SA

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Nail Fungus Treatments

Nail fungus infections are difficult to treat

because microorganisms live under the
nail and are difficult to eradicate. Treatments require months to years for resolution. Left alone they will not go away
and generally spread to other nails. Oral
medications are not always the best choice
for a patient who may have alcoholism
or who has liver damage due to a disease,
as these drugs can be highly toxic to the
liver. Topical treatments bypass the liver
metabolism and are applied directly to the
source (nail) of the infection in the form of
a nail paint or lacquer.

NUMBER 4

cream preparation that podiatrists, hand

surgeons, dermatologists, and family
medicine practitioners have shown success
when prescribed:
Terbinafine 1% in Dimethyl Sulfoxide, USP
Terbinafine 1.67% in Dimethyl Sulfoxide, USP
Terbinafine 2.5% Tincture
Ketoconazole 2% and Ibuprofen 2%
in Dimethyl Sulfoxide, USP
Fluconazole 16-mg/mL in Dimethyl
Sulfoxide, USP
Thymol 4% in Isopropyl Alcohol
Thymol 0.2% in Isopropyl Alcohol
Fluconazole, Tea Tree Oil, and Ibuprofen in Dimethyl Sulfoxide, USP
Clotrimazole 2%, Ibuprofen 2%, and
Tea Tree Oil 5% in Dimethyl Sulfoxide, USP
Itraconazole in place of clotrimazole,
fluconazole, ketoconazole or terbinafine in any of the formulas above
Butenafine Hydrochloride 2% and
Tea Tree Oil 5% in a cream base

LE

Not all of us have nails that are just alike.

Most nails infected with a fungus are hard,
flaky, discolored, and uncomfortable and
may require different strengths of the medication in different penetration enhancing
bases in order to get rid of the infection.
There are many antifungal medications
available commercially for oral therapy
but only a few available in commercially
manufactured topical products resulting
in the need for individualized therapy to
be compounded.

VO L U M E 1 0

During treatment, it is important to soak

the nail(s) and keep them short by clipping
or filing off loose nail material at least
weekly. Topical treatments should be applied to the nail(s) and the skin under and
around the nail(s) and allowed to dry for at
least 1 minute before putting on socks or
stockings. This medication should not be
applied to any other parts of the patients
body. It is good to clean the nail weekly
with a cotton ball or tissue that is soaked
with alcohol.
Here are 2 case reports of the treatment
of nail fungus with compounded topical
anti fungal preparations rather than commercial oral treatments. Commercial oral
treatments can have many side effects that
can be even more pronounced due to the
long-term therapy needed.

Here is a list of these plus other topical

nail solution preparations and one topical

Although no documented studies support

this, 6% ibuprofen added to the solutions
has been reported to help soften the nail.

Resources:
Syed TA, Qureshi ZA, Ali SM et al.
Treatment of toenail onychomycosis
with 2% butenafine and 5% Malaleuca
alternifolia (tea tree) oil in cream. Trop
Med Intl Health 1999; 4: 284-287.

The information for this article was compiled by various subscribers of

IJPCs Compounders Network List between 2003-2005.

Case Report:
Terbinafine 1.67% Topical
Nail Solution for
Onychomycosis

SA

Steve Toney, RPh

Erin King, CPhT

in a 1% concentration is recommended for the treatment of nail

fungus. Product information on the topical forms of terbinafine does
not include a warning about the possibility of hepatic failure.1 The
patients physician asked whether we could compound a formulation
of terbinafine in a vehicle that could penetrate the nail and skin, and
we recommended terbinafine 1.67% topical nail solution, which the
physician prescribed. The patient was instructed to apply the solution
twice a day on top of and under the nail after washing his hands with
antibacterial soap for 1 minute.

