Lanosterol 14α-demethylase (CYP51)/histone deacetylase (HDAC) dual inhibitors for treatment of Candida tropicalis and Cryptococcus neoformans infections.

Invasive fungal infections remain a challenge due to lack of effective antifungal agents and serious drug resistance. Discovery of antifungal agents with novel antifungal mechanism is important and urgent. Previously, we designed the first CYP51/HDAC dual inhibitors with potent activity against resistant Candida albicans infections. To better understand the antifungal spectrum and synergistic mechanism, herein new CYP51/HDAC dual inhibitors were designed which showed potent in vitro and in vivo antifungal activity against C. neoformans and C. tropicalis infections. Antifungal mechanism studies revealed that the CYP51/HDAC dual inhibitors acted by inhibiting various virulence factors of C. tropicalis and C. neoformans and down-regulating resistance-associated genes. This study highlights the potential of CYP51/HDAC dual inhibitors as a promising strategy for the discovery of novel broad-spectrum antifungal agents.

Cutaneous candidiasis - an evidence-based review of topical and systemic treatments to inform clinical practice.

Cutaneous candidiasis is a common skin disease, and several treatments have been investigated within the last fifty years. Yet, systematic reviews are lacking, and evidence-based topical and systemic treatment strategies remain unclear. Thus, the aim of this review was to summarize efficacy and adverse effects of topical and oral therapies for cutaneous candidiasis in all age groups. Two individual researchers searched PubMed and EMBASE for 'cutaneous candidiasis' and 'cutaneous candidiasis treatment', 'intertrigo', 'diaper dermatitis' and 'cheilitis'. Searches were limited to 'English language', 'clinical trials' and 'human subjects', and prospective clinical trials published in abstracts or articles were included. In total, 149 studies were identified, of which 44 were eligible, comprising 41 studies of 19 topical therapies and four studies of three systemic therapies for cutaneous candidiasis. Topical therapies were investigated in infants, children, adolescents, adults and elderly, while studies of systemic therapies were limited to adolescents and adults. Clotrimazole, nystatin and miconazole were the most studied topical drugs and demonstrated similar efficacy with complete cure rates of 73%-100%. Single-drug therapy was as effective as combinations of antifungal, antibacterial and topical corticosteroid. Four studies investigated systemic therapy, and oral fluconazole demonstrated similar efficacy to oral ketoconazole and topical clotrimazole. Limitations to this review were mainly that heterogeneity of studies hindered meta-analyses. In conclusions, clotrimazole, nystatin and miconazole were the most studied topical drugs and demonstrated equal good efficacy and mild adverse effects similar to combinations of antifungal, antibacterial and topical corticosteroids. Oral fluconazole was as effective as topical clotrimazole and is the only commercially available evidence-based option for systemic treatment of cutaneous candidiasis.

Impact of Process Parameters on Particle Size Involved in Media Milling Technique Used for Preparing Clotrimazole Nanocrystals for the Management of Cutaneous Candidiasis.

Clotrimazole is widely used for the management of cutaneous candidiasis infection. The low solubility of clotrimazole and excipient-related topical side effects (of currently available marketed products) cause the compromised efficacy of the therapy with poor patient compliance. In the present investigation, a clotrimazole nanocrystal-based nanogel was developed. Clotrimazole nanocrystals were optimized with studying the impact of individual process parameters of the media milling technique. The optimum level of individual process parameters was considered in the development of optimized batches. A promising result was obtained with a non-ionic stabilizer, polysorbate 80, at a concentration of 1.5%w/v, showing a distinct reduction in the particle size from above 31 µm to 264 nm and a polydispersity index of 0.211 with media milling at 1500 rpm for 6 h. This result was found to be in concordance with the TEM images, revealing a sharp diminution in particle morphology. Powder X-ray diffraction and differential scanning calorimetry results revealed crystallinity of clotrimazole (CTZ) in nanocrystal form. The optimized nanocrystal suspension was formulated into nanogel with carbopol 934, having a viscosity of 86.43 ± 2.06 Pa s at 25°C, which enhanced the ease of application of CTZ nanocrystals topically. A diffusion study showed around 82% of CTZ is transported across the membrane with the flux of 110.07 µg cm-2 h-1. In vivo results of the nanogel revealed improvement in CTZ release with 52% CTZ retention in different strata of the skin. The developed nanogel showed a significant improvement in the eradication of fungal infection within 10 days of application over Candida albicans-induced Wistar rat model. In a nutshell, the CTZ nanocrystal-loaded nanogel could achieve the goal of retaining CTZ in skin layers providing a prolonged effect and was able to treat cutaneous candidiasis in a short span with improved compliance for the candidiasis patients.

