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Generic Nizoral (Ketoconazole) - Editorial Review

Generic Nizoral Is Effective In Dealing With Onychomycosis

It is a common infectious toenail disease which shows an increased prevalence with age. It affects 15% of the general population and 40% of the individuals over the age 60. Onychomycosis accounts for approximately 50% of the onychopathies. According to an epidemiological survey, called Achilles project in Europe, revealed the fact that 27% of the people suffered from onychomycosis. The increased prevalence can be attributed to tight shoes, increased number of immunosuppressed individuals and the increased use of communal locker rooms.
generic Nizoral or Ketoconazole is effective in dealing with onychomycosis.

It is caused by 3 major groups of fungi:

1. Dermatophyte fungi
2. Non- dermatophyte fungi
3. Yeasts

85% of the infections are due to dermatophyte fungi, whereas around 15% are due to non-dermatophytes and less than 5% is caused by yeasts. The non dermatophytes are predominantly seen antecedently diseased or aged nails. Yeast infections are mostly due to Candida infections which usually occur in conjunction with chronic mucocutaneous candidiasis. Tinea unguium strictly refers to the dermatophyte infection of the nail plate.

Clinical features depend on the type of nail invasion. Based on the clinical presentations, it is classified as:

1. Distal subungual onychomycosis
2. Proximal subungual onychomycosis (PSO)
3. White superficial onychomycosis (WSO)
4. Candidial onychomycosis

It begins as Tinea pedis and may extend to nail bed, where eradication becomes more difficult. Then the nail bed becomes a reservoir for recurrent skin infections mainly in hot and humid environment created by occlusion or tropical climates.

Clinical findings vary with the type of infection. The distal subungual onychomycosis begins with the invasion of stratum corneum of the hyponychium, and distal nail bed, forming a whitish to brownish-yellow opacification at the distal edge of the nail. The infection spreads proximally up the nail bed to the ventral nail plate. In response to this infection, there is a hyper proliferation of the nail bed which produces subungual hyperkeratosis. There is progressive invasion of the nail plate leading to a condition known as dystrophic nail plate.

PSO begins as a white to beige opacity on the proximal nail plate with an increase in the opacity affecting the entire toe nail. It further produces subungual hyperkeratosis, leuconychia, proximal onycholysis and destruction of the entire nail unit.

In WSO, there is a direct invasion of dorsal nail plate resulting in white to dull yellow sharply bordered patches anywhere on the surface of the toe nail. Candida infection invades via the hyponychial epithelium to affect the entire thickness of the nail plate.

A similar presentation can be seen in psoriasis and hand eczema that needs to excluded before confirming the fungal infection by doing KOH examination, nail biopsy and fungal culture on SDA with or without antimicrobials.

The cure rates for toe nail onychomycosis is 80% with systemic Antifungals with a recurrence rate of 20%. It can be effectively treated by both topical and systemic drugs. Topically ciclopirox and amorolfine can be used whereas Terbinafine, Itraconazole and Flucanazole can be given systemically. Personal hygiene is also essential for successful treatment.

Generic Nizoral In The Treatment Of Oral Thrush

It is fungal infection caused by Candida albicans. Though immuno suppression is the main reason for acquiring oral thrush, yet there are a number of factors that are predisposing to Candida infections. It can be due to mechanical factors like; trauma, local occlusion, dentures, occlusive dressings or garments, obesity; Nutritional factors like avitaminosis, iron deficiency and generalized malnutrition; Physiologic alterations like extremes of age, pregnancy and menses; systemic illnesses like Down syndrome, acrodermatitis enteropathica, malignancy, endocrine disease, uremia and immunodeficiency, ; and Iatrogenic causes like indwelling catheters, X-ray radiation, IV lines and medications like steroids.

All these factors mainly increase the pathogenicity of the Candida albicans which would otherwise be normal commensals of the oral cavity.

The most common form of oral thrush is acute pseudomembranous type which almost 1/3 of the HIV patient develop and over 90% of people with acquired immunodeficiency syndrome. It appears as discrete white patches mainly on the buccal mucosa, tongue, palate and Gingivae. This friable pseudo membrane resembles milk curds which consist of desquamated epithelial cells, fungal elements, inflammatory cells, and fibrin and food debris. Scraping the patches exposes a bright erythematous surface underneath.

Acute atrophic candidiasis or erythematous candidiasis commonly occurs after sloughing of the thrush pseudo membrane. It is mainly associated with broad spectrum antibiotic therapy, glucocorticoid use and HIV. It commonly occurs on the dorsal surface of the tongue. It may be either symptomatic or asymptomatic. Burning sensation or pain is the most common symptom.

Chronic atrophic candidiasis also known as denture stomatitis is seen in 24-60% of people with dentures. Females are more affected than male. Clinically it presents as chronic erythema and edema of palatal mucosa that contacts the dentures and angular cheilitis. Dentures actually cause low grade trauma and occlusion which predisposes to candidal colonization and infection.

Generic Nizoral or Ketoconazole is also used in the treatment of Oral Thrush.

Candidal chielosis, also known as angular cheilitis, is called as perleche and is characterized by erythema, fissuring, maceration and soreness at the angles of the mouth. In the young it is commonly seen among habitual lip lickers whereas in the elderly, it is associated with sagging skin at the oral commissure. Predisposing factors for this condition includes loss of dentition, poor fitting dentures, and malocclusion and riboflavin deficiency.

A thrush like condition can be seen in other diseases like lichen planus, herpetic infections, erythema multiformae, and pernicious anemia. So a careful history, clinical diagnosis and lab diagnosis is essential to rule out these differential diagnoses.

Once confirmed about the oral thrush, the etiology must be found out for complete treatment. Say for instance, for a person with HIV infection suffering from thrush, ART should be given along with this antifungal treatment. Or else the infection would recur if you fail to treat the HIV infection. In uncomplicated cases of thrush, nystatin suspensions should be given 400,000 to 600,000 units 4 times/day. Or it can be treated with Clotrimazole touches 10 mg dissolved in mouth 5 times/ day. In recurrent cases, oral azoles can be given like Flucanazole, Itraconazole, etc.