Article  PubMed  Google Scholar 

  34. 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: s87–94

    Article  Google Scholar 

  35. Gupta AK, Gover MD, Lynde CW. Pulse itraconazole vs. continuous terbinafine for the treatment of dermatophyte toenail onychomycosis in patients with diabetes mellitus. J Eur Acad Dermatol Venereol 2006; 20: 1188–93

    Article  PubMed  CAS  Google Scholar 

  36. Kill J. Treatment options for onychomycosis [online]. Available from URL: http://www.infectiousdiseasenews.com/article/33478.aspx [Accessed 2009 Apr 28]

    Google Scholar 

  37. Gupta AK, Ryder JE, Lynch LE, et al. The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence. J Drugs Dermatol 2005; 4: 302–8

    PubMed  Google Scholar 

  38. Warshaw EM, Fett DD, Bloomfield HE, et al. Pulse versus continuous terbinafine for onychomycosis: a randomized, double-blind, controlled trial. J Am Acad Dermatol 2005; 53: 578–84

    Article  PubMed  Google Scholar 

  39. Evans EG, Sigurgeirsson B. Double blind, randomised study of continuous terbinafine compared with intermittent itraconazole in treatment of toenail onychomycosis: the LION Study Group. BMJ 1999; 318: 1031–5

    Article  PubMed  CAS  Google Scholar 

  40. Sigurgeirsson B, Olafsson JH, Steinsson JB, et al. Long-term effectiveness of treatment with terbinafine vs itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol 2002; 138: 353–7

    Article  PubMed  CAS  Google Scholar 

  41. Rich F, Karchmer A, Atillasoy ES. The safety and efficacy of oral terbinafine in the treatment of onychomycosis in diabetic patients. J Eur Acad Dermatol Venereol 1999; 12 Suppl. 2: 229

    Google Scholar 

  42. Bohannon NJ, Streja L. Effectiveness of terbinafine therapy for toenail onychomycosis in persons with diabetes. Diabetes 2000; 49 Suppl. 1: A195

    Google Scholar 

  43. Baran R, Sigurgeirsson B, de Berker D, et al. A multicentre, randomized, controlled study of the efficacy, safety and cost-effectiveness of a combination therapy with amorolfine nail lacquer and oral terbinafine compared with oral terbinafine alone for the treatment of onychomycosis with matrix involvement. Br J Dermatol 2007; 157: 149–57

    Article  PubMed  CAS  Google Scholar 

  44. Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatol Treat 2005; 16: 327–30

    Article  CAS  Google Scholar 

  45. Gupta AK, Katz I, Shear NH. Drug interactions with itraconazole, fluconazole, and terbinafine and their management. J Am Acad Dermatol 1999; 41: 237–49

    Article  PubMed  CAS  Google Scholar 

  46. Verspeelt J, Marynissen G, Gupta AK, et al. Safety of itraconazole in diabetic patients. Dermatology 1999; 198: 382–4

    Article  PubMed  CAS  Google Scholar 

  47. Albreski DA, Gross EG. The safety of itraconazole in the diabetic population. J Am Podiatr Med Assoc 1999; 89: 339–45

    PubMed  CAS  Google Scholar 

  48. Pollak R, Billstein SA. Safety of oral terbinafine for toenail onychomycosis. J Am Podiatr Med Assoc 1987; 87: 565–70

    Google Scholar 

  49. Grover C, Bansal S, Nanda S, et al. Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial. Br J Dermatol 2007; 157: 364–8

    Article  PubMed  CAS  Google Scholar 

  50. Sumikawa M, Egawa T, Honda I, et al. Effects of foot care intervention including nail drilling combined with topical antifungal application in diabetic patients with onychomycosis. J Dermatol 2007; 34: 456–64

    Article  PubMed  CAS  Google Scholar 

  51. Bild DE, Selby JV, Sinnock P, et al. Lower-extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Care 1989; 12: 24–31

    Article  PubMed  CAS  Google Scholar 

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Acknowledgment

No sources of funding were used to assist in the preparation of this review. Prof. Mayser has spoken at symposia sponsored by sanofi aventis, Novartis and Janssen-Cilag. Drs Freund and Budihardja have no conflicts of interest that are directly relevant to the content of this review.

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  1. Center of Dermatology and Andrology, Justus Liebig University, Giessen, Germany

    Peter Mayser, Viviane Freund & Debby Budihardja

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  1. Peter Mayser
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  2. Viviane Freund
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Correspondence to Peter Mayser.

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Mayser, P., Freund, V. & Budihardja, D. Toenail Onychomycosis in Diabetic Patients. AM J Clin Dermatol 10, 211–220 (2009). https://doi.org/10.2165/00128071-200910040-00001

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