Itraconazole Pulse Therapy Research Articles

Efficacy of topical trichloroacetic acid 100% either alone or combined with topical tioconazole 28% versus systemic itraconazole in the treatment of onychomycosis.

Treatment of onychomycosis is still challenging and warrants the development of new treatment strategies. Different trials were conducted to increase the penetration and efficacy of topical antifungals aiming at finding an alternative treatment especially when systemic antifungals are contraindicated. To evaluate the efficacy of trichloroacetic acid (TCA) 100% either alone or combined with topical tioconazole 28% versus itraconazole pulse therapy in the treatment of onychomycosis. Forty-five patients with onychomycosis were divided into three groups: group (A) treated by topical TCA 100% for 12 sessions, group (B) treated by TCA 100% for 12 sessions combined with topical tioconazole 28% for 18 weeks and group (C) treated by itraconazole (400 mg/day for 1 week/month for 4 months). TCA 100% combined with topical tioconazole 28% showed the highest therapeutic response; however, the difference between the groups was statistically insignificant. Mycological cure (negative culture) was reported in 66.7% of group B versus 60% of group A and 40% of group C at the 20 week. TCA 100% is an effective and safe treatment option for onychomycosis especially when combined with antifungals. This modality is promising in the treatment of onychomycosis especially with the increased resistance to different antifungals.

Justified use of 5 % amorolfine nail lacquer, in the treatment of toe onychomycosis

The article presents the description of three clinical cases of the successful treatment of toe onychomycosis and athlete's foot of various etiologies using 5% amorolfine antifungal nail lacquer. The first case: a 31-year-old woman was diagnosed with white superficial onychomycosis of great toe caused by T.rubrum. The treatment with 5 % amorolfine once a week for 6 months resulted in full recovery. The initiation of long-term preventive therapy with 5 % amorolfine lacquer prevented from recurrent toe onychomycosis.The second case: a 42-year-old woman developed onychomycosis after the application of decorative coating on her nails; onychomycosis was caused by Scopulariopsis brevicaulis. She was treated with itraconazole pulse therapy and 5% amorolfine lacquer. She fully recovered.
 The third case: a 65-year-old man with total onychomycosis of 10 toes developed the skin mycosis of the left foot and lower third of the leg. He was prescribed a therapy with sertaconazole cream and 5 % amorolfine lacquer. The use of 5 % amorolfine lacquer was continued to prevent from recurrent dermatomycosis.Thus, the above mentioned cases are a good example of the advantages of using 5% amorolfine lacquer in the treatment of most toe onychomycosis types caused by any pathogens (dermatophytes, yeasts or molds).

The Domestic Isolation of Terbinafine- and Itraconazole-Resistant Trichophyton indotineae in Chinese Mainland.

Trichophyton indotineae, a new species of dermatophytes, has become a significant concern in treating dermatophytosis due to the high level of terbinafine resistance reported in India and even worldwide. This study aimed to report the terbinafine- and itraconazole-resistant T. indotineae in Chinese mainland, by identifying the phylogenetic classification of the isolate strain, and detecting the drug resistance, gene mutation and expression. The skin scales of the patient were cultured on SDA and the isolate was authenticated by DNA sequencing and MALDI-TOF MS. Antifungal susceptibility testing was performed following the M38-A2 CLSI protocol to examine the MICs values of terbinafine, itraconazole, fluconazole, etc. The strain was screened for mutations in the squalene epoxidase (SQLE) gene by Sanger sequencing and detected the expression of CYP51A and CYP51B by qRT-PCR. A multi-resistant ITS genotype VIII sibling of the T. mentagrophytes complex (T. indotineae) was isolated in Chinese mainland. The strain harbored high terbinafine MIC of > 32μg/mL and itraconazole MIC of 1.0μg/mL, which was identified a mutation in the squalene epoxidase gene with amino acid substitution (Phe397Leu, mutation 1191C > A). In addition, overexpression of CYP51A and CYP51B was observed. With multiple relapses, the patient finally achieved clinical cure by itraconazole pulse therapy and topical clotrimazole cream for 5weeks. The first domestic strain of terbinafine- and itraconazole-resistant T. indotineae from a patient in Chinese mainland was isolated. Itraconazole pulse therapy can be an effective method for the treatment of T. indotineae.

