Onychomycosis therapy with Terbinafine, Ciclopirox and time controlled application of 3% hydrogen peroxide (H2O2) and 1% formaldehyde solutions

Günter Valet

Summary: Onychomycosis is frequentlys difficult to cure by locally applied antimycotics and may require systemic treatment (Terbinafine) that is sometimes accompanied by significant side effects for the entire organism such as heart problems or substantial hair loss. Consecutive local application of 1% Terbinafine and 1% Ciclopirox ointments every 24h slows fungus cell wall synthesis and blocks the katalase enzyme of fungus spores. This enzyme protects spores from oxidative attack like by H2O2 from granulocytes or macrophages. The local application of a 3% H2O2 solution 15min prior to the next antimycotic treatment meets spores with blocked katalase and inactivates them, while the additional application of a 1% formaldehyde solution 5 min later blocks free amino groups of protein amino acids in fungus cells (fixation) but also in keratin molecules of superficial skin cells (food deprivation) as efficient antifungus measure. Six weeks therapy followed by 8 weeks further treatment for spore eradication were in the authors experience curative without relapse.

Anamnesis and therapy: A never before observed increase of foot perspiration odor was observed by the end of December 2022. Inspection of the toenails revealed a yellowish around 3-5mm broad area on the nail of the left big toe extending from the right sided nail bed to the nail end. The right big toe was affected in the distal half of the nail suggesting altogether a nail mycosis of unknown origin. There had been no contact with typical infection sites like public swimming pools, saunas, hotels or camping grounds for more than a year prior to the infection. The own wife remained unaffected. Both nails were carefully grinded off with grain size 40 sandpaper as much as possible in the affected areas for better nail penetration of the antimycotic ointment (fig.1 right). Grinding was repeated every week during the first month of therapy to minimize remaining fungus affected nail areas. Therapy was similar as for the earlier treated tinea corporis of the lower leg . Affected nails were treated 15min prior to the every 24h scheduled application of Terbinafin and Cicloprirox

   

3% H2O2- and 1% formaldehyde solutions were applied with separately wetted toilette paper swabs that were twice folded lengthwise and once across (fig.2 top left) to avoid skin contact by well adapting to the nail form (Abb.2 top right). The wetted toilette paper swabs were placed as close as possible to the nail fold. A too close position manifests after around 5sec by local irritation, disappearing after a few minutes when more precisely positioned. The imprgnated swabs were applied for 3min. This softened the nails, favoring drug molecule penetration. Sandpaper with corn size 40 (fig.2 bottom left) diminished the mass of potentially surviving fungus cells. Terbinafine (1%) and Ciclopirox (1%) ointments were subsequently applied (fig.2 bottom right) to lower growth speed and to block the H2O2 degrading spore enzyme katalase. This permitted their oxidative destruction by 3% H2O2 solution. Spores as robust survival entity are formed in case of lack of food or growth inhibition by adverse environment conditions.

 
 

Initially nothing visible happened after therapy start. The more intensive than usual odor of foot perspiration disappeared after 6 weeks of therapy indicating fungus cell destruction. Therapy was continued for 8 more weeks to securely inactivate viable spores. Total therapy time was 14 weeks with 3mm of heathy nail grown after 12 weeks (fig.1 right between the white lines).