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`Diagnosis, Therapy and Prophylaxis of Fungal Diseases
`
`Official Publication of Deutschsprachige l\/lykologische Gesellschaft
`
`VoLUMi: 52
`
`IANUARY 2()()9
`
`Nummau 1
`
`CONT ENTS
`
`REVIEW /\R’l‘lCl.l7.S
`
`M. Kruppa. Quorum sensing
`(lll)l('(lllS
`
`and
`
`Cnmlidu
`1
`
`S. R. Torres, A. Garzino-Demo, '1‘. I’. Meiller,
`V. Meeks, M. A. ]abra-Rizk. Salivary histatin—
`5 and oral fungal colonisation in l—IIV+ indivi-
`duals
`1 1
`
`ORIGINAL AR'I‘lCI.ES
`
`M. C. Esposto, M. Cogliati, A. M. Tortorano,
`M. A. Viviani. Electrophoretic karyotyping of
`Ci‘ypt0m('(‘iis l1(‘0f0l‘Il1{lllS Al)-hybrid strains
`l6
`
`X. P. Liu, S. R. Fan, F. Y. Bai, ]. Li, Q. P. Liao.
`Antifungal susceptibility and genotypes of Cundicla
`albimns strains from patients with vulvovaginal
`candidiasis
`24
`
`I. Fidan, A. Kalkanci, Yesilyurt, B. Yalein,
`B. Erdal, S. Kustimur,
`'1‘. Imir. Effects of
`Su('('Iim‘0inyces l)0ltl(ll‘(lll on cytokine secretion from
`intraepithelial lymphocytes infected by US(Tll(’l'l('lll(l
`vali and C(Il1(ll(l(l (lll)l(‘(ll1S
`29
`
`Izol, A. Ates,
`I. A. Aridogan, M. Ilkit, V.
`H. Demirhindi. Clans penis
`and
`prcpuce
`colonisation of yeast fungi in a paediatric popula-
`tion: pre- and postcircumcision results
`49
`
`A. G. Luque, M. S. Biasoli, M. E. Tosello,
`A. Binolli,
`Lupo, H. M. Magaré. Oral yeast
`carriage in HIV-infected and non—infected popula-
`tions in Rosario. Argentina
`53
`
`I. P. Talarmin, 1). Boutoille, P. Tattevin,
`P. Abgueguen,
`S. Ansart,
`F. Roblot,
`I’. Raffi. Candizla
`endocarditis:
`role
`of new
`
`antifungal agents
`
`(70
`
`C. Romano, L. Massai, A. Gallo, M. Fimiani.
`Microsporum gypscum infection in the Siena area in
`2()()5—2()()6
`67
`
`Iliruma, Y. Shiraki,
`Y. Takahata, M.
`Y. Tokuhisa, '1‘. Sugita, M. Muto. Treatment
`of dermatophyte onychomycosis with three pulses
`of terbinaline (500 mg day” for a week)
`72
`
`LlZ'l"|‘lERS 'l‘() 'l‘lllZ l§l)l'l‘()R
`
`M. A. Ghannoum, L. Long, W. R. Plistcr.