Onychomycosis Involving Multiple Nails in Healthy Infants - Uncommon but Emerging Fungal Infection

Onychomycosis (OM) is common in adults but extremely rare in healthy infants. Here, we describe OM caused by Candida albicans and Trichophyton rubrum in two healthy and nonimmunocompromised infants. Multiple fingernails and toenails were involved in the form of onycholysis and yellowish discoloration in a 4-week-old neonate, whereas a 6-month-old infant presented with distal and lateral subungual type of OM. The diagnosis was established in both cases by the direct microscopic examination and fungal culture from nail scrapings. The infant with Candida OM responded to topical amorolfine with complete recovery within 3 months, while the case with T. rubrum OM was put on itraconazole pulse therapy for 3 months in the dosage of 5 mg/kg/day. We reported these cases for rarity of OM in infants, very young age of onset and multiple nail involvement in immunocompetent infants.

Q-switched Nd:YAG laser versus itraconazole pulse therapy in treatment of onychomycosis: A clinical dermoscopic and mycologic study.

Onychomycosis (OM) represents about 50% of nail disorders. Oral antifungals have proven efficacy in the treatment of onychomycosis but their associated side effects limit their use. Accordingly, there is an increased need for a safe and effective therapy to induce clearance and improve the esthetic appearance of diseased nails. The current study is an attempt to evaluate and compare the efficacy of Q-Switched Nd:YAG (1064 nm) laser as monotherapy versus pulse itraconazole in the clearance of onychomycosis. In this prospective study, 40 onychomycosis patients were equally divided into two groups: Groups I (laser group) and II (Itraconazole group). Patients of Group I are treated with six biweekly sessions of Q-Switched Nd:YAG (1064 nm) laser. Patients of Group II are treated with itraconazole pulse therapy. The assessment of clearance was rated using the "Onychomycosis Severity Index (OSI)", photographs, dermoscopy, and mycology. All 40 patients were followed up for 3months after the end of treatment. Group I's clinical improvement response was a marked improvement in 19 cases and moderate improvement in one case (OSI before treatment was 24.5 and after was 0). A dermoscopic cure occurred in 19 cases. Mycological cure was obtained in 19 cases. Group II's clinical improvement response was marked in 15 and moderate in 5 (OSI before treatment was 24 and after was 0). Dermoscopic cure occurred in 15 cases. Mycological cure was obtained in 15 cases. There were no adverse effects. The clinical response, the dermoscopic cure, and the mycological cure were equal in both groups, with no significant difference found between them. Q-Switched Nd:YAG (1064 nm) laser can be used as an effective and safe modality in the clearance of nail onychomycosis, particularly in patients who have a contraindication to or refuse the use of oral antifungals.

Fractional CO2 laser with topical 1% terbinafine cream versus oral itraconazole in the management of onychomycosis: A randomized controlled trial.

Background Onychomycosis accounts for 20-40% of all nail disorders. It is difficult to cure with resistance to anti-fungal drugs, their side effects and drug interactions limiting treatment options. Itraconazole is a widely accepted oral medication used for onychomycosis while fractional CO2 laser along with a topical anti-fungal has shown promising results for nail plate clearance in onychomycosis. Aim To compare the efficacy of fractional CO2 laser with 1% terbinafine cream versus itraconazole in the management of onychomycosis. Methods A prospective, randomised, single-centre, two-arm, parallel-group interventional study was conducted at Command Hospital Air Force, Bangalore. Onychomycosis cases confirmed by KOH mount/culture-positive were included. Patients were randomly divided into two groups. Group A received 4 sessions of fractional CO2 laser every fourth week with twice-daily application of 1% terbinafine cream; Group B received one-week pulse therapy with capsule itraconazole once every four-week for three pulses. The response was assessed by Onychomycosis Severity Index, a validated onychomycosis assessment scale, at baseline and at six months. Results Group A had 50 patients with a total of 98 nails. Clinical improvement was seen in 83/98 (84.7%) nails. The average reduction in Onychomycosis Severity Index was 8.65 (P < 0.05). Group B had 50 patients with a total of 136 nails. Clinical improvement was seen in 104/136 (76.5%) nails. The average reduction in Onychomycosis Severity Index was 7.37 (P < 0.05). Both groups showed statistically significant improvement measured by 'Reduction in Onychomycosis Severity Index' at six months; however, there was no significant difference between the two arms. Limitations The main limitations of the study are the small sample size and lack of long-term follow-up to assess recurrence of infection. Conclusion Fractional CO2 laser with 1% terbinafine cream is an effective and safe method for inducing nail clearance in onychomycosis and has efficacy similar to itraconazole pulse therapy.

