What are the topical anti-yeast (antifungal) medications for treating toe ulcers?

From the Guidelines

Topical antifungal medications are recommended for treating toe ulcers with yeast infections, particularly in patients with diabetes, as they have a low risk of drug interactions and can be effective for mild-to-moderate infections. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, topical treatments may be appropriate for mild-to-moderate infections and where the risk of drug interaction is considered high. The International Working Group on the Diabetic Foot (IWGDF) guidance on the prevention of foot ulcers in at-risk patients with diabetes also recommends treating fungal infections with antifungal treatment 1.

When selecting a topical antifungal medication, options such as clotrimazole 1% cream, miconazole 2% cream, or nystatin cream can be considered. These medications should be applied to the affected area twice daily for 2-4 weeks. Before application, gently clean the ulcer with warm saline solution and pat dry. Apply a thin layer of the medication and cover with a sterile, non-adhesive dressing.

It's essential to monitor the ulcer for signs of bacterial co-infection, such as increased redness, warmth, or purulent discharge, and seek medical attention if necessary. Additionally, if the infection doesn't improve within two weeks, or if the ulcer worsens or spreads, consult a healthcare provider as oral antifungals may be necessary. The treatment of pre-ulcerative signs, including fungal infections, is crucial in preventing foot ulcers in at-risk patients with diabetes, as emphasized by the IWGDF guidance 1.

Key considerations for treatment include:

• Gentle cleaning and drying of the ulcer before applying topical medication
• Using a thin layer of medication and covering with a sterile, non-adhesive dressing
• Monitoring for signs of bacterial co-infection
• Seeking medical attention if the infection doesn't improve or worsens
• Continuing treatment for the full recommended duration to prevent recurrence.

From the FDA Drug Label

PRINCIPAL DISPLAY PANEL - 30 g Carton Cures Most Athlete's Foot Terbinafine Hydrochloride Cream 1% Antifungal Cream Full Prescription Strength NET WT 1 oz (30 g)

DESCRIPTION Ciclopirox Topical Solution, 8%, (Nail Lacquer) contains a synthetic antifungal agent, ciclopirox. It is intended for topical use on fingernails and toenails and immediately adjacent skin

Topical anti-yeast medications for toe ulcer are not explicitly mentioned in the provided drug labels.

• Terbinafine is used to cure athlete's foot, but its use for toe ulcers is not directly stated 2.
• Ciclopirox is intended for use on fingernails and toenails and immediately adjacent skin, but its use for toe ulcers is not directly stated 3.

From the Research

Topical Anti-Yeast Medications for Toe Ulcer

• The use of topical antimicrobial agents for treating foot ulcers in people with diabetes has been evaluated in several studies 4, 5, 6, 7.
• A systematic review of 22 trials found that the use of antimicrobial dressings may increase the number of diabetic foot ulcers healed over a medium-term follow-up period, although the evidence was of low certainty 4.
• Another study found that oral terbinafine is as safe and effective as oral itraconazole therapy for the treatment of onychomycosis in people with diabetes, although efficacy results were poor 8.
• The International Working Group on the Diabetic Foot (IWGDF) has published guidelines on the diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes, which include recommendations for topical treatments 6, 7.
• However, there is limited evidence on the effectiveness of topical anti-yeast medications specifically for toe ulcers, and further research is needed to establish the evidence for these treatments 4, 8, 5.

Treatment Options

• Antimicrobial dressings, such as silver or iodides, may be effective in promoting wound healing and preventing infection 4.
• Topical antimicrobial agents, such as chloramine or pexiganan cream, may also be effective in treating infected foot ulcers 4.
• Oral antifungal medications, such as terbinafine or itraconazole, may be effective in treating onychomycosis in people with diabetes, but may not be suitable for topical use on toe ulcers 8.

Limitations and Future Research

• The current evidence on topical anti-yeast medications for toe ulcers is limited, and further research is needed to establish the effectiveness and safety of these treatments 4, 8, 5.
• Future studies should investigate the use of topical antimicrobial agents and antifungal medications specifically for toe ulcers, and should include larger sample sizes and longer follow-up periods to provide more robust evidence 4, 6, 7.