Brote de dermatofitosis en región de cabeza y cuello asociadas al rasurado en peluquerías: estudio descriptivo multicéntrico de una serie de casos / Outbreak of Dermatophyte Infections on the Head and Neck Related to Shave Haircuts: Description of a Multicenter Case Series

Introducción Desde 2021 se ha detectado un aumento de casos de tiñas del cuero cabelludo en adolescentes que se cortan el pelo mediante rasurado o degradado. Pacientes y métodos Estudio observacional retrospectivo multicéntrico de casos de dermatofitosis del polo cefálico con el antecedente de haber sido contraídas tras el rasurado frecuente en peluquería. Se realizó una llamada a dermatólogos de la Academia Española de Dermatología y Venereología (AEDV) para que aportaran casos observados entre enero de 2021 y diciembre de 2022. Se incluyeron pacientes con confirmación microbiológica mediante cultivo o examen directo con KOH. Resultados Se recogieron 107 casos, siendo 106 pacientes varones. Se observaron 78 formas no inflamatorias frente a 29 inflamatorias. El hongo aislado con mayor frecuencia fue Trichophyton tonsurans (75,7% de los casos). Las lesiones aparecieron predominantemente en la nuca y en el área temporal. Conclusiones La distribución por sexo, edad y localización lesional parece apuntar a que una nueva tendencia social, en la que adolescentes varones acuden asiduamente a peluquerías para el afeitado de las zonas occipital y temporal, sería la causante de esta agrupación de casos de tiña del cuero cabelludo. El microorganismo más frecuente en nuestro estudio (T.tonsurans) coincide con el más prevalente en nuestro medio. Con el presente estudio se evidencia un acúmulo de casos susceptible de ser tenido en cuenta por organismos competentes de salud pública, a los cuales corresponde velar por el cumplimiento de las normas de desinfección del material empleado para el rasurado (AU)

Introduction Since 2021, an increase in cases of tinea capitis has been detected in adolescents who shave their hair with fade haircut. Patients and methods Multicenter retrospective observational study of cases of cephalic pole dermatophytosis with a history of having been acquired after frequent shaving in hairdressing. A call was made to dermatologists from the Spanish Academy of Dermatology and Venereology (AEDV) to provide cases observed between January 2021 and December 2022. Patients with microbiological confirmation by culture or direct examination with KOH were included. Results 107 cases were collected, 106 of which were male. 78 non-inflammatory forms were observed, compared to 29 inflammatory. The most frequently isolated fungus was Trichophyton tonsurans (75.7% of cases). The lesions appeared predominantly on the nape of the neck and temporal area. Conclusions The distribution by sex, age and lesional location seems to indicate that a new social trend, in which male adolescents regularly go to hairdressers to shave the occipital and temporal areas, would be the cause of this grouping of cases of ringworm of the scalp. The most frequent microorganism in our study (T.tonsurans) coincides with the most prevalent in our environment. This study shows an accumulation of cases that can be taken into account by competent Public Health agencies, which are responsible for ensuring compliance with the rules of disinfection of the material used for shaving (AU)

[Translated article] Outbreak of Dermatophyte Infections on the Head and Neck Related to Shave Haircuts: Description of a Multicenter Case Series / Brote de dermatofitosis en región de cabeza y cuello asociadas al rasurado en peluquerías: estudio descriptivo multicéntrico de una serie de casos

Introduction Since 2021, an increase in cases of tinea capitis has been detected in adolescents who shave their hair with fade haircut. Patients and methods Multicenter retrospective observational study of cases of cephalic pole dermatophytosis with a history of having been acquired after frequent shaving in hairdressing. A call was made to dermatologists from the Spanish Academy of Dermatology and Venereology (AEDV) to provide cases observed between January 2021 and December 2022. Patients with microbiological confirmation by culture or direct examination with KOH were included. Results 107 cases were collected, 106 of which were male. 78 non-inflammatory forms were observed, compared to 29 inflammatory. The most frequently isolated fungus was Trichophyton tonsurans (75.7% of cases). The lesions appeared predominantly on the nape of the neck and temporal area. Conclusions The distribution by sex, age and lesional location seems to indicate that a new social trend, in which male adolescents regularly go to hairdressers to shave the occipital and temporal areas, would be the cause of this grouping of cases of ringworm of the scalp. The most frequent microorganism in our study (T.tonsurans) coincides with the most prevalent in our environment. This study shows an accumulation of cases that can be taken into account by competent Public Health agencies, which are responsible for ensuring compliance with the rules of disinfection of the material used for shaving (AU)