Novel ethosomal gel of clove oil for the treatment of cutaneous candidiasis.

BACKGROUND: Dual-release mechanism of ethosomal gels (ie, ethosomes and gel) makes them as versatile drug delivery systems for topical applications. Clove oil is obtained from the clove buds exhibited broad antifungal and antibacterial activity. Cutaneous candidiasis is the infection caused by Candida albicans or other Candida species. AIM: The aim of the present study was to prepare ethosomal gel of clove oil and evaluate its effectiveness in the treatment of cutaneous candidiasis. METHODS: Ethosomes of clove oil was formulated by using varying concentrations of soyaphosphotidyl choline and ethanol, and later, it was incorporated into carbapol 974 base gels to form ethosomal gel. The prepared ethosomal gels were also evaluated for spreadability, drug release studies, ex vivo permeation study, and antifungal activity. RESULTS: The optimized formulation did not cause any irritation to the skin since the pH of formulation was in the pH range of skin. The ethosomal gel showed satisfactory antifungal activity against the fungus C. albicans compared to pure clove oil. CONCLUSIONS: The results showed that developed formulation could be promising one in the topical delivery of clove oil for the treatment of cutaneous candidiasis.

Cutaneous Candidiasis in a Gottingen Minipig: A Potential Pitfall in Preclinical Studies.

The Göttingen minipig is often used in preclinical toxicity studies. Therefore, knowledge of spontaneously occurring pathologies is important to differentiate them from test drug-related effects. We report on a Göttingen minipig, which developed exudating widespread dermatitis during a preclinical toxicity study with a subcutaneously injected drug. The lesions were resistant to topical and oral antibacterial medications. Skin cultures were positive for Candida albicans, and treatment was changed to topical antifungal cream with quick resolution of the skin lesions. Cutaneous candidiasis in pigs has been rarely reported in the literature, and this is the first report on such condition in preclinical toxicity studies. Knowledge of this condition, which is not drug related, is important, especially in toxicity studies involving subcutaneous injections that are commonly accompanied by inflammatory skin reactions.

Successful treatment of recalcitrant candidal intertrigo with Dr Michaels® (Fungatinex®) product family.

Candidal intertrigo is an infection of the skin caused by Candida albicans that typically occurs in opposing cutaneous or muco-cutaneous surfaces. Because Candidiasis requires a damaged and moist environment for infection, it typically occurs in areas of friction such as the skin folds of the body. Candidal intertrigo is often difficult to treat and results are often unsatisfactory. In addition, there is a lack of evidence-based literature supporting prevention and treatments for candidal intertrigo. The aim of the study was to evaluate the efficacy of Dr Michaels® (also branded as Fungatinex®) products in the treatment of fungal intertrigo, in 20 women and 2 men with a mean age of 72. Five patients (3 female and 2 male) had type 2 diabetes and 16 (14 female and 2 male) were obese. The patients were treated with Dr Michaels® (Fungatinex®) moisturising bar, topical ointment (twice daily application) and oral herbal formulation, PSC 200 two tablets twice daily with food. After 2 weeks of treatment, the lesions had mostly resolved in all patients with only slight erythema evident. After six weeks of treatment using the moisturising bar, topical ointment and oral herbal formulations from the Dr Michaels® (Fungatinex®) product family, the lesions had totally resolved in 18 patients, while 4 patients had to continue the therapeutic protocol for another 2 weeks. Our results demonstrate that the Dr Michaels® (Fungatinex®) complementary product family is efficacious in the treatment of recalcitrant candidal intertrigo. Furthermore, this study highlights that the Dr Michaels® (Fungatinex®) product family is fast-acting and well tolerated with no serious adverse events reported. These data have important implications for resistant cases of candidal intertrigo where traditional therapies have failed.

