Modern methods of treating onychomycosis

In order not to confuse the whitish coating, which signals the proliferation of Candida fungi, with the usual coating after feeding with formula, you need to lightly rub the skin with a soft napkin or handkerchief. Plaque from food will be easily erased, unlike the area affected by thrush; moreover, reddish inflamed areas will become noticeable on the mucous membrane.

In most cases, thrush in infants occurs due to infection from the mother. The fungus can be transmitted during childbirth and during breastfeeding.

Thrush in infants causes poor sleep, tearfulness, and in some cases even refusal to eat. If you notice symptoms that resemble thrush in your newborn, especially if they cause discomfort, you should consult a doctor as soon as possible.

Thrush in infants

Karanashev Artur Adamovich
4.9
Urologist, Surgeon, Andrologist 33 years of experience

Consultation from 2100 rub.

Calling a doctor to your home

Provides treatment for andrological and urological diseases: medical support for married couples in pregnancy planning, treatment of male infertility, preparation for in vitro fertilization; treatment of prostatitis (abacterial, bacterial, congestive and other forms of the disease), including complex drug treatment, modern physiotherapy techniques, prostate massage; sexually transmitted infections; prostate adenomas; erectile dysfunction, organic and inorganic nature; accelerated, premature, painful ejaculation (ejaculation); acute and chronic inflammatory diseases of the upper, lower urinary tract, scrotal organs (pyelonephritis, cystitis, urethritis, orchitis, epididymitis); hormonal deficiency (androgen deficiency); urolithiasis (diagnosis, prevention, drug and surgical treatment, metaphylaxis of kidney stones, ureters, bladder). Performs all types of endoscopic and radiological examinations in urology: urethroscopy, cystoscopy, excretory urography, urethrography, cystography, retrograde ureteropyelography, diagnosis of vesicoureteral reflux. Operative urology-andrology: plastic surgery for short frenulum of the penis; circumcision - circumcision for phimosis; operations for paraphimosis - dissection of the pinching ring, circumcision; surgical treatment of premature ejaculation - microsurgical denervation of the glans penis; operations according to Winkelmann, Lord, Bergman operation for hydrocele of the testicular membranes; excision of testicular cysts, epididymis; surgical treatment of varicocele on the left (varicose veins of the left testicle) - Ivanissevich operation, Palomo operation, Marmara microsurgical operation; surgical treatment of erectile dysfunction - penile replacement; implantation of testicular prosthesis; Sapozhkov-Reich plastic surgery for oleogranuloma of the penis; Nesbitt operation for Peyronie's disease, a congenital curved penis; anterior, posterior, lower pyelolithotomy, subcapsular pyelolithotomy, nephrolithotomy for large kidney stones. ureterolithotomy for impacted, long-standing ureteral stones; plastic surgery of the ureteropelvic segment with stricture of the ureteropelvic segment, accessory vessel. nephrectomy, nephroureterectomy; nephropexy according to Rivoir-Pytel-Lopatkin for nephroptosis; trocar cystostomy, open cystostomy; transvesical adenomectomy for large adenomas; sling operations for stress urinary incontinence TVT-O. Endoscopic surgical treatment, transurethral endoscopic operations: transurethral resection of bladder formations; urethrotomy for non-extended urethral structures; internal drainage of the urinary tract - installation of a stent in the ureter for urolithiasis, ureteral strictures, renal colic; remote lithotripsy of kidney and ureteral stones; contact cystolithotripsy, lithoextraction - crushing and removal of bladder stones; contact ureterolithotripsy, lithoextraction - crushing and removal of ureteral stones. Performs shock wave therapy.

The doctor was attentive to my problem. Everything was explained and explained clearly

4.5

– Alexey
, July 26, 2021

Growing up healthy

The winter season is traditionally considered the peak incidence in children. Why is this happening?