Acitretin: Could it be a new therapeutic player in the field of onychomycosis?

Onychomycosis represents a therapeutic challenge. The complete cure rate with itraconazole pulse therapy remains unsatisfactory implying the need for an effective therapeutic regimen. Given the successful treatment of recurrent dermatophytosis with isotretinoin and itraconazole, we investigated the therapeutic use of acitretin in onychomycosis. To evaluate and compare the efficacy of combined itraconazole and acitretin versus monotherapy with each in onychomycosis. The study included 135 adult patients with finger- and/or toenail onychomycosis. They were equally subdivided into 3 groups: itraconazole pulse therapy, acitretin and combined itraconazole/acitretin therapy. The drugs were administered for 3months. Evaluation of severity was done by onychomycosis severity index score. Potassium hydroxide microscopy and culture were performed at baseline and at the end of the study. Mycological and complete cure of onychomycosis was observed in 51.1% and 20% of the itraconazole group, 28.9% and 28.9% of the acitretin group, and 80% and 53.3% of the combined group. There was a statistically significant difference between groups in favour of the combined itraconazole/acitretin therapy (P≤.05). Small sample and short therapy duration. Acitretin could be a powerful therapeutic player in the field of onychomycosis, with greater efficacy when combined with itraconazole.

Combined long-pulsed Nd-Yag laser and itraconazole versus itraconazole alone in the treatment of onychomycosis nails

Background: Oral antifungal therapies are effective for onychomycosis but it was complicated by systemic effects. Effective and safe therapy is needed to improve esthetic appearance of nails.Objective: The present study is an attempt to evaluate and compare the efficacy of of combined treatment of onychomycosis with 1,064-nm long-pulsed Nd-Yag laser and pulse itraconazole therapy versus pulse itraconazole alone.Methods: Thirty onychomycosis patients were divided into two groups: Groups I and II. Patients of Group I are treated by itraconazole pulse therapy. Patients of Group II received six laser sessions with long-pulsed Nd:Yag laser and itraconazole pulse therapy. The investigators rated clearance using “Onychomycosis Severity Index (OSI)”, photographs, and mycology at 6 and 9 months after treatment.Results: Group I’s clinical improvement response was excellent in two cases, good in six cases, moderate in five cases, and mild in two cases. Mycological improvement response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.4 ± 3.02 and after was 6.67 ± 3.6). Group II’s clinical improvement response was excellent in 10, good in 3, moderate in 1, and mild in 1. Mycological improvement’s response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.33 ± 3.11 and after was 5.07 ± 4.15). There were no adverse effects. The clinical response showed best results with Group II, but the mycological cure was equal in both groups.Conclusions: The use of combined long-pulsed Nd-Yag laser and itraconazole pulse therapy gives the best clinical results and patient's satisfaction.

Randomized, double-blind, comparative study on efficacy and safety of itraconazole pulse therapy and terbinafine pulse therapy on nondermatophyte mold onychomycosis: A study with 90 patients

Background: Nondermatophyte mold (NDM) onychomycosis shows poor response to current topical, oral or device-related antifungal therapies. This study was aimed to determine the efficacy and safety of itraconazole and terbinafine pulse therapy on NDM onychomycosis. Methods: Mycologically proven subjects were treated with itraconazole 400 mg daily or terbinafine 500 mg daily for 7 days/month; two pulses for fingernails and three pulses for toenails(SLCTR/2013/013). Results: One-hundred seventy-eight patients underwent mycological studies and 148 had positive fungal isolates. NDM were the prevailing fungi, 68.2%, followed by candida species 21.6%, and dermatophytes made up only 10.1%. Out of NDM Aspergillus spp (75.1%) predominated followed by 8.9% Fusarium spp and 4.95% Penicillium spp. The clinical cure at completion of pulse therapy was statistically significant 9.2% versus 2.0% (p < 0.05) in itraconazole group. But no statistically significant difference was detected between the two regimens at the end of 12 months; 65.1% versus 54.64%. Recurrences observed in both groups (6.5% vs. 4.1%) were not statistically significant. With itraconazole pulse 68.22% Aspergillus spp, 50.0% Fusarium spp and 84.6% Penicillium spp showed clinical cure, while terbinafine pulse cured 55.0% Aspergillus spp and 50.0% Fusarium spp. Conclusions: NDM was the prevailing fungi in onychomycosis in Sri Lanka. Both itraconazole and terbinafine were partially effective on NDM onychomycosis showing a clinical cure of 54–65%. Future research should focus on searching more effective antifungal for NDM onychomycosis.