`l)etermination of the efficacy of terbinaline hydro-
`chloride nail solution in the topical treatment of
`
`dermatophytosis in a guinea pig model
`
`35
`
`C. Serrano Falcon, M. del Mar Serrano
`Falcfm,
`]. Delgado Ceballos, V. Delgado
`Floreneio, V. Crespo Erchiga, S. Serrano
`Ortega. Onycliomycosis by Clmctoniiiuiz spp. 77
`
`C. P. Girish Kumar, '1‘. Menon, S. Rajasekar-
`an, B. Sekar, D. Prabu. Carriage of Camlizlu
`species in oral cavities of HIV infected patients in
`South India
`44
`
`II. Yumikura,
`R. Kano, K. Edamura,
`I-I. Maruyama, K. Asano,
`S. Tanaka,
`A. I-lasegawa. Confirmed case of feline myceto-
`ma due t() 1\/li(‘r0sp0r1im (‘unis
`80
`
`This material wasmpiead
`at the N LM a rid may be
`L‘-.u'l:»ject US.~Ca~py‘rig.ht Laws
`
`CFAD V. Anacor, |PR2015-01776
`ANACOR EX. 2107 - 3/13
`
`CFAD v. Anacor, IPR2015-01776
`ANACOR EX. 2107 - 3/13
`
`

`
`
`
`A. Akyol Erikci, M. Ozyurt, H. Terekeei,
`A. Ozturk, O. Karabudak, K. Oncu. ()eso-
`phageal aspergillosis in a case of acute lympho-
`blastic leukaemia successfully treated with Caspe-
`fungin alone due to liposomal amphotericin B
`induced severe hepatotoxicity
`84
`
`S. Verghese, '1‘. Chellamma, K. M. Cherian.
`Osteomyelitis of the rib caused by Aspergillus flavlis
`following cardiac surgery
`91
`
`Book Review
`
`Corrigenda
`
`Congress Calendar
`
`94
`
`9 3
`
`97
`
`resistant
`report
`
`T.—A. Vyzantiadis, A. Kioumi, E. Papadakis,
`M. Braimi, E. Dermitzakis, I. Tsitouridis,
`A. Antoniadis. Rhino~cercbral
`zygomycosis
`treatment:
`a
`case
`8 7
`
`to
`
`antimycotic
`
`CAPTION or THE COVER lLLUS'l‘RA’l‘l()N. Histopatholgical analysis of skin from untreated control (a) and guinea
`pigs treated with terbinaline HCI nail solutions (TNS) (terbinaline HCl 1%, dodeeyl-2—N,N-dimethylaminopr0-
`pionate hydrochloride 5%) (b). Sections were stained with Grocott Methenamine Silver stain. As can be seen in
`( a), dark-coloured Trichophyton menta grophytes hyphae were present (arrows) in the stratum corncum of the
`epidermis and (b) shows the structure of intact skin from '[‘NS-treated animals. See M. A. Ghannoum et aI..
`Determination of the ellicaey of
`terbinaline hydrochloride nail solution in the topical
`treatment of
`dermatophytosis in a guinea pig model, pp. 3 5-43 in this issue.
`
`This material was to-pied
`at the NLM and may be
`Subjes:T.‘ UE {in-pzyrigrht Laws
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`
`I Original article
`
`i
`
`This material may be protected by Copyright law (Title 17 US. Code)
`
`Determination of the efficacy of terbinafine hydrochloride nail
`solution in the topical treatment of dermatophytosis in a guinea pig
`model
`
`Mahmoud A. Ghannoum,” Lisa Long‘ and William R. Pfister3
`‘Center for Medical Mycology, Case Western Reserve University, Cleveland, Zunil/ersity Hospitals of Cleveland, Cleveland, OH and 3NexMed Inc, East Windsor,
`NJ, USA
`
`Summary
`
`Currently available topical antifungals are often not satisfactory for the treatment of
`nail infections, because of the inability to penetrate the nail plate. Terbinafine I--lCl
`nail solution is a novel antifungal
`formulation containing a nail penetration
`enhancer dodecyl—2-N,N-dimethylaminopropionate hydrochloride (DDAIP HCI, trade
`name NexACT®-88).
`In this study, we used a guinea pig model of Triciiopiiytoii
`lil(3l'lf(igl‘0pll}]fUS dermatophytosis and evaluated the clinical and mycological efficacy
`of different terbinaline HCI nail solutions (TNS) formulated with or without DDAIP
`l'lCl. Cielopirox (8%) nail lacquer (Penlac®), the only Food and Drug Administration
`approved topical treatment for onyehomycosis, was used as a comparator. Following
`the IACUC Guidelines,
`the skin of male albino guinea pigs was abraded under
`anaesthesia. Each animal was infected with T.