Thiamine antivitamins--an opportunity of therapy of fungal infections caused by Malassezia pachydermatis and Candida albicans.

Severe skin diseases and systemic fungaemia are caused by Malassezia pachydermatis and Candida albicans respectively. Antifungal therapies are less effective because of chronic character of infections and high percentage of relapses. Therefore, there is a great need to develop new strategies of antifungal therapies. We previously found that oxythiamine decreases proliferation of yeast (Saccharomyces cerevisiae), therefore we suggest that thiamine antivitamins can be considered as antifungal agents. The aim of this study was the comparison of thiamine antivitamins (oxythiamine, amprolium, thiochrome, tetrahydrothiamine and tetrahydrooxythiamine) inhibitory effect on the growth rate and energetic metabolism efficiency in non-pathogenic S. cerevisiae and two potentially pathogenic species M. pachydermatis and C. albicans. Investigated species were cultured on a Sabouraud medium supplemented with trace elements in the presence (40 mg l(-1)) or absence of each tested antivitamins to estimate their influence on growth rate, enzyme activity and kinetic parameters of pyruvate decarboxylase and malate dehydrogenase of each tested species. Oxythiamine was the only antivitamin with antifungal potential. M. pachydermatis and S. cerevisiae were the most sensitive, whereas C. albicans was the least sensitive to oxythiamine action. Oxythiamine can be considered as supportive agent in superficial mycoses treatment, especially those caused by species from the genus Malassezia.

Efficacy and Safety in 1% Clotrimazole Powder, Adjuvant Therapy in Patients with Superficial Fungal Cutaneous Infection in Intertriginous Areas.

Background: Superficial fungal cutaneous infection is commonly found in intertriginous area. Objective: To assess 1% clotrimazole powder (1% CP) efficacy for adjuvant treatment of superficial fungal cutaneous infection in intertriginous areas. Material and Method: The study performed as an open-label, randomized, comparative study for evaluating the effects of 1% clotrimazole cream (1% CC) with 1% CP in patients infected with dermatophytes (DMPs) or Candida spp. in intertriginous area, comparing to patients treated with 1% CC as control by demonstrating complete cure rate at 4, 8, and 12 weeks as well as relapse rates during a 24-week period including patient satisfaction. Results: Sixty-seven patients with mean age of 54.6 years were included in this study. Of those, 61.2% were males. Thirty-five patients were infected with DMPs and 32 with Candida spp. The complete cure rates of experimental group were significantly higher than the control group, as observed within four weeks (p = 0.01), especially for dermatophyte infection (p = 0.039). Two cases had recurrent candidiasis in the control group. In both groups, relapse up to 24 weeks were not statistically different. Additionally, there was no difference in patients' satisfaction towards convenience of drug application. Conclusion: Using of the 1% CP could be suggested as an adjuvant therapy and possibly preventive agent for superficial fungal cutaneous infection in intertriginous areas.

Potentiation of azole antifungals by 2-adamantanamine.

Azoles are among the most successful classes of antifungals. They act by inhibiting α-14 lanosterol demethylase in the ergosterol biosynthesis pathway. Oropharyngeal candidiasis (OPC) occurs in about 90% of HIV-infected individuals, and 4 to 5% are refractory to current therapies, including azoles, due to the formation of resistant biofilms produced in the course of OPC. We reasoned that compounds affecting a different target may potentiate azoles to produce increased killing and an antibiofilm therapeutic. 2-Adamantanamine (AC17) was identified in a screen for compounds potentiating the action of miconazole against biofilms of Candida albicans. AC17, a close structural analog to the antiviral amantadine, did not affect the viability of C. albicans but caused the normally fungistatic azoles to become fungicidal. Transcriptome analysis of cells treated with AC17 revealed that the ergosterol and filamentation pathways were affected. Indeed, cells exposed to AC17 had decreased ergosterol contents and were unable to invade agar. In vivo, the combination of AC17 and fluconazole produced a significant reduction in fungal tissue burden in a guinea pig model of cutaneous candidiasis, while each treatment alone did not have a significant effect. The combination of fluconazole and AC17 also showed improved efficacy (P value of 0.018) compared to fluconazole alone when fungal lesions were evaluated. AC17 is a promising lead in the search for more effective antifungal therapeutics.

