Siklopiroks olamin topikal pada onikomikosis rekalsitran yang disebabkan Aspergillus spp.: sebuah laporan kasus

Pande Agung Mahariski; Ni Luh Putu Ratih Vibriyanti Karna; Ketut Kwartantaya Winaya; Andrew Yoshihiro Wirya

doi:10.15562/ism.v14i2.1795

Siklopiroks olamin topikal pada onikomikosis rekalsitran yang disebabkan Aspergillus spp.: sebuah laporan kasus

Pande Agung Mahariski ,

Ni Luh Putu Ratih Vibriyanti Karna ,

Ketut Kwartantaya Winaya ,

Andrew Yoshihiro Wirya ,

pdf |
DOI: https://doi.org/10.15562/ism.v14i2.1795 |
Published: 2023-08-30

Abstract

Background: Aspergillus spp., Scopulariopsis spp., Alternaria spp., Acremonium spp. and Fusarium spp. is reported to be responsible as the causative agent of infection in 2-25% of all cases of onychomycosis. The resistance of three types of azole (triazole) antifungals has increased in cases of infection due to Aspergillus spp. This case report discusses combining ciclopirox olamine and fluconazole in recalcitrant onychomycosis due to Aspergillus spp. as an alternative therapy.

Case: A 26-year-old woman complained of yellow fingernails 1 year ago. Solitary geographic hyperpigmented macule, brownish yellow onychodyschromia, onycholysis and subungual debris were observed on the fourth digit of the left manus. On examination of 20% potassium hydroxide, long hyphae, and saboraoud dextrose agar (SDA) culture identified Aspergillus spp. Previous treatment was itraconazole 4 pulses and fluconazole 150 mg/week for 3 months showed no improvement. Ciclopirox olamine for 4 months combined with fluconazole 150 mg/week showed healthy nail matrix growth and negative fungal element on a 20% potassium hydroxide examination after 8 weeks of treatment.

Conclusion: Recalcitrant onychomycosis can occur due to resistance to azole antifungals. Administration of topical azoles and ciclopirox combination therapy showed clinical and immunological improvements.

Latar belakang: Aspergillus spp., Scopulariopsis spp., Alternaria spp., Acremonium spp. dan Fusarium spp. merupakan kapang nondermatofita tersering yang dilaporkan bertanggung jawab sebagai agen penyebab infeksi pada 2-25% dari semua kasus onikomikosis. Saat ini resistensi tiga jenis antijamur golongan azol (triazol) meningkat pada kasus infeksi akibat Aspergillus spp. dan terapi inadekuat dapat menyebabkan resistensi dan rekurensi. Laporan kasus ini membahas penggunaan kombinasi siklopiroks olamin dan flukonazol pada onikomikosis rekalsitran karena Aspergilus spp. sebagai terapi alternatif.

Kasus: Seorang perempuan 26 tahun mengeluh kuku jari tangan menguning sejak 1 tahun lalu. Pada digiti IV manus sinistra didapatkan makula hiperpigmentasi soliter bentuk geografika, onikodiskromia kuning kecoklatan, onikolisis dan subungual debris dengan pemeriksaan kalium hidroksida (KOH) 20% ditemukan hifa-hifa panjang dan kultur saboraoud dextrose agar (SDA) teridentifikasi Aspergillus spp. Riwayat terapi sebelumnya dengan itrakonazol 4 denyut dan flukonazol 150mg/minggu selama 3 bulan tidak menunjukkan perbaikan. Siklopiroks olamin selama 4 bulan dengan melanjutkan flukonazol diberikan dan menunjukkan perbaikan matriks kuku normal dan KOH negatif setelah 8 minggu perawatan.

Simpulan: Onikomikosis rekalsitran dapat terjadi karena adanya resistensi terhadap antijamur golongan azol. Pemberian terapi kombinasi golongan azol dan siklopiroks topikal menunjukkan perbaikan klinis serta imunologis.