Throughout the summer, our kids were isolated from large crowds of people. But now the time of vacations and holidays is coming to an end, parents return to work, children go to kindergarten and school, where the volume of harmful microorganisms and bacteria increases sharply, both quantitatively and qualitatively, and then it comes - a “family” micro-epidemic, which affects both children and adults.

Most often we get sick in the off-season and in winter - this fact is not surprising: a sharp change in weather conditions, increasing cold, air dried out by heating in living quarters, lack of vitamins, depletion of our “internal” reserves - all these factors together lead to weakening immune system. Add to this being in rooms with a large number of people, which, unfortunately, are not always regularly ventilated - and now we are already in the risk zone.

By themselves, hypothermia and a lack of vitamins can only reduce immunity, but the disease is caused by viruses and bacteria, which must be present in the body in a certain titer (concentration). This is a purely individual value, and if the titer is insufficient, the bacteria or virus will be quickly killed by our immune cells. If we talk about the children's immune system, it develops gradually, so it is more difficult for children to resist infection, and they are more often susceptible to diseases.

How to protect yourself and your child during this period? Fighting colds is a common task for the whole family, and there are a few simple rules that will reduce the risk of infection and help cope with the problem if one of your loved ones does get sick.

1. The most basic, but at the same time very important rule, which must be followed strictly and, in general, at any time of the year: wash your hands with soap after going out and immediately upon returning home.

2. Regularly ventilate the room you are in - this will help prevent the circulation of viruses in a closed environment. If we are talking about a nursery, then it is necessary to ventilate it at least 2-3 times a day for 10 minutes - in this case, of course, it is better to move the baby to another room while airing. If possible, leave rooms for airing when you go for a walk or shopping - when you return, the room will have purified air.

3. It would be a good idea to use humidifiers and air purifiers - today there is a wide selection of such devices in a variety of price categories, which will allow you to choose the best option from the point of view of the family budget.

4. Don’t forget to monitor your diet and your child’s diet - the diet should be as balanced as possible, taking into account vitamin deficiencies, and it must contain fruits and vegetables.

5. Walk more, remembering to dress for the weather. Walking has a positive effect on the body's condition, and the risk of contracting an infection in the fresh air is minimal.

6. If there is already a sick person in the house, try to ensure that he is isolated in a separate room, not forgetting about separate hygiene products (a towel, for example) and cutlery - this will help reduce the risk of spreading the infection.

7. During periods of seasonal epidemics of influenza and ARVI, as a preventive measure for diseases, it is recommended to rinse the nose in order to remove bacteria and other harmful microorganisms from the mucous membranes. You can use a seawater spray - it helps get rid of bacteria, has no side effects and is not addictive, and is effective both as a treatment for respiratory infections and for daily hygiene.

8. We begin to prepare for winter in the summer - a sufficient amount of vitamins and physical activity in the fresh air will help prepare the body for the autumn-winter season and increase its protective functions.

Symptoms of thrush in a newborn

The first and most obvious manifestation of childhood candidiasis is white spots on the tongue, palate and lips. It is very easy to distinguish such plaque from the plaque remaining after regurgitation - just rub it with a dry handkerchief. If the spot is easily erased, then you can calm down - the child is definitely not sick, since the gryuk plaque is much more difficult to erase, and after its removal, inflamed areas of the mucous membrane are usually exposed.

Also, signs of candidiasis in an infant may include:

• loss of appetite;
• anxiety;
• sleep disturbance.

Modern methods of treating onychomycosis

Onychomycosis is the most common nail disease. It has been established that 50% of cases of changes in the nail plates are associated with a mycotic infection. Epidemiological studies conducted in Russia and foreign countries have revealed a high incidence of onychomycosis, which ranged from 2 to 13% in the general population [1, 2, 3]. The risk of developing onychomycosis is highest in older patients. For example, in people over 70 years of age, the prevalence of onychomycosis of the feet can be 50% or higher [2, 4, 5]. It is believed that this is facilitated by the slow growth of nail plates and disorders of peripheral and main circulation in the elderly [6]. A high frequency of onychomycosis is also detected in patients with immunodeficiency conditions (including AIDS patients) and in patients with diabetes mellitus [6, 7, 8].