Good response in a patient with deep-seated subcutaneous ulcer due to Candida species.

Deep-seated subcutaneous ulcers infected with Candida species are rare. We are reporting a 51-year-old Cantonese woman who had a large, deep-seated subcutaneous ulcer on her right shoulder for more than a year. Direct smears of the purulent extrusion revealed many pseudohyphae and yeast cells. Candida species were isolated from the purulent extrusion and further identified as Candida albicans and C. parapsilosis. A skin lesion biopsy contained yeast cells and pseudohyphae. C. parapsilosis were once isolated from the biopsy specimen. Total healing was obtained with itraconazole (200 mg twice daily for 16 days and then 100 mg twice daily for 14 days) combined with phototherapy.

Antifungal activity of Lavandula angustifolia essential oil against Candida albicans yeast and mycelial form.

The antifungal activity of the essential oil of Lavandula angustifolia Mill. (lavender oil) and its main components, linalool and linalyl acetate, was investigated against 50 clinical isolates of Candida albicans (28 oropharyngeal strains, 22 vaginal strains) and C. albicans ATCC 3153. Growth inhibition, killing time and inhibition of germ tube formation were evaluated. The chemical composition of the essential oil was determined by gas chromatography and mass spectrometry. Lavender oil inhibited C. albicans growth: mean minimum inhibitory concentration (MIC) of 0.69% (vol./vol.) (vaginal strains) and 1.04% (oropharyngeal strains); mean MFC of 1.1% (vaginal strains) and 1.8% (oropharyngeal strains). Linalool was more effective than essential oil: mean MIC of 0.09% (vaginal strains) and 0.29% (oropharyngeal strains); mean MFC of 0.1% (vaginal strains) and 0.3% (oropharyngeal strains). Linalyl acetate was almost ineffective. Lavender oil (2%) killed 100% of the C. albicans ATCC 3153 cells within 15 min; linalool (0.5%) killed 100% of the cells within 30 s. The essential oil inhibited germ tube formation (mean MIC of 0.09%), as did the main components (MIC of 0.11% for linalool and 0.08% for linalyl acetate). Both the essential oil and its main components inhibited hyphal elongation of C. albicans ATCC 3153 (about 50% inhibition at 0.016% with each substance). Lavender oil shows both fungistatic and fungicidal activity against C. albicans strains. At lower concentrations, it inhibits germ tube formation and hyphal elongation, indicating that it is effective against C. albicans dimorphism and may thus reduce fungal progression and the spread of infection in host tissues.

Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone) often utilize it in inappropriate settings regardless of their knowledge of the drug's potency.

Clotrimazole-betamethasone diproprionate (C-BMV) is a fluorinated, high potency topical steroid that has been formulated with clotrimazole in the brand-named product, Lotrisone. The product is frequently used inappropriately in intertriginous areas, particularly in children. The following evaluates the use of this combination based upon a survey of 106 US-based pediatricians with at least two years post-residency, who attended the 1999 American Academy of Pediatrics. Of pediatricians who prescribe C-BMV, 23% prescribe it for diaper dermatitis. 11% of C-BMV prescriptions exceed the recommended duration of therapy. Only 18% of prescribing pediatricians correctly identify "Lotrisone" as a high potency steroid. There is no significant association between knowledge of C-BMV potency and frequency of use (p>.1). These self-reported data confirm and complement the findings of previous studies that used representative national data to assess the use of C-BMV. Pediatricians continue to utilize C-BMV in inappropriate settings, such as diaper dermatitis, regardless of their knowledge of the agent's potency. Our advice is to refrain from using high-potency steroids, such as C-BMV, in pediatric cases as there are more appropriate, safer alternatives with many fewer side effects.