Treatment of Onychomycosis - a Clinical Study.

Introduction:Onychomycosis is a fungal infection of the nail unit. Anatomical and physiological characteristics of the nail apparatus impose the need for long-term treatment to achieve complete cure.Goal:The main goal of this project is to study the effectiveness of several treatment protocols for onychomycosis based on Scoring Clinical Index for Onychomycosis (SCIO).Material and methods:The study included 133 patients with onychomycosis, diagnosed by KOH microscopy and culture. Based on disease severity, patients were grouped into groups with SCIO values: 6-9, and 12-16. These groups were randomly subdivided to 5 subgroups according to the given treatment protocols: fluconazole 150 mg 1x weekly, itraconazole continual therapy, itraconazole pulse therapy, terbinafine 250 mg/d, and terbinafine + ciclopirox 8% lacquer, respectively. The cure rate was evaluated at the end of 48 week.Results:The obtained cure rates according to the above mentioned protocols were: 92.30%, 81.81%, 83.33%, 90.90%, and 100%, respectively for groups of patients with SCIO values 6 – 9. Within patients with SCIO values 12-16, were achieved cure rates as follows: 78.57%, 78.57%, 75%, 80%, and 86.66%.Conclusions:There was no statistically significant difference in cure rate between five treatment protocols applied in this study. In patients with high SCIO values is expected a decrease in cure rate.

趾爪白癬患者におけるランダム化二重盲検並行群間比較試験によるイトラコナゾール（ITCZ）パルス療法至適用量・サイクル試験―1年間のフォローアップを含めて―

趾爪白癬患者におけるランダム化二重盲検並行群間比較試験によるイトラコナゾール（ITCZ）パルス療法至適用量・サイクル試験―1年間のフォローアップを含めて―

Longitudinal monitoring of CYP3A activity in patients receiving 3 cycles of itraconazole pulse therapy for onychomycosis

Itraconazole, a CYP3A inhibitor, is used for the treatment for onychomycosis with a three-cycle pulse therapy over 3months, but its effects on in vivo CYP3A activity during the entire course remain unknown. Urinary 6β-hydroxycortisol/cortisol ratios were determined in 19 patients with onychomycosis, before therapy, during three cycles of itraconazole pulse therapy (200mg twice daily for a week in each monthly cycle) and at 3month after completion of therapy. The mean 6β-hydroxycortisol/cortisol ratio was reduced by 68% from baseline (P<0·05) after the 1st pulse dosing, but the inhibitory effect appeared to be resolved before the next pulse dosing and at 3months post-treatment. The magnitude of inhibition appeared in proportion to the baseline CYP3A activity. The inhibitory effect of itraconazole pulse therapy on the in vivo CYP3A activity appears clinically relevant at the end of each cycle, but the inhibition resolves, on average, within 3weeks.

A study to compare efficacy of various oral antifungals (Fluconazole, Terbinafine, Itraconazole) in treatment of Onychomycosis

Background: Onychomycosis is accounting for upto 50% all nail disorders. It causes not only physical but also psychosocial and emotional distress to the patient. Treatment of the disease is far from satisfactory mainly due to high cost and long duration of therapy with poor patient compliance. Objective: to compare the efficacy of pulse therapy of oral Fluconazole, Terbinafine and Itraconazole. Methods: 90 patients of Onychomycosis were randomly divided into 3 treatment groups and followed up regularly. KOH smear and culture were done of all patients. Group A was given tablet Fluconazole 150 mg per week for 6 months in fingernail and 12 months in toenail onychomycosis. Group B was given tablet Terbinafine 250 mg and group C was given capsule Itraconazole 200 mg twice daily for 1st 7 days/month for 3 or 4 months in finger or toe nails involvement respectively. Results: Male Female ratio was 1:2.46 with Mostly housewives (53.33%). Distal & Lateral Subungual Onychomycosis was the most common type in 82.22% patients. Grade IV improvement was seen in 46.66% patients in group B, 40% patients in group C and 33.33% patients in group A at the end of the study. Conclusion: Both Terbinafine and Itraconazole pulse therapy is equivalent in terms of clinical cure and relapse. But Terbinafine being cost effective and having minimal drug interaction appears to be the best drug. Keywords: Onychomycosis, fluconazole, terbinafine, itraconazole