References

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Bongomin F, Batac CR, Richardson MD, Denning DW. A Review of Onychomycosis Due to Aspergillus Species. Mycopathologia. 2018;183(3):485–93.
Martínez-Herrera EO, Arroyo-Camarena S, Tejada-García DL, Porras-López CF, Arenas R. Onychomycosis due to opportunistic molds. An Bras Dermatol. 2015;90(3):334–7.
Motamedi M, Ghasemi Z, Shidfar MR, Hosseinpour L, Khodadadi H, Zomorodian K, et al. Growing incidence of non-dermatophyte onychomycosis in tehran, Iran. Jundishapur J Microbiol. 2016;9(8):1–6.
Wijesuriya T, Kottahachchi J, Gunasekara T, Bulugahapitiya U, Ranasinghe K, Neluka Fernando S, et al. Aspergillus species: An emerging pathogen in onychomycosis among diabetics. Indian J Endocrinol Metab. 2015;19(6):811–6.
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Bridan W, Baiu S, Kalfa H. Non-Dermatophyte as Pathogens of Onychomycosis among Elderly Diabetic Patients. J Microbiol Exp. 2017;5(4):1–3.
Soltani M, Khosravi AR, Shokri H, Sharifzadeh A, Balal A. A study of onychomycosis in patients attending a dermatology center in Tehran, Iran. J Mycol Med. 2015;25(2):e81–7.
Erdogan F, Yildirim D, Akay G. Onychomycosis Unresponsive to Antifungals: Etiology and Treatment with a New Direct Technique. Indian J Dermatol. 2019;64(6):476–81.
Putri G, Lubis IA, Putra IB. Quality of life in onychomycosis patients at H. Adam Malik General Hospital, Medan - Indonesia, 2016. Bali Med J. 2018;7(3):712–6.
Nouripour-Sisakht S, Mirhendi H, Shidfar MR, Ahmadi B, Rezaei-Matehkolaei A, Geramishoar M, et al. Aspergillus species as emerging causative agents of onychomycosis. J Mycol Med. 2015;25(2):101–7.
Pakshir K, Kamali M, Nouraei H, Zomorodian K, Motamedi M, Mahmoodi M. Molecular characterization and antifungal activity against non-dermatophyte molds causing onychomycosis. Sci Rep. 2021;11(1):1–8.
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Ski Appendage Disord. 2021;7(5):351–8.
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[1] Leung AKC, Lam JM, Leong KF, Hon KL, Barankin B, Leung AAM, et al. Onychomycosis: An Updated Review. Recent Pat Inflamm Allergy Drug Discov. 2019;14(1):32–45.

[2] Craddock L, Schieke S. Superficial Fungal Infection. In: Kang S, Amagi M, Bruckner A, Enk A, Margolis D, McMichael A, et al., editors. Fitzpatrick’s Dermatology 9th Edition. New York: Mc Graw Hill Education; 2019. p. 2925–51.

[3] Bongomin F, Batac CR, Richardson MD, Denning DW. A Review of Onychomycosis Due to Aspergillus Species. Mycopathologia. 2018;183(3):485–93.

[4] Martínez-Herrera EO, Arroyo-Camarena S, Tejada-García DL, Porras-López CF, Arenas R. Onychomycosis due to opportunistic molds. An Bras Dermatol. 2015;90(3):334–7.

[5] Motamedi M, Ghasemi Z, Shidfar MR, Hosseinpour L, Khodadadi H, Zomorodian K, et al. Growing incidence of non-dermatophyte onychomycosis in tehran, Iran. Jundishapur J Microbiol. 2016;9(8):1–6.

[6] Wijesuriya T, Kottahachchi J, Gunasekara T, Bulugahapitiya U, Ranasinghe K, Neluka Fernando S, et al. Aspergillus species: An emerging pathogen in onychomycosis among diabetics. Indian J Endocrinol Metab. 2015;19(6):811–6.