MyrtleTowne Pharmacy
Henderson Center Pharmacy
Eureka, California

A 55-year-old man was diagnosed as

having a fungal infection (onychomycosis) on the thumb of his right hand.
He saw his physician, who wanted to
initiate therapy with terbinafine (Lamisil), an orally administered treatment.
The dose of terbinafine usually used
to treat onychomycosis of the fingernail is one 250-mg tablet daily
for 6 weeks. This patient has a high level of alcohol intake socially;
his physician is aware of this. However, terbinafine oral therapy has
been associated with rare cases of liver failure that have occurred in
individuals with and without preexisting liver disease. The severity
of these hepatic events or their outcome may be worse in patients
with active or chronic liver disease.1 The physician discussed his concerns with the patient, who asked if there were alternate routes of
administration. Neither the cream nor the gel form of terbinafine

After 4 weeks of therapy, signs of improvement were evident: The

nail had begun to reattach to the nail bed. At that time, treatment
was interrupted for 4 weeks but was then reinitiated. Two weeks after
therapy was reinitiated the nail had completely reattached to the nail
bed, and no signs of a fungal infection remained. The treatment was
considered successful and was discontinued.
References

1. [No author listed.] Drug Facts and Comparisons. St. Louis, MO: Facts and
Comparisons, Inc.; 2001.

Suggested reading

1. Buck DS, Nidorf DM, Addino JG. Comparison of two topical preparations for the treatment of onychomycosis: Melaleuca alternifolia (tea tree)
oil and clotrimazole. J Fam Pract 1994; 38: 601-605.
2. Castle SS, Duncan MC, Allman JG. Onychomycosis therapy: Continuing
education. Americas Pharmacist 2001; July: 45-52.

Reprinted from November 2001 RxTriad.

Tea Tree Oil

MP

Tea tree oil is an essential volatile oil from the tea tree plant, Malaleuca alternifolia, said to have antiseptic properties. It is used for insect bites,
nail fungus infections, acne, vaginal fungal infections, as a deodorant, mouthwash, and a shampoo.
Read more about this essential volatile oil in this article:
Bottoni DJ. Tea Tree Oil. IJPC 1998; 2(4): 284-285.

Case Report:
Ketoconazole 2% and Ibuprofen 2% in Dimethyl
Sulfoxide, USP, Topical Nail Solution for
Onychomycosis
Barb Anliker, RPh
Kathy Jackson, Pharmacy Technician

into a stable solution, she prescribed a compounded nail solution containing ketoconazole 2% and ibuprofen 2% in dimethyl sulfoxide,
USP, 15 mL of which was dispensed in a brush applicator bottle of
the type that contains nail polish. The patient was instructed to use
the brush to apply the solution twice daily on top of and under each
affected toenail and to the surrounding tissue.
This patient was very compliant. After 6 weeks of the topical therapy
described, signs of improvement were evident; the nail had begun to
reattach to the nail bed. The patient was to continue that treatment
until each toenail had completely reattached to its nail bed.

Northwest Iowa Compounding

Emmetsburg, Iowa

Luan Montag, Physician Assistant-Certified (PA-C)

Patricia A. Banwart, DO

References

West Bend Medical Clinic, West Bend, Iowa

LE

A 47-year-old white woman who loved to wear sandals had been embarrassed to do so for several years because her toenails had become
hard, yellow, and detached from the nail bed. Before coming to
our clinic, she had been diagnosed as having a bilateral fungal
infection (onychomycosis) of the great toenails and was treated
with terbinafine (Lamisil) and ketoconazole (Nizoral), both of
which were administered orally. Neither of these therapies was
effective in eliminating the infection. In December 2001, she
sought treatment from a member (PB) of the staff at the West
Bend Medical Clinic. The patient was treated with three 1-week
courses (pulse dosing) of itraconazole (Sporanox)1 (2 capsules
[100 mg per capsule] twice daily). Each week of therapy was
followed by a 3-week drug-free interval. At the conclusion of
that protocol, the patient was to return to the clinic for further
evaluation.

1. Olin BR, ed. Drug Facts and Comparisons. 56th ed. St. Louis, MO: Facts
and Comparisons 2002: 1448-1454.
2. Toney S, King E. Terbinafine 1.67% topical nail solution for onychomycosis. RxTriad 2001; November.

When the patients toenails were reevaluated 3 weeks after she

had taken the last dose of itraconazole, it was determined that
oral treatment with that drug had been ineffective. One of the
staff members (LM) at the West Bend Medical Clinic had read
about a compounded terbinafine preparation that was applied
topically to fingernails and toenails and that had been effective in treating onychomycosis in several patients whose disease
was refractory to conventional therapy.2 Our patient stated that
orally administered ketoconazole had produced the greatest
amount of improvement in her onychomycosis. When LM had
determined that our pharmacy could compound ketoconazole

RxTriad-A publication of the International Journal of Pharmaceutical Compounding. 2007 IJPC. All rights reserved.