Jessner's Peel as Adjuvant for Onychomycosis Treatment

INTRODUCTION

Toenail onychomycosis is a common form of dermatophytic infection, particularly in the elderly, diabetics, and those with vascular peripheral insufficiency or those who live with any form of immunosuppression.^[1]

The oral antifungals have to be taken for several months, are expensive, and have potential drug interactions.^[2] Regarding the topical treatments, various lacquers are available, and no significant difference in cure rates is reported among all of them. Amorolfine 5% and Ciclopirox 8% are the most common and report a cure rate between 5–10% after at least 48 weeks of monotherapy.^[1–5]

On the bright side, side effects are generally few and limited to local exfoliation, erythema, and irritation at the application site, but on the downside, the penetration rate of the lacquer in the nail plate is low, so the results are far from ideal.^[6]

Isolated reports mention the application of different kinds of acids onto the nail plate with the intent to obtain peeling for cosmetic purposes in conditions such as pitting, ridging, or discoloured nails, and the authors concluded that they are effective.^[7]

Other studies have applied glycolic acid with mild adverse effects and good cosmetic results.^[8] Inspired by these works, some authors used it for onychomycosis treatment because no other option was suitable for their patients. One report mentions applying a black peel, which is normally used for acne and is considered a superficial-to-medium depth peel, obtaining good results in two cases.^[2,9]

CLINICAL PEARL/INNOVATION

This study was approved by the ethics committee of our institution, and patients signed an informed consent. We designed a pilot study with adults diagnosed (clinical and mycological) with onychomycosis with a mild (1–5) to moderate (6–15) Onychomycosis Severity Index (OSI) score.

We applied Jessner’s peel as a single coat, waited for it to dry out, and reapplied it once more. After that, we instructed the participants to apply the 8% ciclopirox lacquer every day on that nail for 1 month. These procedures were repeated for 3 months, and the patients were followed for a total of 6 months.

We included ten patients and lost one to follow-up. The first toenail was involved in all of our patients. Of the nine participants, one resolved completely, and five improved by 50% or more. Two patients showed only slight improvement (<50%) while one worsened. Table 1 shows the baseline and final OSI scores of the patients. Calculated in percentage, the results are summarised in Figure 1. Some of the cases can be seen in Figures 2, 3 and 4.

Close

Figure 1:

Percentage of improvement by patient. Colours in the graph represent individual patients serially. Patient 4 actually worsened, with OSI score of 20 from baseline OSI score of 12. Patient 10 was lost to follow up. OSI: Onychomycosis severity index.

Export to PPT

Close

Figure 2:

Patient 2 (a) Before treatment, (b) After treatment.

Export to PPT

Close

Figure 3:

Patient 5 (a) Before treatment, (b) After treatment.

Export to PPT

Close

Figure 4:

Patient 3 (a) Before treatment, (b) After treatment.

Export to PPT

All our patients showed involvement of the first toenail. None of them reported any side effects, either of the Jessner peeling or the ciclopirox lacquer that was provided.

DISCUSSION

By altering the nail plate surface with the acids, we disrupt the tight structure of the nail plate, allowing the lacquer to have better penetration and, thus, better action, as we already know that the main deficit of the topical lacquers is its low penetration rate. Most of our patients had at least some improvement in nail disease. So, after this pilot study, we conclude that independently of the initial OSI score, patients can have an important improvement in most cases, which poses several advantages such as sparing the need to take systemic antifungals, enhance the use of lacquers, or be an aide to shorten the treatment course, reduce costs and risks that accompany these practices.

CONCLUSION

We still need to study more patients and probably, as the tolerance to the peel was very good, increase the number of applications to see if we can raise the cure rate.

We consider this can be a good option for topical treatment once we standardise the regime.