A Tosti

Amanda Oakley

Bruce Arroll

D de Assis Santos

DS Loo

EM Warshaw

JO Sobera

PH Huang

TC Olde Hartman

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Preventing long term relapsing tinea unguium with topical 
anti-fungal cream: a case report
Bruce Arroll*1 and Amanda Oakley2
Address: 1University of Auckland, Private Bag 92019, Auckland, New Zealand and 2Department of Dermatology, Waikato Hospital, Private Bag 
3200, Hamilton 3001, New Zealand
Email: Bruce Arroll* - b.arroll@auckland.ac.nz; Amanda Oakley - oakley@wave.co.nz
* Corresponding author    
Abstract
Background: The patient was aged 34 when he consulted a dermatologist in Vancouver BC with
onychomycosis affecting the right great toenail.
Case presentation: Trichophyton rubrum was cultured from nail clippings. Griseofulvin was taken
for 6 months, resulting in clinical and mycological cure. Over the next 27 years there were multiple
relapses. Each course of treatment with oral terbinafine (for up to 18 months) or itraconazole
resulted in clinical and mycological cure. A dermatological colleague suggested the reason for
relapse was likely to be self re-infection.
Conclusion: No clinical relapse has occurred with once-weekly miconazole cream applied to the
toenail and webspaces of the right foot over the last four years.
Background
Onychomycosis is fungal infection affecting fingernails or
toenails, and may be due to dermatophyte, yeast or
mould. Tinea unguium is the term used when a dermato-
phyte has been identified on culture.
Oral medication is recommended for extensive or symp-
tomatic tinea unguium, and is particularly appropriate in
diabetics at risk of secondary bacterial infection. The most
effect fungicide is terbinafine with reported 70% cure rates
for toenails and 80% for fingernails. Itraconazole also has
a high success rate. Recurrence is common.[1]
Oral antifungal medications may be taken intermittently
or continuously, and typically a course of 3 to 6 months is
prescribed, depending on response and severity. Pro-
longed courses may be prescribed in older patients but
treatment may fail because of slow-growing nails and
poor peripheral circulation. Minor side effects are com-
mon. Terbinafine occasionally results in serious adverse
reactions including toxic epidermal necrolysis, hepatitis
and agranulocytosis. Drug interactions, cardiac and
hepatic toxicity are the main concern with azoles.[2]
Topical antifungal agents are often prescribed for tinea
unguium. They have impressive in vitro cure rates. How-
ever they are rarely curative in vivo [3], presumably because
of poor penetration into the nail plate, frequent involve-
ment of inaccessible proximal nail matrix, and non-adher-
ence to instructions. It is understandable that patients
would get tired of applying a solution or lacquer once or
twice weekly for a year or longer, if no improvement is seen
within a few weeks of use. Therefore topical medications
should be restricted to confirmed distal infection of one or
two nails only, in those able to debride their own nails. In
more extensive disease they may be used concurrently with
oral drugs, or alone if oral medications are contraindicated
to reduce spread to cutaneous sites.
Published: 21 January 2009
Cases Journal 2009, 2:70 doi:10.1186/1757-1626-2-70
Received: 31 December 2008
Accepted: 21 January 2009
This article is available from: http://www.casesjournal.com/content/2/1/70
© 2009 Arroll and Oakley; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:70 http://www.casesjournal.com/content/2/1/70A Medline search of tinea unguium and recurrence
revealed few references and little evidence regarding the
use of topical medication in preventing relapse.[4]
Case presentation
Age 35 at time of diagnosis 56 at time of writing
Sex Male
Occupation Doctor
Ethnicity Caucasian
Weight 90 kg
Height 1.87 m
Social. The patient was working in Vancouver BC Canada.
He now lives in New Zealand
Medical history (At the time of diagnosis, hand eczema
and recurrent tinea pedis; subsequently hypertension
(1994), currently treated with chlorthalidone, lisinopril
and metoprolol.)