[7] Karmila IGAAD, Adiguna MS, Rusyati LMM. Profil onikomikosis pada pasien lanjut usia di Rumah Sakit Umum Pusat Sanglah, Bali, Indonesia: studi retrospektif. Intisari Sains Medis. 2020;11(1):364–8.

[8] Bridan W, Baiu S, Kalfa H. Non-Dermatophyte as Pathogens of Onychomycosis among Elderly Diabetic Patients. J Microbiol Exp. 2017;5(4):1–3.

[9] Soltani M, Khosravi AR, Shokri H, Sharifzadeh A, Balal A. A study of onychomycosis in patients attending a dermatology center in Tehran, Iran. J Mycol Med. 2015;25(2):e81–7.

[10] Erdogan F, Yildirim D, Akay G. Onychomycosis Unresponsive to Antifungals: Etiology and Treatment with a New Direct Technique. Indian J Dermatol. 2019;64(6):476–81.

[11] Putri G, Lubis IA, Putra IB. Quality of life in onychomycosis patients at H. Adam Malik General Hospital, Medan - Indonesia, 2016. Bali Med J. 2018;7(3):712–6.

[12] Nouripour-Sisakht S, Mirhendi H, Shidfar MR, Ahmadi B, Rezaei-Matehkolaei A, Geramishoar M, et al. Aspergillus species as emerging causative agents of onychomycosis. J Mycol Med. 2015;25(2):101–7.

[13] Pakshir K, Kamali M, Nouraei H, Zomorodian K, Motamedi M, Mahmoodi M. Molecular characterization and antifungal activity against non-dermatophyte molds causing onychomycosis. Sci Rep. 2021;11(1):1–8.

[14] Gupta AK, Versteeg SG, Shear NH, Piguet V, Tosti A, Piraccini BM. A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level. Am J Clin Dermatol. 2019;20(1):123–33.

[15] Gupta AK, Stec N, Summerbell RC, Shear NH, Piguet V, Tosti A, et al. Onychomycosis: a review. J Eur Acad Dermatology Venereol. 2020;34(9):1972–90.

[16] Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. A Paradigm Shift in the Treatment and Management of Onychomycosis. Ski Appendage Disord. 2021;7(5):351–8.

[17] Gupta AK, Daigle D, Carviel JL. The role of biofilms in onychomycosis. J Am Acad Dermatol. 2016;74(6):1241–6.

[18] Ogundijo OA, Adetunji VO. Biofilm formation by Aspergillus flavus and Aspergillus niger : Influence of cultural conditions and their controls. Trop Vet. 2017;335(4):191–203.

[19] Shishodia SK, Tiwari S, Shankar J. Resistance mechanism and proteins in Aspergillus species against antifungal agents. Mycology. 2019;1–15. Available from: https://doi.org/10.1080/21501203.2019.1574927

[20] Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol. 2019;80(4):853–67.

[21] Berger S, Chazli Y El, Babu AF, Coste AT. Azole resistance in Aspergillus fumigatus: A consequence of antifungal use in agriculture? Front Microbiol. 2017;8:1–6.

[22] Garcia-Rubio R, Cuenca-Estrella M, Mellado E. Triazole Resistance in Aspergillus Species: An Emerging Problem. Drugs. 2017;77(6):599–613.

[23] Rivero-Menendez O, Alastruey-Izquierdo A, Mellado E, Cuenca-Estrella M. Triazole resistance in Aspergillus spp.: A worldwide problem? J Fungi. 2016;2(3):1–30.

[24] Duong TMN, Nguyen PT, Van Le T, Nguyen HLP, Nguyen BNT, Nguyen BPT, et al. Drug-resistant aspergillus flavus is highly prevalent in the environment of Vietnam: A new challenge for the management of aspergillosis? J Fungi. 2020;6(4):1–8.

Siklopiroks olamin topikal pada onikomikosis rekalsitran yang disebabkan Aspergillus spp.: sebuah laporan kasus

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References

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