`l'llt3i'if(lgl‘0[7f'iyfCS ATCC 24953 (cell
`suspension containing 1 X 107 conidia). The experimental animals were divided into
`11 groups (live animals per group) and tested with the following formulations:
`Vehicle control, ().5% DDAIP HCl, 1%, 5% and l()% TNS (without DDAIP HCl), 1%
`TNS with 0.5%, 2.5% and 5.0% DDAII’ HCl, 5% and 10% TNS with 0.5% DD/\ll’
`HCl, 8% ciclopirox nail
`lacquer and an untreated control group. Evaluation of
`clinical and mycological eliicacy was performed 72 h after completion of a 7-day
`treatment
`regimen. Skin biopsy samples were processed for histopathological
`examination. The infected untreated control guinea pigs showed patches of hair
`loss and ulcerated or scaly skin and fungal invasion of hair roots. The vehicle and
`().5% DDAI1’ HCl
`treated groups showed minimal clinical efficacy (only 11% and
`5%, respectively). In contrast, all three concentrations of TNS (1%, 5% and 10%
`terbinafine I-1C1)
`formulated with or without 0.5% DDAIP HCl showed 100%
`mycological ellicacy by the hair root invasion test. Clinical efficacy of the 5% and
`10% TNS improved with addition of 0.5% DDAII’ HCl (47.4% and 73.8% vs. 68.4%
`and 89.5%,
`respectively).
`In addition, no fungal elements were detected in the
`treated guinea pig skin. All formulations of TNS resulted in a higher clinical and
`mycological ellicacy compared with the 8% ciclopirox nail lacquer (P = 0.0444). In
`conclusion, TNS containing 1%, 5% and 1()% terbinafine HCI formulated with and
`without DDAI1’ HCl demonstrated high antifungal
`ellicacy in
`experimental
`dermatophytosis. Addition of ().5% DDAI1’ HCl
`to 5% and 10% TNS significantly
`enhanced the clinical and mycological ellicacy of these formulations which were
`superior compared with the 8% ciclopirox nail lacquer. Evaluation of the 1%, 5%
`and 10% TNS in clinical
`trials
`for
`the treatment of dermatophytosis and
`onychomycosis is warranted.
`
`Correspondence: Mahmoud A. Ghannoum, Center for Medical Mycology, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid
`Avenue, Cleveland, OH 44106-5028, USA. Tel: +1 216 844 8580. Fax: +1 216 844 1076. E—mail: mahmoud.ghannoum@case.edu
`
`Accepted for publication 25 March 2008
`
`© 2008 The Authors
`
`Journal compilation © 2008 Blackwell Publishing Ltd - Mycoses 52, 35413
`
`doi:10.l 1 i 1/H439-0507»2008.01540%
`
`Subject‘ LlS€Zo~py‘rightLaws
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`
`M. A. Ghannoum rt (:1.
`
`Key words: Antifungal agent, dermatophytosis, efficacy, guinea pig model, terbinafine HCI nail solution. enhancer.
`
`Introduction
`
`Superficial fungal infections such as onychomycosis and
`dermatophytosis in the initial stages are principally
`cosmetic in nature, but if left untreated onychomycosis
`
`can lead to progressive deterioration of the nail (ony-
`cholysis) that is often painful and negatively impact the
`quality of life.l‘3 ()nychomycosis and dermatophytosis
`are infections of the nail and skin, respectively, caused
`principally by the same three fungal genera that belong
`to the dermatophytes. namely, Tricliopliyton, Microspo-
`rum and E[)l(lCl‘l'I10[7l'iyf()ll.I
`The treatment of onychomycosis and recalcitrant
`dermatophytosis has improved considerably over the
`decades following the introduction of the oral antifun-
`gals such as terbinafine and itraconazole.4 However. in
`spite of the encouraging cure rate with these agents.