Chromoblastomycosis after a leech bite complicated by myiasis: a case report

BackgroundChromoblastomycosis is a chronic mycotic infection, most common in the tropics and subtropics, following traumatic fungal implantation.Case presentationA 72 year-old farmer was admitted to Luang Namtha Provincial Hospital, northern Laos, with a growth on the left lower leg which began 1 week after a forefoot leech bite 10 years previously. He presented with a cauliflower-like mass and plaque-like lesions on his lower leg/foot and cellulitis with a purulent tender swelling of his left heel. Twenty-two Chrysomya bezziana larvae were extracted from his heel. PCR of a biopsy of a left lower leg nodule demonstrated Fonsecaea pedrosoi, monophora, or F. nubica. He was successfully treated with long term terbinafin plus itraconazole pulse-therapy and local debridement.ConclusionsChromoblastomycosis is reported for the first time from Laos. It carries the danger of bacterial and myiasis superinfection. Leech bites may facilitate infection.

A Clinical Study of 35 Cases of Pincer Nails

BackgroundPincer nail is a nail deformity characterized by transverse overcurvature of the nail plate. Pincer nail can affect a patient's quality of life due to its chronic, recurrent course; however, there have been no clinical studies on the pincer nail condition in Korean patients.ObjectiveThe purpose of this study was to characterize the clinical findings and treatment of pincer nail. In addition, possible etiological factors were considered, and treatment efficacy was evaluated.MethodsThe medical records and clinical photographs of 35 patients (12 males, 23 females) who were diagnosed with pincer nail between August 1, 2005 and July 31, 2009 were studied.ResultsPatient age ranged from 10 to 77 (52.09±17.26) years, and there was a predominance of female (23 out of 35 patients, F:M=2:1). The mean duration of the disorder was 7.45 years (range 0.25~40); 85% had pincer nail for at least 1 year. In addition, 40% had a history of previous treatment and recurrence. There were 82.8% patients with the common type of pincer nails. The most commonly involved nails were both great toenails. Among 35 patients, nail grinding was started in 30 patients, and 25 patients showed clinical improvement with nail grinding. The width index increased and the height index decreased after treatment. The mean follow up period was 8.42 months (range 1~27), and 7 patients showed recurrence after 8.8 months (range 2~20). Among 35 patients, 5 patients were treated with nail extraction with matricectomy, and the symptoms resolved immediately. The mean follow up period was 7.6 months (range 0~19), and recurrence was not observed. Onychomycosis was also present in 37.1% of patients, and itraconazole pulse therapy for 3 months was added.ConclusionThe results of this study demonstrate the clinical features of pincer nail in Korean patients. The findings show that the common type of pincer nail was most common, and nail grinding as a conservative treatment greatly improved pincer nails despite a risk of recurrence. When onychomycosis was also present, oral antifungal therapy added to nail grinding resulted in a more rapid change in nail thickness and clinical improvement.

Small-dose Itraconazole Pulse Therapy in the Treatment of Onychomycosis and Itraconazole Levels in the Nail

Small-dose Itraconazole Pulse Therapy in the Treatment of Onychomycosis and Itraconazole Levels in the Nail

Superficial white onychomycosis caused by Nigrospora sphaerica: a case report.