Family history (Mother died of a myelodysplasia, aged 86
years. She also had recurrent melanoma on one leg. Father
died at age 87 of congestive heart failure and multiple
myeloma. Sister has asthma and hypertension.
Non smoker
Alcohol less than 1 standard drink per week
Current medications: Chlorthalidone 25 mg daily, lisino-
pril 20 mg daily and metoprolol succinate 190 mg per day.
The description of the case
Symptoms presented with: There were no symptoms. The
main concerns were the appearance, and risk of transmit-
ting infection to family members. Signs on presentation:
Distal and lateral aspects of the right toenail were yellow,
thickened and opacified, with onycholysis and irregular
subungual hyperkeratosis (figure 1). All the other nails
were normal. There was also tinea pedis in the form of
toeweb maceration in both 4th to 5th webspaces on the toes.
Diagnostic tests. Mycological testing of the nail revealed
fungal elements on microscopy and Trichophyton rubrum
on culture.
Any imaging carried out; None
Primary diagnosis: Tinea pedis and tinea unguium due to
T rubrum
Any subsequent diagnoses. Recurrent tinea pedis and
tinea unguium
Pharmacological treatments – The first treatment was gri-
seofulvin 1000 mg per day and was taken for 6 months.
Itraconazole was later used in a dose of 400 mg daily for
one week, repeated each month for 6 months. Two
courses of pulse Itraconazole and continuous therapy
with 400 mg daily for 6 months followed. Multiple
courses of terbinafine 250 mg per day for 6 months were
tried and one course went for 18 months.
Surgical interventions. Nil
Any other interventions: At the age of 52 he started apply-
ing topical miconazole once per week to the affected large
toe and to the toe clefts of his right foot.
Outcome of the case: All courses of oral antifungal medi-
cations resulted in a clinical cure. Mycological cure was
confirmed on three occasions. Until recently, apparent
cure was always followed by relapse. However, there has
been no recurrence of tinea unguium since starting pro-
phylactic topical miconazole (figure 2).
Discussion
The patient has been extremely relieved by the outcome of
topical prophylaxis, as he has been concerned about
potential harm of repeated courses of oral antifungal
agents.
The relapse rate for onychomycosis is known to be high
and increases with time: "The relapse rate increased from
8. 3% at month 12 to 19.4% at month 24 and to 22.2% at
month 36." [5].
Risk factors for recurrent onychomycosis are older age,
abnormal nail morphology (especially a thickened nail
plate due to trauma and psoriasis), immunodeficiency
and genetic factors. A search of medical literature and text-
books suggests "Successful treatment does not prevent
future reinfection", but specific advice on how to prevent
re-infection is rarely described.[3] Topical ciclopirox or
amorolfine lacquer for the nail is often suggested. Prevent-
ative measures include protective footwear and cotton
socks, antifungal or absorbent powders, and frequent nail
clipping. Old shoes often harbour large numbers of infec-
tious organisms and should be discarded or treated with
disinfectants or antifungal powders.[6]
It is recognised that tinea pedis needs to be treated vigor-
ously, yet a double-blind trial reported no statistical dif-
ference between miconazole powder and placebo used to
prevent recurrence of onychomycosis in 48 patients. The
small sample size indicates type 2 statistical error was pos-Page 2 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:70 http://www.casesjournal.com/content/2/1/70sible (i.e. no change found when a true difference exists).
[7]
In vivo, miconazole is effctive for tinea pedis but it is not
effective for active onychomycosis. Topical miconazole is
active in vitro against T rubrum, although less potent than
terbinafine and itraconazole. An increase in minimum
inhibitory concentration has been noted in organisms iso-
lated post treatment compared to pretreatment of ony-
chomycosis. [8] We were unable to find any reports of
clinical resistance to topical miconazole, but this is a the-
oretical concern with prophylactic use of this drug.