`some patients inevitably fail therapy or relapses Once
`cured, the use of an effective topical antifungal may help
`to prevent a recurrence of onychomycosis. Another
`reason for using topical agents is
`that
`the patient
`population being treated is elderly and too often on
`multiple drug therapy, which creates drug-drug inter-
`action management challenges for physicians. Cerise-
`quently, use of topical treatments is often preferred to
`the oral antifungal agents. Currently,
`the only nail
`lacquer approved by the Food and Drug Administration
`for
`the treatment of mild to moderate nail
`fungal
`infection is Penlac'”(Dermik Laboratories, Sanoli-Aven-
`tis, Bridgewater, NJ, USA). Unfortunately. this agent has
`poor efficacy with only 55-85% of patients reaching
`clinical cure.‘ Consequently,
`there is still an unmet
`medical need for a more effective topical treatment for
`onychomycosis.
`to enhance the antifungal activity of
`In an effort
`terbinaline as a topical agent, dodecyl-2-N,N—dimethyl-
`aminopropionate hydrochloride
`(DDAIP HCI,
`trade
`name NexACT"”—88: NexMed (USA), Inc., Robbinsville,
`N], USA), a novel permeation enhancement excipient
`was incorporated into several formulations of terbina-
`fine HCI (TH) nail solution (TNS). The objective of this
`study was to use a dermatophytosis guinea pig model
`that is reproducible and mimics infection in human“) to
`evaluate the eflicacy of these ’l‘NS formulations.
`In this study, the clinical and mycological efficacy of
`several dosage strengths of the TNS (e.g. 1%, 5% and
`10% TH) formulated with and without various cor1cen-
`
`trations of DDAIP HCl was evaluated in the treatment of
`
`dermatophyt.osis caused by ’l'ri('l10pliyton llit’!lt(lgl‘())}llytt’S-
`In addition, the efficacy of 8% Ciclopirox nail lacquer
`was also evaluated as a comparative control. The data
`showed that TNS formulated with or without DDAIP
`
`resulted in significant clinical and mycological
`HCI
`efficacy in the treatment of dermatophytosis in this
`animal model. Further,
`the clinical and myeological
`efficacy of all TNS formulations was superior to the 8%
`ciclopirox nail
`lacquer. These data suggest that TNS
`formulations may be effective in the topical treatment
`ofsuperlieial dermatophytosis: therefore, clinical evalu—
`ation is warranted.
`
`Materials and methods
`
`Laboratory animals
`
`The in viva experimental protocol was approved by
`the Institutional Animal Care and Use Committee
`
`(IACUC) and the experimental procedures followed the
`Guidelines of
`the IACUC in compliance with the
`Association for the Assessment and Accreditation of
`
`International. Male albino
`Laboratory Animal Care,
`guinea pigs (Harlan Sprague Dawley, San Diego, CA.
`USA) with a body weight of 4S()—5()() g were housed
`in the Animal Resource Center, Case Western Reserve
`
`University and assigned rooms under standard condi-
`tions. The animals were allowed to acclimate for
`
`minimum of 5 days. The animals were kept in rooms
`maintained at 2()—22 °C, 70% humidity, 12 : 12 light
`and dark cycle and fed pelleted food and water
`(id flf)ft1,llli.
`
`Dermatophyte organism
`
`Incritagrop/iytes ATCC 24953 strain
`'1'.
`In this study,
`was selected as the infecting fungus. This particular
`strain was chosen because it
`is one of the major
`causative organisms associated with onychomycosis
`and can infect the skin resulting in skin and hair root
`invasion. To prepare the inoeulum used to challenge
`the guinea pigs, several Petri dishes of potato dextrose
`agar (PDA; Difco Laboratories, Detroit. MI, USA) were
`seeded with T.