Objective To report a case of superficial white onychomycosis caused by Nigrospora sphaerica. Methods Natl specimens were obtained from the patient and examined by direct microscopy, fungal culture and histopathology. Subsequently, the isolate was subjected to DNA sequencing analysis, gelatin liquefaction test, antifungal susceptibility test and nail-plate invasion test. Results A 21-year-old male presented with a 5-month history of whitening of the right hallux. Direct microscopy of nail scrapings showed spores, hyphae and lobiform conidiophores, and histopathology of decalcifying nail clippings revealed the presence of fungal elements including numerous spores and hyphae. A black woolly colony was formed in Sabouraud's dextrose agar (SDA). DNA sequencing analysis showed that the isolate was highly consis-tent with genus Nigrospora. Also, the isolate possessed the ability to liquefy gelatin and to invade normal nail plate. Antifungal susceptibility test showed that the isolate was highly susceptible to itraconazole, clotrimazole, amphotericin B and nystatin. The onychomycosis was cured after 5-month treatment with oral itra-conazole pulse therapy. Conclusions The isolate is identified as Nigrospora sphaerica by morphological features and DNA sequencing analysis. It is the first reported case of superficial white onychomycosis caused by N. Sphaerica in China, and it was effectively treated by itraeonazolc. Key words: Onychomycosis; Nigrospora sphaerica; Itraconazole

Fatal Hepatitis After Long-Term Pulse Itraconazole Treatment for Onychomycosis

To report the occurrence of acute cytolytic hepatitis in a patient exposed to pulse itraconazole therapy for 24 weeks and provide a concise review of the literature on cases of itraconazole-induced hepatitis. A 61-year-old woman with no apparent risk factors for liver injury developed acute hepatitis one week after the final dose of a long-term course of pulse itraconazole therapy (200 mg orally twice daily, 1 wk on, 3 wk off, for 24 wk) for onychomycosis. Monitoring of liver enzymes was not performed during the treatment period. Serologic evaluations on presentation ruled out infectious diseases or other etiological factors. Liver function tests showed alanine aminotransferase 3330 U/L, aspartate aminotransferase 3250 U/L, and bilirubin 21 mg/dL. Liver function continued to deteriorate, and the patient underwent liver transplantation 17 days after admission. Her liver displayed reduced volume and there was a mild accumulation of ascitic fluid in the retroperitoneal cavity. Histologic evaluation showed massive panlobular necrosis. Complications occurred after transplantation and a rejection crisis worsened the clinical picture until the patient died about 4 months later. Use of the Naranjo probability scale showed the relationship of itraconazole therapy and the occurrence of acute hepatitis as probable. Itraconazole pulse therapy for onychomycosis appears to be at least as effective as and safer than a continuous treatment regimen, particularly from the perspective of potential liver damage. Only one case of severe symptomatic hepatitis occurring after pulse therapy with itraconazole for onychomycosis and requiring transplantation has been reported previously. In that case, as well as the one reported here, hepatitis symptoms occurred after completion of long-term treatment in patients who were asymptomatic both before and during therapy. Prolonged exposure to itraconazole, administered either continuously or intermittently, may precipitate severe and irreversible hepatotoxic events. Accordingly, careful monitoring of liver function parameters should be performed both during and after treatment when onychomycosis requires prolonged itraconazole administration, even in asymptomatic patients lacking apparent risk factors of hepatic injury.

Eight Cases of Drug Eruption Due to Itraconazole Pulse Therapy

Eight Cases of Drug Eruption Due to Itraconazole Pulse Therapy

Toenail abnormalities and onychomycosis in chronic venous insufficiency of the legs: should we treat?

Toenail manifestations of chronic venous insufficiency (CVI) may often mimic the nail changes of onychomycosis. The current study aims to determine the frequency of toenails deformations in patients with CVI, onychomycosis prevalence among deformed toenails and the outcome of itraconazole treatment. Patients with clinical evidence of (CVI) were enrolled. All patients with toenails deformations and proven onychomycosis were treated by itraconazole pulse therapy for 4 months and then followed-up for additional 5 to 6 months. Forty-four patients with CVI entered the study. Thirty-seven patients (84%) had nail deformations; 28 of 37 patients (75%) had onychomycosis; and 24 patients completed the follow-up period. Total cure was achieved in 6 of 24 patients (25%), and 14 patients (58%) had no improvement. Patients' age and CVI duration were significantly correlated to onychomycosis cure rate. Nail deformations are more prevalent in CVI patients (84%) then in the general elderly population, and 75% of affected nails had also onychomycosis. In these patients, itraconazole achieved only 25% total cure rate compared with the 60% to 70% cure rate commonly cited in the literature, probably due to irreversible nail deformity caused by the CVI and due to the thickened nail that prevented penetrance of itraconazole into the nail plate. Therefore, before antifungal treatment is started for onychomycosis in patients with CVI, especially in older patients, the caregiver must stress out that the final outcome might not be as desirable as in pure onychomycosis patients.