Nail Infection/Removal ↓

Nail health can be a mirror of overall health. For example, Muehrcke’s lines (horizontal bands of nail discoloration) are typically caused by low serum albumin. Nail clubbing, which develops over years, is associated with low oxygen in the blood and has been described in patients suffering from severe gastrointestinal disorders, cardiovascular disease, and immune dysfunction. Koilonychia, a spoon-like depression of the nail bed, may indicate hypochromic anemia or other disruptions of iron absorption. Beau’s lines, indentations that run across the nail, can be a sign of trauma but can also be a sign of zinc deficiency. Finally, nail pitting, scaling, and thickening is common to psoriasis involving the nails and can accompany onychomycosis, or fungal infection of the nail.Topical preparations are the preferred route of treatment of nail disorders due to the relatively toxic effects of systemic therapy. Since treatment can be prolonged, oral regimens may require regular side effect monitoring and may even interact with other oral medications; elderly patients with comorbidities are particularly at risk for experiencing adverse effects and drug interactions from oral therapy. Generally, it’s important to use a combination of medications to promote healing and prevent nail disorder relapse.

Nail Psoriasis and Onychomycosis psoriatic nail disease generally occurs in patients with cutaneous psoriasis; however, it can rarely (5%) be seen in the absence of clinically evident psoriasis of the skin. Nail psoriasis can be treated using compounded topical agents and treatment may include an antifungal component since nail psoriasis and fungal nail infections are often comorbid conditions. Medications typically found in compounded nail psoriasis therapy include fluorouracil, glucocorticoids and/or vitamin D3 analogues. These agents can be compounded into creams, ointments, and gels. A study which included 48 patients, tested the efficacy of a preparation containing calcipotriol and clobetasol propionate in the treatment of nail psoriasis. After a year of treatment, nail thickness was reduced by 81.2% and 72.5% in finger and toe nails, respectively.

J Drug Deliv Sci Technol. 2015; 30A: 63–73

Nail psoriasis: An updated review of clinical reports on therapy and formulation aspects for topical delivery

Click here to access the abstract of this article.

Novel Formulations that Potentiate Antifungal Activities

Terbinafine, an orally and topically active antifungal agent, has been available for the treatment of dermatophytic infections and onychomycosis for more than a decade. Oral administration has been shown to be associated with drug-drug interactions, hepatotoxicity, low concentration at the infected sites, gastrointestinal and systemic side effects and other adverse effects. Since topical drug delivery can provide higher patient compliance, allow immediate access to the infected site and reduce unwanted systemic drug exposure, an improved topical drug delivery approach with high permeability, sustained release and prolonged retention at the site could overcome the limitations and side effects caused by oral administration. Conventional topical formulations cannot keep the drug in the targeted sites for a long duration of time. To overcome this limitation, our compounding pharmacy utilized a novel drug delivery system based on polymers and nanostructure carriers for the topical delivery of terbinafine and other medications.

Drugs Today (Barc). 2015 Mar;51(3):197-208.

Terbinafine: novel formulations that potentiate antifungal activities.

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Therapy for Onychomycosis

In a randomized, double-blind study of 70 patients with onychomycosis of the finger and toenails. The results indicated topical treatment of onychomycosis with a combination of fluconazole 1% and urea 40% was more effective (82.8%) than fluconazole 1% nail lacquer (62.8%) alone in treatment of onychomycosis. Fluconazole was well tolerated and side effects were negligible.

J Dermatolog Treat. 2012 Dec;23(6):453-6.

A comparative evaluation of combination therapy of fluconazole 1% and urea 40% compared with fluconazole 1% alone in a nail lacquer for treatment of onychomycosis: therapeutic trial.

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Treatment of Fingernail Lichen Planus

Nail lichen planus most commonly occurs during the fifth and sixth decade of life and can be notoriously recalcitrant to many forms of treatment. Prevost and English of the University of Pittsburgh Department of Dermatology reported a case of successful treatment of destructive inflammatory lichen planus of the nails with combined topical therapy of tazarotene gel and clobetasol gel, without the occurrence of potential adverse effects of systemic treatments.

J Drugs Dermatol. 2007 Feb;6(2):202-4.

Palliative treatment of fingernail lichen planus.

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Although surgical excision is the most popular method for removing nails, the use of concentrated urea plasters applied under occlusion may be superior. The use of urea plasters has inherent advantages – they are inexpensive, several nails can be treated in one session, and the procedure is essentially painless. Various synergistic combinations and topical medications with penetrant enhancers can be compounded for antifungal therapy. Topical medications usually have a lower adverse drug-reaction profile than systemic medications.

IJDVL 2012; 78(3):299-308

Nail avulsion: Indications and methods (surgical nail avulsion)

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Cutis. 1980 Jun;25(6):609-12

Urea ointment in the nonsurgical avulsion of nail dystrophies–a reappraisal.

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Cutis. 1980 Apr;25(4):397, 405

Combination urea and salicylic acid ointment nail avulsion in nondystrophic nails: a follow-up observation.

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JAMA 1979 Apr 13;241(15):1559, 1563

Urea plasters alternative to surgery for nail removal.

PMID: 430701 (No abstract available)

Clin Exp Dermatol 1982 May;7(3):273-6

The treatment of fungus and yeast infections of nails by the method of “chemical removal”.

PMID: 7105479 (No abstract available)

Management of onychomycosis, a fungal infection of the fingernails and toenails, usually consists of systemic antifungal medications, topical therapy (e.g., urea ointment, desiccating solutions, keratolytics, vital dyes), or surgical intervention (e.g., nail plate avulsion, laser therapy). Topical prescription antifungal preparations, containing the active ingredient of your choice, may be less likely to cause the serious systemic side effects that can occur with oral antifungal therapy and can provide a more economical alternative, as lower doses are needed when the medication is applied topically at the site. Penetrant enhancers can be included in the preparation to improve the effectiveness of topical antifungals.

Trop Med Int Health 1999 Apr;4(4):284-7

Treatment of toenail onychomycosis with 2% butenafine and 5% Melaleuca alternifolia (tea tree) oil in cream.

Click here to access the PubMed abstract of this article.