`inentugropliytes and incubated at 30 °C
`for 7 days. The conidia were scraped from the plates
`with sterile cell scrapers (Becton-Dickinson, Sparks,
`
`36
`
`© 2008 The Authors
`Journal compilation © 2008 Blackwell Publishing Ltd - Mycoses 52, 35——43
`This material was stapled
`atitha NLM and may be
`Subjzam: US Enmrright Laws
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`
`in normal saline (NS). The cell suspen-
`MI), USA)
`sions were centrifuged and washed twice in NS, then
`re-suspended to adjust
`the cell count
`to 1 X 107
`conidia mL"1 using a haemacytometre. The working
`solution (WS) was prepared fresh in NS and 10() pl
`used to inoculate the guinea pigs. Ten~fold serial
`dilutions of WS were prepared in NS and then cultured
`in Sabouraud Dextrose agar
`(Difco Laboratories)
`to
`confirm the inoculum cell count (quantitative culture).
`
`Antifungal agents
`
`The antifungal agents. Tlrl and ciclopirox were evalu-
`ated in this study. All the test articles were provided by
`NexMed Inc.
`(Robbinsville, N], USA).
`In addition to
`0.5% DDAII’ HCl control nail solution formulations
`
`which did not contain the active drug TH was tested at
`three different concentrations (1%, 5% and 1()% TH;
`w/v). In addition. 1% TNS formulated with DDAII’ HCl
`at three different concentrations (().5%, 2.5% and 5%
`DDAIP HCI: w/V) and 5% and I()% TNS, each
`containing ().5% DDAIP HCI were tested. The commer-
`cial product, 8% ciclopirox nail lacquer (I’enlac®) was
`purchased from a pharmacy and was evaluated as a
`comparator.
`
`Animal infection and treatment
`
`infection was performed following our previ-
`Animal
`ously published method.“ Briefly. animals were anaes-
`thetized
`intramuscularly
`(().2 ml
`per
`animal)
`of
`anaesthetic cocktail (acepromazine. ketamine and xyla-
`zine, 1 : 3 : 3; v/v/v). An area of skin on the left side of
`the guinea pig’s back was clipped and shaved, and a
`2.5 cm X 2.5 cm (6.25 emf) area outline was drawn
`on the guinea pig, and the marked area was abraded
`with sandpaper. A cell suspension of
`I()() tll of NS
`containing 1 X 107 '1‘.
`n1z’ntagropliytcs conidia was
`applied to the marked area using a sterile pipette-tip
`and rubbed thoroughly. The experimental animals were
`randomly divided into eleven groups.
`()ne group
`received a vehicle control containing 0.5% DDAIP HCl
`and a second group received a vehicle control without
`excipient. In addition, three groups were treated with
`1%. 5% or 10% TNS (Without DDAIP l*ICl), while
`another three groups received 1% TNS containing the
`cxcipient at three different concentrations (0.5%, 2.5%
`and 5% DDAII’
`IICl). Two addition'al groups were
`treated with either 5% or 10% TNS (containing 0.5%
`DDAII’
`I-ICI). Finally, one group was an untreated
`control. In this study, one group was treated with 8%
`ciclopirox nail
`lacquer as
`a comparator.
`In these
`
`’l‘crbinalinc HCI nail solution in a dermatophytosis model
`
`experiments, formulations were applied in a volume of
`0.1 ml per application topically to the infected area
`beginning 72 h postinfection once a day and the
`treatment were continued for 7 days.
`
`Clinical and mycological evaluation of treatment efficacy
`
`Both clinical and mycological criteria were used to
`evaluate the efficacy of
`the various
`formulations.
`Clinical assessment was performed first, then the hairs
`were epilated and evaluated for eradication of fungal
`infection
`(mycological
`cure). Control
`and treated
`guinea pigs were monitored daily during the course
`of
`the
`infection. Final
`clinical
`and mycological
`assessments were performed on the thirteenth day
`postchallenge.