Introducción Desde 2021 se ha detectado un aumento de casos de tiñas del cuero cabelludo en adolescentes que se cortan el pelo mediante rasurado o degradado. Pacientes y métodos Estudio observacional retrospectivo multicéntrico de casos de dermatofitosis del polo cefálico con el antecedente de haber sido contraídas tras el rasurado frecuente en peluquería. Se realizó una llamada a dermatólogos de la Academia Española de Dermatología y Venereología (AEDV) para que aportaran casos observados entre enero de 2021 y diciembre de 2022. Se incluyeron pacientes con confirmación microbiológica mediante cultivo o examen directo con KOH. Resultados Se recogieron 107 casos, siendo 106 pacientes varones. Se observaron 78 formas no inflamatorias frente a 29 inflamatorias. El hongo aislado con mayor frecuencia fue Trichophyton tonsurans (75,7% de los casos). Las lesiones aparecieron predominantemente en la nuca y en el área temporal. Conclusiones La distribución por sexo, edad y localización lesional parece apuntar a que una nueva tendencia social, en la que adolescentes varones acuden asiduamente a peluquerías para el afeitado de las zonas occipital y temporal, sería la causante de esta agrupación de casos de tiña del cuero cabelludo. El microorganismo más frecuente en nuestro estudio (T.tonsurans) coincide con el más prevalente en nuestro medio. Con el presente estudio se evidencia un acúmulo de casos susceptible de ser tenido en cuenta por organismos competentes de salud pública, a los cuales corresponde velar por el cumplimiento de las normas de desinfección del material empleado para el rasurado (AU)

Olive oil and clove oil-based nanoemulsion for topical delivery of terbinafine hydrochloride: in vitro and ex vivo evaluation.

In this article, formulation studies for terbinafine hydrochloride nanoemulsions, prepared by high-energy ultrasonication technique, are described. Pseudo-ternary phase diagram was constructed in order to find out the optimal ratios of oil and surfactant/co-solvent mixture for nanoemulsion production. Clove and olive oils were selected as oil phase. Based on the droplet size evaluation, maximum nanoemulsion region were determined for formulation development. Further characterization included polydispersity index (PDI), zeta potential, Fourier transform infrared (FT-IR) spectroscopy, morphology, pH, viscosity, refractive index, ex vivo skin permeation, skin irritation, and histopathological examination. Droplet sizes of optimized formulations were in colloidal range. PDI values below 0.35 indicated considerably homogeneous nanoemulsions. Zeta potential values were from 13.2 to 18.1 mV indicating good stability, which was also confirmed by dispersion stability studies. Ex vivo permeation studies revealed almost total skin permeation of terbinafine hydrochloride from the nanoemulsions (96-98%) in 6 hours whereas commercial product reached only 57% permeation at the same time. Maximum drug amounts were seen in epidermis and dermis layers. Skin irritation and histopathological examination demonstrated dermatologically safe formulations. In conclusion, olive oil and clove oil-based nanoemulsion systems have potential to serve as promising carriers for topical terbinafine hydrochloride delivery.

Determination of terbinafine in healthy Chinese human plasma using a simple and fast LC-MS/MS method and its application to a bioequivalence study.

A rapid, simple, and selective liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was validated for the determination of terbinafine concentrations in the plasma of healthy Chinese subjects. Terbinafine-d7 was used as the internal standard (IS), and the acetonitrile protein precipitation method was selected. The processed samples were chromatographically separated with a C18 column. The mobile phases were 0.1% formic acid (FA) in water (A), and methanol (B), respectively, and the gradient elution program was used with a flow rate of 0.8 mL/min. Quantification was achieved by positive electrospray ionization containing multiple reaction monitoring (MRM) transitions of m/z 292.5 â†’ 141.1 for terbinafine and m/z 299.5 â†’ 148.1 for IS. The calibration curve range was 2.00-1200 ng/mL; the intra- and inter-batch precision (coefficient of variation, %CV) was <8.2%, with the accuracy deviation (relative error, %RE) of -6.5% to 10.2%. The selectivity, sensitivity, extraction recovery, matrix effect, dilution reliability, carryover, and stability were within the acceptable range. This method was successfully applied to a bioequivalence study that orally administered 125 mg of terbinafine hydrochloride tablets in 84 healthy Chinese subjects.

Onychomycosis: Rapid Evidence Review.