In vitro antifungal activity of KP-103, a novel triazole derivative, and its therapeutic efficacy against experimental plantar tinea pedis and cutaneous candidiasis in guinea pigs.

The in vitro activity of KP-103, a novel triazole derivative, against pathogenic fungi that cause dermatomycoses and its therapeutic efficacy against plantar tinea pedis and cutaneous candidiasis in guinea pigs were investigated. MICs were determined by a broth microdilution method with morpholinepropanesulfonic acid-buffered RPMI 1640 medium for Candida species and with Sabouraud dextrose broth for dermatophytes and by an agar dilution method with medium C for Malassezia furfur. KP-103 was the most active of all the drugs tested against Candida albicans (geometric mean [GM] MIC, 0.002 microg/ml), other Candida species including Candida parapsilosis and Candida glabrata (GM MICs, 0.0039 to 0.0442 microg/ml), and M. furfur (GM MIC, 0.025 microg/ml). KP-103 (1% solution) was highly effective as a treatment for guinea pigs with cutaneous candidiasis and achieved mycological eradication in 8 of the 10 infected animals, whereas none of the imidazoles tested (1% solutions) was effective in even reducing the levels of the infecting fungi. KP-103 was as active as clotrimazole and neticonazole but was less active than lanoconazole and butenafine against Trichophyton rubrum (MIC at which 80% of isolates are inhibited [MIC(80)], 0.125 microg/ml) and Trichophyton mentagrophytes (MIC(80), 0.25 microg/ml). However, KP-103 (1% solution) exerted therapeutic efficacy superior to that of neticonazole and comparable to those of lanoconazole and butenafine, yielding negative cultures for all samples from guinea pigs with plantar tinea pedis tested. This suggests that KP-103 has better pharmacokinetic properties in skin tissue than the reference drugs. Because the in vitro activity of KP-103, unlike those of the reference drugs, against T. mentagrophytes was not affected by hair as a keratinic substance, its excellent therapeutic efficacy seems to be attributable to good retention of its antifungal activity in skin tissue, in addition to its potency.

Therapeutic efficacy of hamycin, a polyene antimycotic agent, for experimental cutaneous candidiasis in guinea pigs.

The therapeutic efficacy of 1% cream and 1% solution of hamycin, a polyene antimycotic agent, in the model of cutaneous candidiasis in prednisolone-treated guinea pigs was evaluated in comparison with that of comparable formulations of miconazole. Each preparation was topically applied once a day for three consecutive days starting on the fifth day post infection, and quantitative culture study was conducted on the ninth day post infection. Both formulations were much more highly effective in terms of eradication of fungi like miconazole formulations.

Topical treatment of dermatophytosis and cutaneous candidosis with flutrimazole 1% cream: double-blind, randomized comparative trial with ketoconazole 2% cream.

In a double-blind, randomized study the efficacy and tolerance of flutrimazole 1% cream were compared with ketoconazole 2% cream, applied once daily for 4 weeks, in 60 patients with culturally proven dermatophytosis (47 patients) or cutaneous candidosis (13 patients). Both groups of patients and distribution of target lesions were similar. The sum of clinical scores had an even distribution in both groups at the end of treatment. The proportion of patients with negative microscopy and culture after 4 weeks of treatment was 70% in the flutrimazole group and 53% in the ketoconazole group; seven ketoconazole-treated patients (23%) compared with two flutrimazole-treated patients (6.6%) were asymptomatic carriers (clinically cured with positive cultures) at the end of treatment. At the assessment 6 weeks after the end of therapy the percentages of flutrimazole- and ketoconazole-treated patients with negative mycology were 57 and 70%, respectively. There were one relapse (3.3%) in the ketoconazole group and four (13.3%) in the flutrimazole group. One patient treated with ketoconazole (3%) had a premature termination due to adverse events attributable to the medication. The results of this study show that flutrimazole 1% cream is as effective and safe as ketoconazole 2% cream for Candida and dermatophyte skin infections.

A double-blind, randomized comparative trial: flutrimazole 1% solution versus bifonazole 1% solution once daily in dermatomycoses.