Our patient has been lucky and has finally achieved long-
term remission; we think this is likely due to topical mico-
nazole prophylaxis, but this impossible to prove.
Conclusion
We have described a case in which sustained remission
from onychomycosis was achieved with weekly micona-
zole cream applied to the affected big toe and toe clefts.
Miconazole may reduce the need for further potentially
hazardous oral treatment in individuals with recurrent
onychomycosis. However, it is important to first achieve
clinical and mycological remission with oral therapy.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
BA is on the advisory board for the educational seminars
run by PHARMAC, New Zealand's government funded
drug purchasing agency. He is also on the primary care
committee of the Future Forum and educational founda-
tion funded by Astra Zeneca (UK). He has accepted travel
and conference funding from Sanofi Aventis.
AO has received fees from PHARMAC for educational
seminars. She is the Website Manager of the New Zealand
Dermatological Society, NZ DermNet, which is funded
mainly by pharmaceutical companies, including those
that market antifungal agents.
Authors' contributions
BA provided the photographs and the idea for the paper.
AO provided the description of the toes and added many
pieces of relevant clinical information and references.
Both edited the paper.
References
1. Huang PH, Paller AH: Itraconazole Pulse Therapy for Dermat-
ophyte Onychomycosis in Children.  Arch Pediatr Adolesc Med
2000, 154:614-618.
2. Loo DS: Onychomycosis in the elderly: drug treatment
options.  Drugs Aging 2007, 24(4):293-302.
3. Crawford F, Hollis S: Topical treatments for fungal infections of
the skin and nails of the foot.  Cochrane Database Syst Rev
2007:CD001434.
4. In First Consult onychomycosis   [http://www.mdconsult.com]
5. Olde Hartman TC, van Rijswijk E: Fungal nail infection.  BMJ 2008,
337:a429.
6. Tosti A, Piraccini BM, Stinchi C, Colombo MD: Relapses of ony-
chomycosis after successful treatment with systemic anti-
fungals: a three-year follow-up.  Dermatology 1998, 197(2):162-6.
7. Sobera JO, Elewski BE: Chapter.76 Fungal infections.  In Derma-
tology 2nd edition. Edited by: Bolognia JL, Jorizzo JL, Rapini RP. Else-
vier; 2008. 
8. Warshaw EM, St Clair KR: Prevention of onychomycosis rein-
fection for patients with complete cure of all 10 toenails:
results of a double-blind, placebo-controlled, pilot study of
prophylactic miconazole powder 2%.  J Am Acad Dermatol 2005,
53(4):717-20.
9. de Assis Santos D, de Carvalho Araújo RA, Kohler LM, Machado-
Pinto J, Hamdan JS, Cisalpino PS: Molecular typing and antifungal
susceptibility of Trichophyton rubrum isolates from patients
with onychomycosis pre- and post-treatment.  Int J Antimicrob
Agents 2007, 29(5):563-9.
Photo 2 current condition of toe 2008Figure 2
Photo 2 current condition of toe 2008.
Photo 1 during a relapse 1994Figure 1
Photo 1 during a relapse 1994.Page 3 of 3
(page number not for citation purposes)


Preventing long term relapsing tinea unguium with topical anti-fungal cream: a case report

Crossref

Cisalpino PS: Molecular typing and antifungal susceptibility of Trichophyton rubrum isolates from patients with onychomycosis pre- and post-treatment.

E: Fungal nail infection. BMJ

Elewski BE: Chapter.76 Fungal infections.

MD: Relapses of onychomycosis after successful treatment with systemic antifungals: a three-year follow-up. Dermatology

Onychomycosis in the elderly: drug treatment options. Drugs Aging

Paller AH: Itraconazole Pulse Therapy for Dermatophyte Onychomycosis in Children. Arch Pediatr Adolesc Med

St Clair KR: Prevention of onychomycosis reinfection for patients with complete cure of all 10 toenails: results of a double-blind, placebo-controlled, pilot study of prophylactic miconazole powder 2%. J Am Acad Dermatol

Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev

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Preventing long term relapsing tinea unguium with topical anti-fungal cream: a case report

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