Onychomycosis is a chronic fungal infection of the fingernail or toenail bed leading to brittle, discolored, and thickened nails. Onychomycosis is not just a cosmetic problem. Untreated onychomycosis can cause pain, discomfort, and physical impairment, negatively impacting quality of life. Onychomycosis should be suspected in patients with discolored nails, nail plate thickening, nail separation, and foul-smelling nails. Accurate diagnosis is important before initiating treatment because therapy is lengthy and can cause adverse effects. A potassium hydroxide preparation with confirmatory fungal culture, periodic acid-Schiff stain, or polymerase chain reaction is the preferred diagnostic approach if confirmative testing is cost prohibitive or not available. Treatment decisions should be based on severity, comorbidities, and patient preference. Oral terbinafine is preferred over topical therapy because of better effectiveness and shorter treatment duration. Patients taking terbinafine in combination with tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antipsychotics, beta blockers, or tamoxifen should be monitored for drug-drug interactions. Topical therapy, including ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, is less effective than oral agents but can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions. Nail trimming and debridement used concurrently with pharmacologic therapy improve treatment response. Although photodynamic and plasma therapies are newer treatment options that have been explored for the treatment of onychomycosis, larger randomized trials are needed. Preventive measures such as avoiding walking barefoot in public places and disinfecting shoes and socks are thought to reduce the 25% relapse rate.

Failure of Warfarin Anticoagulation Therapy after Administration of Oral Terbinafine.

Warfarin is widely used anticoagulant drug for a variety of diseases (thromboembolic disease, atrial fibrillation, etc.). It has three most important parallel metabolic pathways, CYP1A2, CYP3A4 and CYP2C9. Terbinafine is a potent CYP2D6 inhibitor. A possible drug interaction could lead to an increased pharmacological effect of the above drugs. Enzyme induction with CYP3A4, CYP2C9, CYP1A2 inducers may have occurred. Case report: We present a case report of an 88-year-old male patient who has been successfully anticoagulated with warfarin due to atrial fibrillation. He was orally administered terbinafine to treat onychomycosis. Two weeks after initiation of this drug the patient experienced dizziness and feelings of instability, for which he was admitted to the neurology department. A low-efficient INR level was found at the baseline, presumably due to warfarin interaction with terbinafine. The induction of liver enzymes lasts 10-14 days, which matches the introduction of the antifungal agent. Conclusion: Combined therapy with warfarin and oral terbinafine is actually rarely prescribed but, if used, their interaction can have serious consequences in many clinical situations for which anticoagulation therapy with warfarin is indicated.

EFFICACY OF SUBCUTANEOUS IMPLANTS TO PROVIDE CONTINUOUS PLASMA TERBINAFINE IN HELLBENDERS (CRYPTOBRANCHUS ALLEGANIENSI) FOR FUTURE PROPHYLACTIC USE AGAINST CHYTRIDIOMYCOSIS.

Batrachochytrium dendrobatidis (Bd) is an important fungal pathogen present in wild hellbender (Cryptobranchus alleganiensis) populations that appears to cause disease during novel exposure and acute stress. Hellbender repatriation efforts are ongoing to combat declining populations, but mortality by chytridiomycosis (disease from Bd) after release has been reported. The goal was to determine whether a safe antifungal agent could be administered and provide prolonged plasma concentrations without repeated handling. A subcutaneous implant impregnated with 24.5 mg of terbinafine was tested in three juvenile eastern hellbenders (C. a. alleganiensis) raised in human care, and plasma terbinafine concentrations were recorded from weekly to biweekly for 141 days. Plasma concentrations were variable, with peak plasma concentrations of 1,610, 112, and 66 ng/ml between 28 and 56 days postimplant. Although all hellbenders achieved plasma concentrations above the published minimum inhibitory concentration for terbinafine against Bd zoospores (63 ng/ml) at several time points, only one individual remained above this threshold for more than two consecutive time intervals. Results show the potential for these implants as a prophylaxis for chytridiomycosis in captive-to-wild hellbender releases. However, further investigation will be needed to determine the plasma concentrations required to achieve prophylaxis in vivo and implant reliability.

Therapeutic efficacy of topically used luliconazole vs. terbinafine 1% creams.