`
`Clinical evaluation
`
`Changes (mild, moderate, or severe) in redness, ulcer-
`ation, scaling or hair-loss at the site of inoculation were
`visually examined and recorded daily and these signs
`were used in the clinical assessment of efficacy of the
`different treatments and control regimens evaluated in
`this study. To evaluate the clinical efficacy of various
`formulations, the infected 2.5 cm X 2.5 cm area on the
`
`back of each guinea pig was divided into four equal
`quadrants. Each 1.25 cm x 1.25 cm (2.5 emf) quad-
`rant of this area was scored on a scale from 0 to 5 as
`
`1 = few slightly
`infection;
`() = no signs of
`follows:
`2 = well-defined
`erythematous areas on the skin;
`redness, swelling with bristling hairs, bald patches,
`scaly areas; 3 = large areas of marked redness. incrus-
`tation,
`scaling, bald patches, ulcerated in places;
`4 = partial damage to the integument,
`loss of hair;
`and 5 = extensive damage to the integument and
`complete loss of hair at
`the site of infection. These
`scores were summed for the four sites on each animal
`
`(maximum possible score per animal was 20) and were
`used to compare the efficacy of different
`treatment
`groups. Percent eflicacy was calculated using the
`following equation:
`
`Percent efficacy = 1()0 — (T X 100/C)
`
`where '1‘ = total score of treatment group and C = total
`score of untreated control. The total score for any group
`denotes the average clinical score from the different
`animals in the same group. In addition, each criterion
`(i.e. redness, ulceration, scaling and hair-loss) for the
`severity of dermatophytosis was numerically scored as
`
`
`
`0) 2008 The Authors
`Journal compilation to 2008 Blackwell Publishing Ltd - Myceses 52, 35-43
`This material was smpied
`at the N LM a rid may be
`Sulzject US {lo-wright‘ Laws
`
`37
`
`CFAD v. Anacor, |PR201 5-01776
`ANACOR EX. 2107 - 7/‘I3
`
`CFAD v. Anacor, IPR2015-01776
`ANACOR EX. 2107 - 7/13
`
`

`
`M. A. Ghannoum ct (If.
`
`1 = insignificant,
`() = none,
`follows:
`3 = moderate and 4 = severe.
`
`2 = Slight:
`
`Results
`
`Mycological evaluation
`
`’I‘l1e hair root invasion test was used to assess IIIYCO‘
`logical cure resulting from antifungal treatment using
`our previously described methodology.“ Brieflyv the
`2.5 cm X 2.5 cm infected area on the back of each
`guinea pig was divided into four 1.25 cm X 1.25 Cm
`(2.5 cm2) equal quadrants as described in Clinical
`evaluation (see above). Following clinical assessment.
`hairs were removed from each quadrant on each animal
`in the treatment and control groups. Ten hair from each
`quadrant was removed and then planted on the surface
`of FDA Petri dishes (Difco Laboratories). Following
`incubation at 30°C for 2 days, hairs showing fungal
`growth at
`the hair root were counted. Mycological
`evaluation was based on the number of culture positive
`hair obtained from each of the four quadrants. A score
`of 1() was assigned to animals that did not grow hair
`because of extensive infection. Per cent efficacy of
`different treatment and control groups was calculated
`using the same formula used to determine clinical
`efficacy (see above).
`
`Histopathology analysis
`
`For histopathological examination. skin biopsy samples
`were obtained from one animal per group at the end of
`the study. With a disposable sterile dermal biopsy punch
`(Miltex Instruments, Bethpage, NY, USA). a piece of
`skin, 3-mm in diameter was obtained from an anaes-
`
`thetized animal representing the group. Next, the tissue
`was fixed with 1()% neutral buffered formalin (Ever-
`green Scientific, Los Angeles. CA, USA) embedded in
`paraffin and processed for histopathological examina-
`tion. Fungal elements were visualized using Grocott
`Methenamine Silver (GMS) stain. Tissue was examined
`for the presence of fungal elements; inflammation and
`tissue destruction was assessed using light microscopy.