Often patients and some doctors perceive onychomycosis as an exclusively aesthetic problem. However, this is a serious disease that occurs chronically and in cases of immunodeficiency or decompensation of endocrine diseases can cause the development of widespread mycosis of the skin and its appendages. Onychomycosis is often accompanied by the development of severe complications, such as diabetic foot, chronic erysipelas of the extremities, lymphostasis, and elephantiasis [9, 10]. In patients receiving cytostatic or immunosuppressive therapy, the disease can cause the development of invasive mycoses. That is why treatment of onychomycosis is necessary and should be carried out in a timely manner [11].

Just a few decades ago, treatment of onychomycosis was labor-intensive, lengthy and unpromising. Medicines used to treat fungal diseases of the skin and its appendages were characterized by low effectiveness and high toxicity. To achieve a positive result, long-term treatment or an increase in the dose of drugs was required, which was often accompanied by severe complications. Some treatments were potentially life-threatening for patients. For example, X-ray therapy, the use of thallium and mercury led to the development of skin cancer, diseases of the brain and internal organs in patients.

The emergence of highly effective and low-toxic antimycotic drugs has greatly facilitated the treatment of fungal diseases of the skin and its appendages. However, the results of using new antimycotics were not satisfactory. Controlled clinical trials have shown that the effectiveness of systemic antimycotics after treatment is from 40 to 80%, and after 5 years - from 14 to 50% [12]. At the same time, the effectiveness of therapy for onychomycosis increases with the use of complex treatment methods, which involve the use of etiotropic drugs and agents that influence the pathogenesis [13]. Also, as a result of clinical trials conducted in European countries, it was found that the effectiveness of treatment of onychomycosis can be increased by an average of 15% with the combined use of systemic antimycotics and antifungal varnish containing amorolfine [14].

Treatment

For the treatment of onychomycosis, drugs are used that differ in chemical composition, mechanism of action, pharmacokinetics, and spectrum of antifungal activity. A common property for them is a specific effect on pathogenic fungi. This group consists of azoles (itraconazole, fluconazole, ketoconazole), allylamines (terbinafine, naftifine), griseofulvin, amorolfine, ciclopirox. To treat onychomycosis, systemic drugs are used that belong to the azole group - itraconazole, fluconazole, as well as to the allylamine group - terbinafine. Griseofulvin and ketoconazole are currently not prescribed for the treatment of onychomycosis due to low effectiveness and a high risk of adverse events. Varnishes and solutions containing amorolfine and ciclopirox are used as external agents for onychomycosis.

Allylamines are synthetic antimycotics. Allylamines primarily act on dermatomycetes, while they have a fungicidal effect. The mechanism of their action is to inhibit the enzyme squalene epoxidase, which takes part in the synthesis of ergosterol, the main structural component of the cell membrane of dermatomycetes. Allylamines include terbinafine and naftifine.

Allylamines are active against most dermatomycetes (Epidermophyton spp., Trichophyton spp., Microsporum spp., Malassezia spp.), the causative agent of chromomycosis and some other fungi.

Indications for the administration of terbinafine orally are onychomycosis, common forms of dermatomycosis of the skin, mycosis of the scalp, chromomycosis. Indications for external use of terbinafine and naftifine include limited skin lesions due to mycoses, pityriasis versicolor, and skin candidiasis. Terbinafine has high bioavailability and is well absorbed from the gastrointestinal tract regardless of food intake. In high concentrations, the drug accumulates in the stratum corneum of the skin, nail plates, hair, and is secreted with the secretions of the sweat and sebaceous glands. Absorption of terbinafine when applied topically is less than 5%, naftifine - 4-6%. The concentration of terbinafine and naftifine in the skin and its appendages significantly exceeds the MIC for the main pathogens of dermatomycosis. Correction of the terbinafine dosage regimen may be required when combined with inducers (rifampicin) or inhibitors of microsomal liver enzymes (cimetidine), since the former increase its clearance, and the latter reduce it.