In a double-blind, randomized study the efficacy and tolerance of flutrimazole 1% solution were compared with bifonazole 1% solution, applied once daily for 4 weeks, in 40 patients with culturally proven dermatophytosis or cutaneous candidosis. Forty patients with mycologically proven pityriasis versicolor were treated with once-daily application for 1 week. The four groups of patients and distribution of target lesions were similar, although in the flutrimazole group more patients had cutaneous candidosis (n = 8 versus n = 1). The distribution of the sum of clinical scores was also similar in both groups. At the end of therapy the proportion of patients with negative microscopy and culture was 85% in the flutrimazole group and 65% in the bifonazole group. There was a significant difference (P = 0.022) in terms of efficacy, since 80% of patients in the flutrimazole group versus 40% in the bifonazole group were judged to have received effective treatment. At the assessment 6 weeks after the end of therapy the percentages of flutrimazole- and bifonazole-treated patients with negative mycology were 75% and 65% respectively. There were two relapses (one in each group), which represents a 5% rate. Fifteen flutrimazole-treated patients (75%) compared with 12-bifonazole-treated patients (60%) had overall effective therapy. Two patients treated with bifonazole (10%) and one treated with flutrimazole (5%) had a premature termination due to adverse events attributable to the medication. On assessment 3 weeks after the end of treatment, the patients with pityriasis versicolor were all clinically and mycologically healed with negative fluorescence, including the patients who withdrew from the full course of treatment (one in each group). Nine weeks after the end of therapy all the patients remained cured, with no relapses. The overall incidence of adverse events (mild local reactions such as irritation, burning and itching) was one and seven cases for bifonazole and flutrimazole respectively. One patient in each group had to abandon treatment owing to severe intolerance.

Flutrimazole 1% dermal cream in the treatment of dermatomycoses: a multicentre, double-blind, randomized, comparative clinical trial with bifonazole 1% cream. Efficacy of flutrimazole 1% dermal cream in dermatomycoses. Catalan Flutrimazole Study Group.

BACKGROUND: Flutrimazole is a new imidazole derivate. Its antifungal activity has been demonstrated in in vivo and in vitro studies to be comparable to that of clotrimazole and higher than bifonazole. AIM: To compare the efficacy and tolerability of flutrimazole cream 1% with a reference drug, bifonazole, in the treatment of dermatomycoses, eligible for topical treatment exclusively. METHODS: A multicentre, double-blind, randomized, parallel-group clinical trial was conducted. Patients with clinically and mycologically (KHO and/or culture) diagnosed fungal infection of the skin were included in this study and were randomized into two treatment groups: 1% flutrimazole or 1% bifonazole, applied to the affected area (target lesion) once a day. The principal criterion of efficacy, 'cure', was based on clinical and mycological assessment. RESULTS: Four hundred and forty-nine patients were included in the study (228 flutrimazole, 221 bifonazole). 'Intention-to-treat' analysis of the data showed a difference between the treatments in terms of the rate of cure (clinical and mycological) after 4 weeks: 73% in the flutrimazole group and 65% in the bifonazole group (p = 0.05). From a safety point of view, flutrimazole and bifonazole were well tolerated, and the overall incidence of adverse effects (mainly mild local effects like irritation or burning sensation) was 5%. CONCLUSIONS: One percent flutrimazole applied topically once a day in the treatment of fungal infections of the skin presents a better efficacy than bifonazole and a good tolerability.

Therapeutic efficacy of lanoconazole, a new imidazole antimycotic agent, for experimental cutaneous candidiasis in guinea pigs.

The therapeutic efficacy of 1% cream and 1% solution of lanoconazole, a new imidazole antimycotic agent, in the model of cutaneous candidiasis in prednisolone-treated guinea pigs was evaluated in comparison with that of comparable formulations of bifonazole. Each preparation was topically applied once a day for 3 consecutive days, starting on the fifth day postinfection, and quantitative culture study wsa conducted on the ninth day postinfection. Both formulations of lanoconazole were much more highly effective in terms of eradication of fungi than the bifonazole formulations.