`Observations were scored using the following scale:
`— = none, i = none
`to occasional, + = few and
`++ = many.
`
`Statistical analyses
`
`Data for clinical and mycological efficacy were presented
`as the mean i SD. Student’s t—test was performed to
`determine any significant difference between treatment
`groups using STA'l‘VlliW (Berkeley, CA, USA) software. A
`P—value $0.05 was considered statistically significant.
`
`Clinical efficacy of TNS with and without penetration
`enhancer
`
`Figure 1 compares the infection and the appearance of
`guinea pig skin photographs taken on day 13 when
`clinical efficacy of control and various formulations
`tested was conducted. As can be seen in this figure, the
`infected untreated control guinea pigs. vehicle-treated
`and ().5% DDAIP HCI treated groups showed patches of
`hair loss and readily visible ulcerated or scaly skin
`(Fig. 1a, b and c, respectively).
`In contrast, animals
`treated with 1()% TNS formulated without and with
`0.5% DDAII’ HCl showed normal hair growth, with no
`
`signs of infection (Fig. 1d and e, respectively). Similarly.
`improvements in the appearance of guinea pig skins
`were noted in animals treated with other concentrations
`of TNS (1% and 5% TH) formulated without and with
`DDAIP HCI. Unlike TNS-treated animals, guinea pigs
`treated with 8% ciclopirox nail lacquer showed minimal
`improvements in skin appearance with hair loss. ulcer-
`ation and scaly skin still evident (Fig. 1f).
`Figure 2a shows comparative clinical ellicacy scores
`of each tested formulation compared with the infected
`untreated control.
`respectively. Lower clinical scores
`indicate improved efficacy compared with untreated
`controls. As can be seen in Fig. 2a, compared with the
`untreated control, significant clinical efficacy (P < 0.05)
`was demonstrated by 1%, 5% and 10% 'I‘NS formula~
`tions without DDAII’
`I~ICl (’ = ().()01l, 0.0043 and
`0.0011, respectively). In addition, 1% ’I‘NS containing
`0.5% and 2.5% DDAII’ HCl and also the 5% and 10%
`
`TNS containing 0.5% DDAII’ HCl were clinically effec~
`tive (P < 0.05). The only TNS formulation that did not
`demonstrate clinical efficacy was the l.% TNS contain-
`ing 5% DDAIP HCl
`(P > 0.08 5),
`even though it
`demonstrated significant mycological
`efficacy
`(see
`below). Additionally, vehicle~treated control
`(clinical
`score of 17 i 2.58 vs. 19.0 i 1.15) and animals
`treated with 0.5% DDAIP HCl
`(clinical
`score of
`18.40 :t 3.05 vs. 19.0 i 1.15) did not show clinical
`efficacy compared with untreated controls (P = 0.3 5 34
`and 0.7487, respectively). The clinical score for ciclo-
`pirox-treated guinea pigs showed significant efficacy
`(P = 0.0065) compared with untreated controls (clin-
`ical score of 11.4 i 2.19 vs. 17.2 i 1.304). Compar-
`ison of the clinical efficacy of 8% ciclopirox with various
`TNS formulations showed that ciclopirox had similar
`clinical efficacy to 5% TNS without enhancer and 1%
`TNS with 5% DDAIP (P = 0.5012 and 0.8336, respec—
`tively).
`In contrast, ciclopirox was significantly less
`
`38
`
`© 2008 The Authors
`Journal compilation © 2008 Blackwell Publishing Ltd - Mycoses 52, 35-43
`
`This material was an led
`
`CFAD V. Anacor, |PR2015-01776
`ANACOR EX. 2107 - 8/13
`
`CFAD v. Anacor, IPR2015-01776
`ANACOR EX. 2107 - 8/13
`
`

`
`Terbinafine iICl nail solution in a dermatophytosis model
`
`.