As a result of numerous controlled multicenter comparative clinical trials, it was found that terbinafine is the most effective antimycotic in the treatment of onychomycosis [12] (Table 1).

Terbinafine is used for widespread skin lesions, onychomycosis, chromomycosis, in such cases terbinafine is prescribed orally. Terbinafine is the drug of choice in the treatment of onychomycosis, as it is most effective against the main causative agents of onychomycosis - dermatomycetes. Contraindications for the use of allylamines are allergic reactions to drugs of the allylamine group, pregnancy, breastfeeding, age under 2 years, liver diseases accompanied by impaired liver function (increased transaminases).

Azoles are the largest group of synthetic antimycotics. In 1984, the first systemic antifungal drug from the azole group, ketoconazole, was introduced into practice, in 1990, fluconazole, and in 1992, itraconazole.

Azoles used as systemic drugs have predominantly fungistatic activity. An important advantage of azoles over other drugs is their wide spectrum of antifungal activity. Itraconazole is active in vitro against most pathogens of onychomycosis - dermatomycetes (Epidermophyton spp., Trichophyton spp., Microsporum spp.), Candida spp. (C. albicans, C. parapsilosis, C. tropicalis, C. lusitaniae, etc.), Aspergillus spp., Fusarium spp., S. Shenckii, etc. Fluconazole is active against dermatomycetes (Epidermophyton spp., Trichophyton spp., Microsporum spp. .) and Candida spp. (C. albicans, C. parapsilosis, C. tropicalis, C. lusitaniae, etc.), but does not affect Aspergillus spp., Scopulariopsis spp., Scedosporium spp.

The pharmacokinetics of different azoles is different. Fluconazole (90%) is well absorbed from the gastrointestinal tract. For good absorption of itraconazole, a normal level of acidity is necessary. If a patient taking these drugs has low acidity, their absorption decreases and, consequently, their bioavailability decreases. The absorption of itraconazole solution is higher than that of itraconazole capsules. Itraconazole capsules should be taken with food, and Itraconazole solution should be taken on an empty stomach.

Itraconazole is metabolized in the liver and excreted from the body through the gastrointestinal tract. It is also secreted in small quantities by the sebaceous and sweat glands. Fluconazole is partially metabolized and is mainly excreted unchanged by the kidneys (80%).

Itraconazole interacts with many drugs. The bioavailability of ketoconazole and itraconazole decreases when taking antacids, anticholinergics, H2 blockers, proton pump inhibitors, and didanosine. Itraconazole is an active inhibitor of cytochrome P450 isoenzymes and can alter the metabolism of many drugs. Fluconazole affects drug metabolism to a lesser extent. It is unacceptable to take azoles with terfenadine, astemizole, cisapride, quinidine, as deadly ventricular arrhythmias may develop. Concomitant use of azoles and oral antidiabetic drugs requires constant monitoring of blood glucose levels, as hypoglycemia may develop. Taking indirect anticoagulants of the coumarin and azoles group may be accompanied by hypocoagulation and bleeding; therefore, hemostasis control is necessary. Itraconazole can increase the blood concentration of cyclosporine and digoxin, and fluconazole - theophylline and cause the development of a toxic effect. Dose adjustments and constant monitoring of drug concentrations in the blood are required. The combined use of itraconazole with lovastatin, simvastatin, rifampicin, isoniazid, carbamazepine, cimetidine, clarithromycin, erythromycin is contraindicated. Fluconazole should not be used with isoniazid and terfenadine.