OBJECTIVES: Dermatomycoses of zoophilic origin, especially those caused by Trichophyton mentagrophytes, often pose considerable therapeutic problems. This is reflected in the growing number of strains of this species with resistance to terbinafine caused by a mutation in the squalene epoxidase (SQLE) gene. Therefore, it is reasonable to look for alternative therapies to the commonly used terbinafine. The aim of the present study was to assess the in vivo effectiveness of topical therapy with luliconazole or terbinafine 1% cream. METHODS: Therapeutic efficacy was assessed using direct examination in KOH with DMSO, qPCR analysis with pan-dermatophyte primers and culturing. Moreover, in vitro susceptibility tests for luliconazole and terbinafine were performed. RESULTS: The results demonstrated significantly higher antifungal activity of luliconazole than terbinafine against dermatomycoses caused by T. mentagrophytes. The geometric mean of the MIC value for luliconazole against all T. mentagrophytes strains was 0.002 µg/ml, while this value for terbinafine was 0.004 µg/ml. In all studied cases, 28-day local therapy with luliconazole contributed to complete eradication of the aetiological agent of infection. CONCLUSIONS: Given the increasingly frequent reports of difficult-to-treat dermatophytoses caused by zoophilic terbinafine-resistant strains, the 1% luliconazole cream can be alternative solution in topical therapy.

In Vitro Sensitivity Analysis of the Gastrointestinal Dissolution Profile of Weakly Basic Drugs in the Stomach-to-Intestine Fluid Changing System: Explanation for Variable Plasma Exposure after Oral Administration.

An in vitro methodology for simulating the change in the pH and composition of gastrointestinal fluid associated with the transition of orally administered drugs from the stomach to the small intestine was developed (the stomach-to-intestine fluid changing system (the SIFC system)). This system was applied to in vitro sensitivity analysis on the dissolution of weakly basic drugs, and the obtained results were discussed in relation to the intrasubject variability in the plasma exposure in human bioequivalence (BE) study. Three types of protocols were employed (steep pH change: pH 1.6 FaSSGF → pH 6.5 FaSSIF, gradual pH change: pH 1.6 FaSSGF → pH 6.5 FaSSIF, and high gastric pH: pH 4.0 FaSSGF → pH 6.5 FaSSIF). Regardless of the protocols and the forms of drug applied in active pharmaceutical ingredient powder or formulation, dissolution profiles of pioglitazone after fluid shift were similar and the final concentrations in FaSSIF were approximately equal to the saturation solubility in FaSSIF, supporting its small intrasubject variance in human BE study. In contrast, dissolved concentration of terbinafine in the SIFC system became less than half in the high gastric pH protocol than that in other protocols, suggesting the fluctuation of gastric pH as one of the factors of high intrasubject variance of terbinafine in human. Plasma exposure of telmisartan was highly variable especially at the high dose. Although the dissolution of telmisartan in the SIFC system was greatly improved by formulation, it considerably fluctuated during fluid shift especially at the high dose, which corresponds well to in vivo results.

Effect of Different Nail Penetration Enhancers in Solid Lipid Nanoparticles Containing Terbinafine Hydrochloride for Treatment of Onychomycosis.

Onychomycosis is considered a stubborn nail fungal infection that does not respond to conventional topical antifungal treatments. This study aimed to develop and characterize novel solid lipid nanoparticles (SLNs) formulae containing terbinafine HCl (TFH) and loaded with different nail penetration enhancers (nPEs). Three (nPEs) N-acetyl-L-cysteine, thioglycolic acid, and thiourea were used. Characterization of the prepared formulae was done regarding particle size, zeta potential, polydispersity index (PDI), entrapment efficiency (EE%), physical stability, in vitro release study, infrared (FT-IR), and their morphological structures. The selected formulae and the marketed cream Lamifen® were compared in terms of their antifungal activity against Trichophyton rubrum as well as their nail hydration and their drug uptake by the nail clippers. Thiourea was the nPE of choice; formulae (N2 and N8), with thiourea, were considered the optimum TFH SLNs containing nPEs. They were selected for their optimum particle size of 426.3 ± 10.18 and 450.8 ± 11.45 nm as well as their highest EE% of 89.76 ± 1.25 and 90.35 ± 1.33, respectively. The in vitro microbiological screening of the antifungal activity of these two formulae showed significantly larger zones of inhibition in comparison with the marketed product. The ex vivo screening of the drug uptake of the two selected formulae was significantly higher than that of the marketed product. The nPE formulae present a very promising option as they showed optimum physicochemical characterization with high antifungal activity and high drug uptake as well as good nail hydration effect.

