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Terbinafine resistant fungal infection?

Discussion in 'General Issues and Discussion Forum' started by Ian Drakard, Sep 6, 2012.

  1. Ian Drakard

    Ian Drakard Active Member

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    Hi all

    Would like some opinions on what options would be suitable for a patient.

    A 32 year old woman with a long history of tinea pedis and onychomycosis with several nails involved (previously confirmed on culture) She has had 12 months on oral terbinafine which while producing a definite change in nail growth has not apparently resolved the infection. No picture yet I'm afraid (sorry mortal sin on dermatology thread :eek: ) but the nails do not look like 'normal' post infection nail damage- definitely still look fungal with changes in nail quality.

    Both GP and myself are reluctant to continue with terbinafine, as aside from any potential side effects it would seem somewhat pointless if it is not working.

    So questions are: what are current thoughts on prevalence of terbinafine resistance and is this often tested for in these cases?

    And out of the newer antifungals what would be other medications of choice?

    Any thoughts on this would be appreciated

  2. Admin2

    Admin2 Administrator Staff Member


    Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, fungal nail infections, and ringworm including jock itch and athlete's foot.[1][2][3] It is either taken by mouth or applied to the skin as a cream or ointment.[1][4] The cream and ointment are not effective for nail infections.[5]

    Common side effects when taken by mouth include nausea, diarrhea, headache, cough, rash, and elevated liver enzymes.[1] Severe side effects include liver problems and allergic reactions.[1] Liver injury is, however, unusual.[6] Use during pregnancy is not typically recommended.[1] The cream and ointment may result in itchiness but are generally well tolerated.[2] Terbinafine is in the allylamines family of medications.[1] It works by decreasing the ability of fungi to make sterols.[1] It appears to result in fungal cell death.[7]

    Terbinafine was discovered in 1991.[8] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[9] The wholesale cost in the developing world is about 2.20 USD for a 20 g tube.[10] In the United States the price in 1999 was $547 for a 12-week course; this fell to $10 by 2015, after the patent had expired.[11] In 2016 it was the 279th most prescribed medication in the United States with more than a million prescriptions.[12]

    1. ^ a b c d e f g "Terbinafine Hydrochloride". The American Society of Health-System Pharmacists. Archived from the original on 21 December 2016. Retrieved 8 December 2016.
    2. ^ a b "Lamisil 1% w/w Cream - Summary of Product Characteristics (SPC) - (eMC)". electronic Medicines Compendium (eMC). 17 March 2016. Archived from the original on 20 December 2016. Retrieved 17 December 2016.
    3. ^ Crawford, F (20 July 2009). "Athlete's foot". BMJ Clinical Evidence. 2009. PMC 2907807. PMID 21696646.
    4. ^ "19th WHO Model List of Essential Medicines (April 2015)" (PDF). WHO. April 2015. Archived (PDF) from the original on 13 May 2015. Retrieved 10 May 2015.
    5. ^ Hamilton R (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 180. ISBN 978-1-284-05756-0.
    6. ^ Yan, J; Wang, X; Chen, S (August 2014). "Systematic review of severe acute liver injury caused by terbinafine". International Journal of Clinical Pharmacy. 36 (4): 679–83. doi:10.1007/s11096-014-9969-y. PMID 24986266.
    7. ^ "Terbinafine". www.drugbank.ca. Retrieved 2017-11-14.
    8. ^ Ravina E (2011). The Evolution of Drug Discovery: From Traditional Medicines to Modern Drugs. John Wiley & Sons. p. 90. ISBN 978-3-527-32669-3. Archived from the original on 2016-12-20.
    9. ^ "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. Retrieved 8 December 2016.
    10. ^ "Terbinafine". International Drug Price Indicator Guide. Archived from the original on 6 April 2017. Retrieved 8 December 2016.
    11. ^ Mikailov A, Cohen J, Joyce C, Mostaghimi A (2015). "Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis". JAMA Dermatology. 152 (3): 1–6. doi:10.1001/jamadermatol.2015.4190. PMID 26716567.
    12. ^ "The Top 300 of 2019". clincalc.com. Retrieved 22 December 2018.
  3. blinda

    blinda MVP

    Hmmm :butcher:

    Off the top of my head, as i`m a bit pushed for time, could be candida residue which often accompanies dermatophyte infection. Terbinafine isn`t so effective for that. Maybe try an `azole` such as Itraconazole?

  4. blinda

    blinda MVP

    Afterthought: Do you have a copy of the lab report, isolating the cultured pathogen?
  5. Ian Drakard

    Ian Drakard Active Member

    Cheers Bel. That sounds plausible and could be consistent with the appearance. Will try and get a picture in next couple of weeks-promise :D

    No- but can try to obtain it from GP assuming they have it properly recorded. What did you have in mind?
  6. blinda

    blinda MVP

    Pathogen specific meds. Labs vary a great deal in detailing species identified by microscopy and culture, so I would be interested to see what they reported.
  7. jos

    jos Active Member

    So when you say 'a long history of tinea pedis'- do you mean on the skin also? If so, has that cleared up with the terbinafine?
    Just wondering if she may have another nail condition in conjunction with the fungal, eg psoriasis (or candidal as mentioned above). Maybe the fungal component was cleared up but not the psoriasis...?
  8. Craig Payne

    Craig Payne Moderator


    PODKMM Active Member

    I'm with Jos, could be Psoriatic nails?????
  10. Seamus McNally

    Seamus McNally Active Member

    Interesting the positive vibe about the efficacy of treatment in general. The more I go on the more pessimistic I become about the outcomes of any treatment. Indeed this state of mind, if my mind is not playing tricks, has been reinforced by previous threads on the Arena? Anyways, the pessimism is related to the potential systemic nature of the problem, e.g. circulatory problems, the inability of the matrix to nourish the nail due to damage. Far from looking to simply bang a depressing tune on my drum, I am hoping that I can be convinced by colleagues world wide (the great strength of the Arena) that there is great cause for optimism.....please.
  11. Craig Payne

    Craig Payne Moderator

    What are the main risk factors for onychomycosis and tinea?
    How does any of the typical treatments (eg terbinafine) reduce those risk factors?
  12. Seamus McNally

    Seamus McNally Active Member

    In a nutsheel! thanks Craig.
  13. Jeff S

    Jeff S Active Member

    I send my nail specimins to BAKO labs where they perform both a biopsy on the nail plate and KOH w/fungal culture. The biopsy tells me that I may be dealing with a chronic microtrauma induced nail pathology; the culture will tell me if it is a dermatophyte or other fungal pathogen not responsive to lamisil or both. If both - then we have a dilema in that the nail will never look normal again despite getting a clinical cure. On the other hand, you may get bread/cheese mold growing in the nail and require alternative topical meds (itraconazole topical) vs. Laser or both. I guess my point is that prior to any tx, the nail get biopsied and cultured. (all this for toenail fungus....I just shake my head sometimes..)


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