Expert consensus on management of dermatophytosis in elderly patients, patients with comorbidities, and immunocompromised status: an Indian perspective
Keywords:Dermatophytosis, Treatment, Elderly, Comorbidity, Immunocompromised, Polypharmacy
Dermatophytosis is a common fungal infection of skin contributing to increasing disease burden worldwide. Increasing age, presence of comorbid conditions and immunity have a profound impact on the manifestation of dermatophyte infections. Treatment of dermatophytosis includes monotherapy, combination therapy, or sequential therapy of antifungal drugs. However, specific patient populations such as the elderly, people with comorbid conditions, immunocompromised patients, etc. are subjected to inappropriate adverse events due to highly interacting host and drug factors. Thus, the management of dermatophytosis in special populations is a challenge, and it demands a change in the regular treatment plan. A group of Indian experts reviewed the evidence available on different antifungal agents for the management of dermatophytosis and provided their expert opinion on safe and effective management of the condition in special clinical scenarios. This article summarizes the consensus clinical viewpoint of the entire expert panel for a choice of the antifungal drug, factors to be assessed, and treatment considerations in special populations with dermatophytosis. The panel emphasized that complete knowledge of patient's clinical history, presence of comorbid conditions, and pharmacokinetic and pharmacodynamic characteristics of antifungal agents and associated potential drug interactions are essential for the successful management of dermatophytosis in these patients. Also, regular monitoring of drug toxicity is important during antifungal therapy in special population.
Rajagopalan M, Inamadar A, Mittal A. Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC Dermatol. 2018;18(1):6.
Shivanna R, Rajesh. Management of dermatophytosis in elderly and with systemic comorbidities. Clin Dermatol Rev. 2017;1:38-41.
Narang T, Mahajan R, Dogra S. Dermatophytosis: Fighting the Challenge: Conference Proceedings and Learning Points. September 2-3, 2017, PGIMER, Chandigarh, India. Indian Dermatol Online J. 2017;8(6):527-33.
Grimsrud KN, Sherwin CM, Constance JE. Special population considerations and regulatory affairs for clinical research. Clin Res Regul Aff. 2015;32(2):47-56.
Baran R, Hay RJ, Garduno JI. Review of antifungal therapy, part II: Treatment rationale, including specific patient populations. J Dermatolog Treat. 2008;19(3):168-75.
Wu LC, Sun PL, Chang YT. Extensive deep dermatophytosis cause by Trichophyton rubrum in a patient with liver cirrhosis and chronic renal failure. Mycopathologia. 2013;176(5-6):457-62.
Salem A, Gamil H, Hamed M, Galal S. Nail changes in patients with liver disease. J Eur Acad Dermatol Venereol. 2010;24(6):649-54.
Irimie M, Tătaru A, Oantă A, Moga M. In vitro susceptibility of dermatophytes isolated from patients with end-stage renal disease: a case-control study. Mycoses. 2014;57(3):129-34.
Akkus G, Evran M, Gungor D, Karakas M, Sert M, Tetiker T. Tinea pedis and onychomycosis frequency in diabetes mellitus patients and diabetic foot ulcers. A cross sectional - observational study. Pak J Med Sci. 2016;32(4):891-5.
Rouzaud C, Hay R, Chosidow O. Severe Dermatophytosis and Acquired or Innate Immunodeficiency: A Review. J Fungi (Basel). 2015;2(1):4.
Rengasamy M, Shenoy MM, Dogra S, Asokan N, Khurana A, Poojary S, et al. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT). Indian Dermatol Online J. 2020;11(4):502-19.
Singal A, Khanna D. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol. 2011;77(6):659-72.
Kaul S, Yadav S, Dogra S. Treatment of Dermatophytosis in Elderly, Children, and Pregnant Women. Indian Dermatol Online J. 2017;8(5):310-8.
Debruyne D, Coquerel A. Pharmacokinetics of antifungal agents in onychomycoses. Clin Pharmacokinet. 2001;40(6):441-72.
Loo DS. Onychomycosis in the elderly: Drug treatment options. Drugs Aging. 2007;24(4):293-302.
Elewski B, Tavakkol A. Safety and tolerability of oral antifungal agents in the treatment of fungal nail disease: a proven reality. Ther Clin Risk Manag. 2005;1(4):299-306.
Bickers DR. Antifungal therapy: potential interactions with other classes of drugs. J Am Acad Dermatol. 1994;31(3 Pt 2):87-90.
Bebawi E, Jouni SS, Tessier AA, Frenette AJ, Brindamour D, Doré M. A metoprolol-terbinafine combination induced bradycardia. Eur J Drug Metab Pharmacokinet. 2015;40(3):295-9.
Baath NS, Hong J, Sattar SP. Possible carbamazepine toxicity with terbinafine. Can J Clin Pharmacol. 2006;13(2):228-31.
Lo Re V, Carbonari DM, Lewis JD. Oral Azole Antifungal Medications and Risk of Acute Liver Injury, Overall and by Chronic Liver Disease Status. Am J Med. 2016;129(3):283-91.
Narain U, Gupta A. Superficial Fungal Infections in ESRD Patients. Austin Renal Dis. 2016;1(1):1003.
Chang YL, Yu SJ, Heitman J, Wellington M, Chen YL. New facets of antifungal therapy. Virulence. 2017;8(2):222-36.
Salem M, Reichlin T, Fasel D, Leuppi-Taegtmeyer A. Torsade de pointes and systemic azole antifungal agents: Analysis of global spontaneous safety reports. Glob Cardiol Sci Pract. 2017;2:11.
Okuyan H, Altın C. Heart failure induced by itraconazole. Indian J Pharmacol. 2013;45(5):524-5.
De Doncker P, Pande S, Richarz U, Garodia N. Itraconazole: What clinicians should know?. Indian J Drugs Dermatol. 2017;3:4-10.
Laverdière M. Systemic antifungal drugs: Are we making any progress? Can J Infect Dis. 1994;5(2):59-61.
Rengasamy M, Chellam J, Ganapati S. Systemic therapy of dermatophytosis: Practical and systematic approach. Clin Dermatol Rev. 2017;1:19-23.
Tan JS, Joseph WS. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging. 2004;21(2):101-12.
Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Res. 2011;4:26.
Triplitt C. Drug Interactions of Medications Commonly Used in Diabetes. Diabetes Spectrum. 2006;19:202-11.
Cribier BJ, Bakshi R. Terbinafine in the treatment of onychomycosis: a review of its efficacy in high-risk populations and in patients with nondermatophyte infections. Br J Dermatol. 2004;150(3):414-20.
Cathcart S, Cantrell W, Elewski Be. Onychomycosis and diabetes. J Eur Acad Dermatol Venereol. 2009;23(10):1119-22.
Kershenovich R, Sherman S, Reiter O. A Unique Clinicopathological Manifestation of Fungal Infection: A Case Series of Deep Dermatophytosis in Immunosuppressed Patients. Am J Clin Dermatol. 2017;18(5):697-704.