Efficacy and safety of topical terbinafine 10% solution (MOB-015) in the treatment of mild to moderate distal subungual onychomycosis: A randomized, multicenter, double-blind, vehicle-controlled phase 3 study.

BACKGROUND: Onychomycosis is a recalcitrant fungal nail infection. Topical antifungal agents may be preferred over systemic agents due to lack of systemic adverse effects. OBJECTIVE: To investigate the efficacy and safety of topical terbinafine 10% solution (MOB-015) for the treatment of distal and lateral subungual onychomycosis. METHODS: In a multicenter, double-blind, phase III, North American study, patients with mild to moderate distal and lateral subungual onychomycosis involving 20% to 60% of at least 1 great toenail were randomized to once daily application of MOB-015 or matching vehicle for 48 weeks. The primary efficacy variable was complete cure, while the secondary efficacy variables were mycological cure and treatment success. Safety evaluations were also performed. RESULTS: At week 52, the mycological cure (negative culture and potassium hydroxide microscopy) rate in the MOB-015 and vehicle groups was 69.9% and 27.7%, respectively (P < .001), and complete cure (0% clinical disease involvement and mycological cure) was achieved in 4.5% and 0% of patients, respectively (P = .0195). At least 1 adverse event leading to discontinuation of treatment occurred in 2.8% of patients in the MOB-015 group and in 4.2% in the vehicle group. LIMITATION: The follow-up period after end of treatment may not be sufficient to accurately reflect cure in distal and lateral subungual onychomycosis. CONCLUSIONS: MOB-015 is a treatment option for onychomycosis with an adverse event profile similar to vehicle.

Severe onychomycosis management with oral terbinafine in a kidney transplantation setting: Clinical follow-up by image analysis.

BACKGROUND: Severe onychomycosis treatment in kidney transplant recipients (KTR) is challenging because of drug interactions and adverse events. Tacrolimus remains the antirejection treatment (ART) of choice in kidney transplantation but tolerance with systemic terbinafine for the management of severe onychomycosis has not been studied. OBJECTIVE: This study illustrates severe onychomycosis management in a kidney transplantation setting and investigates systemic terbinafine tolerance profile in KTR. PATIENTS/METHODS: We retrospective analysed clinical data of KTR with a confirmed diagnosis of severe onychomycosis. RESULTS: We retrieved a total of 29 KTR with severe onychomycosis needing an oral treatment to manage onychomycosis. In 55.1% (16/29) KTR, altered renal biological parameters or lack of guidelines to manage severe onychomycosis were the main reasons to deterring clinicians from prescribing oral treatments. 13 patients received an oral terbinafine treatment (9, 3 and 1 with a tacrolimus, cyclosporine and everolimus-based ART, respectively). Clinical and biological follow-up did not reveal severe drug interactions. ART blood levels showed significant variations in 2 patients without clinical consequences in renal graft. Two patients reported mild adverse events but after only one dose of terbinafine. Using an open-source image analysis program, clinical evolution of onychomycosis could be retrospectively quantified and followed up. CONCLUSIONS: The results presented here suggest that oral terbinafine can be proposed to treat severe onychomycosis with an acceptable tolerance profile in KTR with different ART such as tacrolimus and highlight the need of multicentric studies to establish guidelines for onychomycosis treatment in KTR.

Mefenoxam, Itraconazole, and Terbinafine Combination Therapy for Management of Pythiosis in Dogs (Six Cases).

Pythium insidiosum is an oomycete that encysts in the skin or gastrointestinal tract, leading to pythiosis. Pythiosis is reported in tropical and subtropical climates, affecting dogs and rarely cats. Surgical resection is the treatment of choice; however, cases present late in the disease and lesions are often nonresectable. Medical management is typically unsuccessful, with uncommon exceptions; however, mefenoxam, an agricultural fungicide, has in vitro efficacy against P insidiosum. We describe the use of mefenoxam, itraconazole, and terbinafine (MIT) in five dogs with gastrointestinal pythiosis and one dog with cutaneous pythiosis. Two of the gastrointestinal cases had disease extending to surgical margins and received MIT: resolution of clinical signs and seronegativity occurred after 189-193 days. Another case underwent surgical resection and MIT. The dog improved but subsequently developed a rectal mass, which responded to addition of prednisone and immunotherapy. Two cases were treated with MIT alone, and response varied. Efficacy of MIT in cutaneous pythiosis could not be determined. MIT may result in improved survival and seronegativity in dogs with incompletely resected gastrointestinal pythiosis. Mefenoxam is EPA registered, and extralabel use under the Animal Medicinal Drug Use Clarification Act does not apply. Additional research is recommended before use.

