Efficacy of itraconazole, terbinafine, fluconazole, griseofulvin and ketoconazole in the treatment of Scopulariopsis brevicaulis causing onychomycosis of the toes.
BACKGROUND
Scopulariopsis brevicaulis is a common non-dermatophyte mould that can cause onychomycosis.


OBJECTIVE
To evaluate the efficacy and safety of the oral antifungal agents griseofulvin, ketoconazole, itraconazole, fluconazole and terbinafine in the treatment of S. brevicaulis.


METHODS
In a prospective, comparative, parallel-group, single-blinded, randomized, non-industry-sponsored study, patients with toe onychomycosis caused by S. brevicaulis sp. were randomized and treated with one of 5 oral antifungal agents, i.e. griseofulvin, ketoconazole, itraconazole (pulse), fluconazole or terbinafine. The treatment regimens were: griseofulvin 600 mg twice daily for 12 months, ketoconazole 200 mg daily for 4 months, itraconazole pulse therapy given for 3 pulses, with each pulse consisting of 200 mg twice daily for 1 week with 3 weeks off between successive pulses, terbinafine 250 mg daily for 12 weeks and fluconazole 150 mg daily for 12 weeks.


RESULTS
There were 59 patients (48 males, 11 females, mean age 35.6 years, range 25-53 years). All patients had clinical evidence of distal and lateral onychomycosis, with moderate to severe disease of the target nail. Between the treatment groups there was no significant difference in the mean age of the patients or the mean area of involvement with onychomycosis at baseline. The efficacy parameters were clinical cure (CC) and mycological cure (MC). At month 12 after the start of treatment, the response was: griseofulvin, CC 3/11, MC 0/11, CC + MC 0/11; ketoconazole, CC 10/12, MC 8/12, CC + MC 8/12; itraconazole, CC 12/12, MC 12/12, CC + MC 12/12; terbinafine, CC 12/12, MC 11/12, CC + MC 11/12, and fluconazole, CC 8/12, MC 8/12, CC + MC 8/12. Adverse effects consisted of: griseofulvin, gastro-intestinal symptoms, allergic reaction, photodermatitis, hepatic and renal dysfunction in 11 patients with discontinuation of treatment in 3 patients; ketoconazole, hepatic dysfunction but no symptomatic changes in 2 patients; itraconazole, nausea and vomiting in 2 patients; terbinafine, taste disturbance in 2 patients, nausea in 3 patients, and fluconazole, severe gastro-intestinal events in 5 patients. None of the patients receiving ketoconazole, itraconazole, terbinafine or fluconazole discontinued treatment.


CONCLUSIONS
Itraconazole and terbinafine demonstrate efficacy against some cases of S. brevicaulis toe onychomycosis. These agents also appear to be safe in the course of therapy for toe onychomycosis. Griseofulvin is ineffective against toe onychomycosis caused by S. brevicaulis. Ketoconazole is not recommended for toe onychomycosis given its potential for adverse effects, particularly with the availability of the newer antifungal agents.
Gupta
A K
AK
Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook site), and University of Toronto, Ont., Canada. agupta@execulink.com
Gregurek-Novak
T
T
D000328:Adult; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D015725:Fluconazole / Q000009:adverse effects / Q000627:therapeutic use; D005500:Follow-Up Studies; D005533:Foot Dermatoses / Q000188:drug therapy* / Q000382:microbiology; D005767:Gastrointestinal Diseases / Q000139:chemically induced; D006118:Griseofulvin / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D017964:Itraconazole / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D003904:Mitosporic Fungi / Q000187:drug effects*; D009281:Naphthalenes / Q000009:adverse effects / Q000627:therapeutic use; D009325:Nausea / Q000139:chemically induced; D014009:Onychomycosis / Q000188:drug therapy* / Q000382:microbiology; D010787:Photosensitivity Disorders / Q000139:chemically induced; D011446:Prospective Studies; D016037:Single-Blind Method; D000077291:Terbinafine; D016896:Treatment Outcome; D014839:Vomiting / Q000139:chemically induced
D000935:Antifungal Agents; D009281:Naphthalenes; D017964:Itraconazole; D006118:Griseofulvin; D015725:Fluconazole; D000077291:Terbinafine