Itraconazole is used for dermatomycosis (athlete's foot, trichophytosis, microsporia), pityriasis versicolor, candidiasis of the skin, nails and mucous membranes, esophagus, vulvovaginal candidiasis, cryptococcosis, aspergillosis, phaeohyphomycosis, sporotrichosis, chromomycosis, endemic mycoses, for the prevention of myco call for AIDS.

Fluconazole is used for the treatment of generalized candidiasis, all forms of invasive candidiasis, including in immunocompromised patients, genital candidiasis, candidiasis of the skin, its appendages and mucous membranes. Recently, due to its safety and good tolerability, fluconazole is increasingly used for the treatment of patients with dermatomycosis with damage to both the skin and its appendages (nails and hair).

Amorolfine is part of a varnish used to treat onychomycosis. The mechanism of action of amorolfine is to disrupt the synthesis of ergosterol, the main component of the cell membrane of the fungus. It has fungistatic and fungicidal effects. Has a wide spectrum of action. The concentration of amorolfine in the nail plate significantly exceeds the MIC for the main pathogens of dermatomycosis for 7 days. Therefore, the drug can be applied no more than 1–2 times a week, which makes its use economically profitable. Contraindications: allergic reactions to amorolfine, infancy and young children. Varnish as monotherapy is prescribed when no more than 1–3 nail plates are affected and no more than 1/2 of the area from the distal end is affected. Amorolfine can also be used in combination with systemic antimycotics for more widespread nail lesions (Table 2).

Ciclopirox has a fungistatic effect. Active against dermatomycetes, yeast-like and filamentous fungi, molds, as well as some gram-negative and gram-positive bacteria. Ciclopirox (varnish) is used as monotherapy when no more than 1-3 nail plates are affected by no more than 1/2 of the area from the distal end. Ciclopirox can also be used in combination with systemic antimycotics for more widespread nail damage. Contraindications: allergic reactions to ciclopirox, infancy and early childhood, pregnancy and lactation.

List of recommended laboratory tests when prescribing systemic antifungal drugs.

• Clinical blood test.
• General urine analysis.
• Biochemical blood test (ALT, AST, bilirubin, creatinine).
• Ultrasound of the abdominal organs and kidneys (preferred).
• Pregnancy test (preferred).

Treatment of underlying diseases. The effectiveness of the use of antimycotics increases with the correction of pathological conditions that contribute to the development of onychomycosis. Before starting antimycotic therapy in patients with somatic, endocrine, neurological diseases, and with circulatory disorders in the extremities, it is necessary to conduct an examination to identify the main symptom complex that contributed to the development of dermatomycosis. Thus, the main objectives of pathogenetic therapy are to improve microcirculation in the distal parts of the extremities, venous outflow of the extremities, normalize the level of thyroid-stimulating hormones in patients with thyroid diseases, carbohydrate metabolism in patients with diabetes mellitus, etc. As a result of many years of research conducted at the Military Medical Academy and St. Petersburg Medical Academy of Postgraduate Education, it has been established that one of the main causes of the development of dermatomycosis is disorders of the pituitary-hypothalamus-gonadal system. This leads to circulatory disorders in the distal extremities, microcirculation disorders, and peripheral innervation. A set of measures aimed at correcting these disorders includes acupuncture, transcranial electrical stimulation of the subcortical centers of the brain, and the prescription of drugs that correct the functioning of the sympathetic and parasympathetic autonomic nervous system. All this makes it possible to achieve a faster clinical effect in the treatment of dermatomycosis. It is advisable to prescribe pathogenetic therapy in patients with dermatomycosis with underlying diseases before the start of etiotropic treatment and continue it during the entire course of taking antifungal drugs.

Symptomatic therapy of dermatomycosis, aimed at reducing subjective complaints of patients and objective manifestations of the disease, cannot replace etiotropic therapy. However, its use in combination with antifungal drugs makes it possible to quickly improve the condition of patients, reduce the feeling of discomfort and eliminate cosmetic defects. With onychomycosis, the greatest concern for patients is caused by deformed, significantly thickened (hypertrophied) nail plates - onychogryphosis. To correct this condition, hardware pedicure is used. Using a device that resembles a dental turbine, in a short period of time, altered areas of the nails, hyperkeratotic areas, horny masses from the skin, and calluses are mechanically removed. In this case, there is no trauma to the nail matrix, and the patient remains functional after the procedure.

