Can aspergillosis (a fungal infection) occur in the nail of an immunocompetent (immune competent) patient, and what is the best antifungal medication, such as itraconazole (Itraconazole), and its ideal dose?

From the Guidelines

Aspergillosis can occur as a fungal nail infection in immunocompetent patients, and the best antifungal to use in such cases is oral itraconazole, with a recommended dosing regimen of 200 mg twice daily for one week per month, typically continued for 2-3 months for fingernail infections and 3-4 months for toenail infections, as suggested by the guidelines for the treatment of aspergillosis 1.

Key Considerations for Treatment

• The treatment of aspergillosis, including nail infections, prioritizes the use of antifungals that can effectively penetrate the site of infection and inhibit fungal growth.
• Itraconazole is preferred for aspergillus nail infections due to its ability to inhibit ergosterol synthesis in the fungal cell membrane, thus disrupting membrane integrity and function.
• The dosing regimen for itraconazole can vary between pulse therapy and continuous therapy, with the choice depending on patient factors and the severity of the infection.

Important Treatment Details

• Pulse therapy with itraconazole involves 200 mg twice daily for one week per month.
• Continuous therapy involves 200 mg daily for 6-12 weeks for fingernail infections and 12-16 weeks for toenail infections.
• Treatment success is contingent upon complete penetration of the antifungal into the nail plate, highlighting the importance of oral therapy over topical treatments for aspergillus nail infections.
• Patients should be monitored for potential drug interactions and hepatotoxicity, and itraconazole should be taken with food to enhance absorption, as indicated by the guidelines for antifungal therapy 1.

Outcome Considerations

• Morbidity, mortality, and quality of life are significantly improved with effective treatment of aspergillosis, including nail infections, emphasizing the importance of selecting the appropriate antifungal regimen.
• The choice of antifungal therapy, such as itraconazole, is guided by the most recent and highest quality evidence, ensuring that treatment decisions are based on the best available data 1.

From the Research

Aspergillosis in Nail as a Fungal Infection

• Aspergillosis can occur in the nail as a fungal infection, even in immune-competent patients, although it is more common in immunocompromised individuals 2.
• The diagnosis and treatment of aspergillosis can be challenging, and antifungal resistance has emerged 2.

Best Antifungal Treatment

• Voriconazole is often considered the treatment of choice for invasive aspergillosis, including nail infections 3, 4, 2.
• However, posaconazole has shown similar efficacy with less toxicity and can be used as an alternative 5, 2.
• Isavuconazole is also an option for the treatment of invasive aspergillosis, with similar efficacy to voriconazole and posaconazole 2.

Ideal Dose of Antifungal Treatment

• The ideal dose of voriconazole for the treatment of invasive aspergillosis is 6 mg/kg intravenously every 12 hours on day 1, followed by 4 mg/kg intravenously every 12 hours for at least 7 days, and then oral voriconazole 200 mg every 12 hours 3.
• The ideal dose of posaconazole for the treatment of invasive aspergillosis is 300 mg orally twice on day 1, followed by 300 mg orally once a day for days 2-84 5.
• The dose of isavuconazole for the treatment of invasive aspergillosis is not specified in the provided studies, but it is recommended to follow the manufacturer's instructions and clinical guidelines.

Treatment-Related Adverse Events

• Voriconazole can cause transient visual disturbances, skin rashes, and other adverse events 3, 4.
• Posaconazole can cause increased aspartate aminotransferase (AST) or alanine aminotransferase (ALT), nausea, hypokalaemia, and vomiting 5.
• Isavuconazole can cause adverse events similar to those of voriconazole and posaconazole, but the specific events are not specified in the provided studies.