Trichophyton erinacei: an emergent pathogen of pediatric dermatophytosis / Trichophyton erinacei: un patógeno emergente en las dermatofitosis en niños

BACKGROUND: Dermatophytoses in children are common pathologies worldwide caused mainly by Trichophyton rubrum. However, due to the globalization and the atypical pets that people nowadays own, some zoonotic species are also involved in these lesions. CASE REPORT: We present two cases of tinea faciei caused by the zoonotic mould Trichophyton erinacei in two children that owned a guinea pig and a hedgehog, respectively. Mycological diagnosis was performed inoculating skin scales on Sabouraud-glucose agar plates supplemented with chloramphenicol, with and without gentamicin, and on Sabouraud-glucose agar tubes, with and without cycloheximide. Microscopical examination in both cases and ITS region sequencing to confirm the identification (performed in one of them) were compatible with T. erinacei. Multiple treatments like corticosteroids and antibiotics were prescribed prior to the accurate diagnosis. Finally, both patients received topical and oral terbinafine, respectively, the lesions being resolved entirely. CONCLUSIONS: Zoonotic fungi must be considered in the diagnosis of skin lesions. An accurate medical record, with a guided anamnesis about possible risk factors and an ongoing and open dialogue between health professionals, are essential to improve both the management of these exotic and zoophilic dermatophytoses

ANTECEDENTES: Las dermatofitosis son patologías comunes en niños y son causadas principalmente por Trichophyton rubrum. Sin embargo, debido a la globalización y a la presencia cada vez más frecuente de animales exóticos como mascotas, algunas especies zoonóticas menos habituales pueden convertirse en agentes causales. CASO CLÍNICO: Nuestro objetivo es describir dos casos de Tinea faciei causados por Trichophyton erinacei en dos niños que poseían, respectivamente, una cobaya y un erizo como mascotas. Se tomó muestra de escamas cutáneas que fueron inoculadas en placas de agar Sabouraud-glucosa suplementado con cloranfenicol, con y sin gentamicina, y en tubos de agar Sabouraud-glucosa con y sin cicloheximida. El examen microscópico fue compatible con Trichophyton erinacei, cuya identificación pudo ser confirmada por secuenciación de la región ITS en uno de los casos. Antes del correcto diagnóstico los pacientes habían recibido múltiples tratamientos (corticosteroides, antibióticos). Finalmente, los dos pacientes recibieron terbinafina tópica y oral, respectivamente, lo que llevó a la resolución completa de las lesiones. CONCLUSIONES: Los hongos zoonóticos deben ser considerados en el diagnóstico diferencial de las lesiones cutáneas. Una historia clínica con anamnesis guiada sobre posibles factores de riesgo, junto con una comunicación multidisciplinar fluida, es indispensable para mejorar el manejo de estas dermatofitosis

Safety of current therapies for onychomycosis.

INTRODUCTION: Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality. AREAS COVERED: This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding. EXPERT OPINION: Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.

A case of anti- pityriasis versicolor therapy that preserves healthy mycobiome.

BACKGROUND: The impact of Malassezia yeasts on skin mycobiome and health has received considerable attention recently. Pityriasis versicolor (PV), a common dermatosis caused by Malassezia genus worldwide, is a manifestation of dysbiosis. PV can be associated with hyper- and/or hypopigmented skin lesions. This disease entity is characterized by high percentage of relapses, which demands a proper antifungal therapy that is based on unambiguous species identification and drug susceptibility testing. CASE PRESENTATION: Comprehensive analysis of PV case in man presenting simultaneously hyper- and hypopigmented skin lesions was performed. Conventional and molecular diagnostic procedures revealed Malassezia furfur and Malassezia sympodialis, respectively as etiological agents of skin lesions observed. Susceptibility tests showed significantly lowered sensitivity of M. furfur cells to fluconazole. Based on susceptibility profiles local antifungal therapy with drugs characterized by entirely different mechanism of action was included. CONCLUSIONS: Our study indicates that cases of PV represented by two types of skin lesions in one patient may be associated with distinct Malassezia species. Moreover, as observed in this case, each of the isolated etiological agents of PV may differ significantly in susceptibility to antifungals. This can significantly complicate the treatment of dermatosis, which by definition is associated with a significant percentage of relapses. In the presented case localized topical treatment was sufficient and successful while allowing maintaining the physiological mycobiome.