`
`H
`
`
`
`0.55%01)/ffiiiliifgfwu
`
`V.-»:____._.x__._
`
` .,»’v‘w
`
`Untreated control
`
`‘
`
`-5.
`
`_
`
`.
`
`1-..‘.
`
`'v....:.«...
`
`,.
`
`,
`
`
`8% Cielopirox Nail Lacquer (Penlac®)
`
`10% Terbinafine HCl + 0.5% DDAIP HCl
`
`
`
`liflieacy of terbinafine compared with untreated controls in the treatment of dermatophytosis caused by 'l‘ri¢'Impliytmi
`Figure 1
`lHt’llL(i_(]i‘0pfi_i][L’S in guinea pig. (a) Terbinafine treatment resulted in complete healing. hair growth and absence of skin lesions and
`(bi ulcerated and crusty lesions are seen on the back of infected guinea pig.
`
`effective compared with the 1% TNS containing ().5%
`DDAIP HCl and without enhancer (P=0.01 and
`0.0002,
`respectively),
`10% TNS containing 0.5%
`DDAIP HCl and without enhancer (P = 0.0026 and
`
`0.0059. respectively). 1% TNS containing 2.5% DDAIP
`HCl
`and
`5% TNS containing ().5% DDAIP HCl
`( ’ = 0.0013 and 0.0053, respectively).
`
`Mycological evaluation
`
`treatment
`the various
`The mycological efficacy of
`groups was assessed using a hair root
`invasion test.
`Figure 2b shows the mean number of hairs that were
`culture positive in each treatment group. Untreated
`control group had 24 i 5 fungal positive hairs indicat-
`ing that the hairs of untreated guinea pigs were heavily
`infected with '1',
`IiI811f{i{]l‘()[)fiytt’S. Treatment of guinea
`pigs with the vehicle resulted in some mycological
`efficacy compared with untreated control (mean fungus-
`positive hair was 12 i 7, P = 0.03534). Similar to the
`untreated guinea pigs,
`the hair of 0.5% DDAIP HCl-
`treated animals was also heavily infected (mean fungus-
`
`positive hair were 21 i 3) and was not statistically
`different from the untreated group (P = ().5017).
`In
`contrast. complete inhibition of fungal growth was
`
`demonstrated by all three concentrations of TNS (i.e.
`1.%. 5% and 1()% 11-1) used alone or in combination
`with DDAIP HCl (Fig. 2b).
`The mycological efficacy of the 8% cielopirox nail
`lacquer compared with the TNS formulations and
`untreated control are also shown in Fig. 2b. Compared
`with the infected untreated control. 8% ciclopirox
`showed a trend towards improved mycological efficacy
`(mean fungus-positive hairs were 6 i 4.64), however.
`this was not
`statistically significant
`(P = 0.1128).
`Moreover. all formulations of TNS tested had a superior
`mycological
`efficacy compared with 8% ciclopirox
`(P = 0.0444 for all comparisons).
`Table 1 provides a summary of per cent clinical and
`mycological efficacy of the various formulations com-
`pared with untreated controls. As can be seen,
`the
`vehicle control possessed some clinical and mycological
`efficacy. 10.5“ii and 50.0%, respectively; as well as the
`vehicle containing ().5% DDAIP I—ICl, which had 5.3%
`and 12.5".» clinical and mycological efficacy. respec-
`tively. All TNS formulations (1%. 5% and 1()% TH)
`produced a marked 100% mycological efficacy response
`and all had a mycological efficacy greater than 36.8%.
`There was a dose—response observed with the 1%, 5%
`and 10% TNS Containing 0.5% DDAIP HCl, which
`
`'9 2008 The Authors
`Journal compilation © 2008 Blackwell Publishing Ltd c Mycoses 52, 35-43
`This material was smpied
`at