For limited damage to nails (no more than 3 nail plates and no more than 1/2 in area from the distal edge), topical preparations are used. It is recommended to begin treatment by cleaning the affected area of ​​the nail plate using the Mycospor set, hardware pedicure or keratolytic agents. Next, antifungal drugs are applied to the affected nail plate. An amorolfine solution containing ciclopirox is applied to the nail plate 1–2 times a week. Before applying the varnish, you do not need to first clean the nail plate of previous layers of the preparation. The varnish is applied daily until the healthy nail plate grows completely. On the 7th day, the nail plate is cleaned using any cosmetic nail polish remover. There are conflicting reports in the literature about the effectiveness of this treatment method. The percentage of cure for patients is indicated from 5–9 to 50%.

In case of widespread damage to the nail plates on the fingers, a complex of treatment measures should include the prescription of a systemic antimycotic, cleaning of the nails and external therapy with antifungal drugs. In order to prevent re-infection, it is necessary to treat the patient’s gloves and disinfect personal hygiene items (washcloths, towels, nail files, graters and scrapers for treating skin and nails).

The drug of choice for the treatment of onychomycosis of any localization is terbinafine. It is prescribed to adults and children weighing more than 10 kg, 250 mg per day for 6 weeks. Children over 2 years old weighing less than 20 kg are prescribed terbinafine at the rate of 67.5 mg/kg per day, from 20 to 40 kg - 125 mg/kg per day for 6 weeks. Reserve drugs are products containing itraconazole and fluconazole. Itraconazole is used in two regimens: 200 mg daily for 3 months or 200 mg twice daily for 7 days in the first and fifth weeks from the start of therapy. Itraconazole is not prescribed for the treatment of onychomycosis in children. Fluconazole is recommended to be taken 150 mg once a week for 3–6 months.

Carrying out complex therapy, consisting of taking a systemic antimycotic, cleaning nails, local use of antifungal drugs, as well as anti-epidemiological measures, ensures high efficiency in curing onychomycosis of the feet. Terbinafine is prescribed to adults and children weighing more than 10 kg, 250 mg per day for 12 weeks or more. For children over 2 years old weighing less than 20 kg, the drug is prescribed at the rate of 67.5 mg/kg per day, from 20 to 40 kg - 125 mg/kg per day for 12 weeks. Fluconazole is recommended to be used at a dose of 150–300 mg once a week for 6–12 months. Itraconazole is used in two regimens: 200 mg daily for 3 months or 200 mg twice daily for 7 days in the first, fifth and ninth weeks. If the big toes are affected, it is recommended to carry out the 4th course of pulse therapy in the thirteenth week from the start of therapy. Itraconazole is not used for the treatment of onychomycosis in children.

The criteria for mycological cure of onychomycosis are negative results of microscopic and cultural examination of the nail plate. After treatment with itraconazole and terbinafine, healthy nail plates do not grow back completely, so complete clinical recovery can be observed only 2–4 months after the end of taking antifungal drugs.

Literature

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14. Baran R., Feuilhade M., Datry A. et al. A randomized trial of amorolfine 5% solution nail lacquer combined with oral compared with terbinafine alone in the treatment of dermatophytic toenail onychomycosis affecting the matrix region //Br J Dermatol. 2000; 142:1177–1183.

L. P. Kotrekhova , Candidate of Medical Sciences, Associate Professor K. I. Raznatovsky , Doctor of Medical Sciences, Professor N. N. Klimko , Doctor of Medical Sciences, Professor of St. Petersburg Medical Academy of Postgraduate Education, St. Petersburg