Clinical Investigations – Research Article

Skin Appendage Disord 2020;6:304–308 Received: March 31, 2020

Accepted: May 26, 2020
DOI: 10.1159/000508926 Published online: July 13, 2020

Once Weekly Application of Urea 40%

and Bifonazole 1% Leads to Earlier Nail
Removal in Onychomycosis
Avner Shemer a, b Yossi Eshel a, b Aditya K. Gupta c, d Renata Farhi e
       

Eckart Haneke f–i Carlton Ralph Daniel j, k Kelly Foley d Emma M. Quinlan d

       

aThe Chaim Sheba Medical Center, Tel Hashomer, Israel; bSackler School of Medicine, Tel-Aviv University, Tel Aviv,
Israel; cDepartment of Dermatology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; dMediprobe
Research Inc., London, ON, Canada; eHospital Nossa Senhora da Saude, University Fundação Tecnico Educacional
Souza Marques, Rio de Janeiro, Brazil; fDepartment of Dermatology, Inselspital, University of Bern, Bern, Switzerland;
gPrivate Dermatology Practice Dermaticum, Freiburg, Germany; hCentro de Dermatología Epidermis, Instituto

CUF, Porto, Portugal; iDepartment of Dermatology, Ghent University Hospital, Ghent, Belgium; jDepartment of
Dermatology, University of Mississippi School of Medicine, Jackson, MS, USA; kDepartment of Dermatology, School
of Medicine, University of Alabama, Birmingham, AL, USA

Keywords imen, respectively. Results: Daily application of ointment

Urea · Bifonazole · Chemical avulsion · Onychomycosis · and sealing resulted in an average length of time (±SD) to
Keratoplastic agent · Nail sealing · Nail treatment · AGISPOR nail removal of 18.7 days (±6.8 days); once every 3 days re-
ONYCHOSET sulted in nail removal at 12.7 days (±6.2 days) and once per
week at 11 days (±4.46 days) (p < 0.001). Age was the only
patient factor that affected duration to nail removal. Conclu-
Abstract sion: Once weekly application of ointment with sealing for a
Introduction: Onychomycosis is a chronic nail fungal infec- 1-week duration is associated with a decrease in time to
tion resulting in nail damage and a decreased quality of life. complete chemical avulsion of the nail by approximately 1
Chemical avulsion of the nail with urea and bifonazole week. © 2020 S. Karger AG, Basel
removes fungally infected debris, increasing antifungal
­
treatment efficacy and penetration. Previous clinical ob­
servations describe patients who applied their urea and
­bifonazole ointment less frequently, achieving earlier nail re- Introduction
moval. In this study, we analyzed the relationship between
duration of urea and bifonazole application and time to nail Onychomycosis is the most common nail disease in
avulsion. Methods: χ2 tests, multiple regression analysis, and the world, constituting 50% of all nail infections [1]. It is
ANOVA were performed to analyze the similarities between a chronic fungal infection of the nail, often presenting as
treatment regimens (daily, every 3 days, or once a week), as-
sociation of regimens or patient characteristics to nail re-
moval, and compare time to nail removal between each reg- Avner Shemer and Yossi Eshel contributed equally to the article.

[email protected] © 2020 S. Karger AG, Basel Aditya K. Gupta

www.karger.com/sad Mediprobe Research Inc.
645 Windermere Road
London, ON N5X 2P1 (Canada)
agupta @ execulink.com
 Table 1. Patient characteristics at baseline

Regimen p value
daily every 3 days weekly

Sample size at baseline 55 58 64

Gender, n (%)
Male 37 (67.3) 36 (62.1) 42 (65.6) 0.837
Female 18 (32.7) 22 (37.9) 22 (34.4)
Diabetes, n (%) 8 (14.5) 6 (10.3) 8 (12.5) 0.729
Age, years, n (%)
<20 3 (5.5) 1 (1.7) 0 0.121
20–39 25 (45.5) 28 (48.3) 22 (34.4)
40–59 23 (41.8) 28 (48.3) 36 (56.3)
60+ 4 (7.3) 1 (1.7) 6 (9.4)
Causative organism, n (%)
Negative culture 8 (14.5) 1 (1.7) 4 (6.3) 0.116
Dermatophyte 33 (60.0) 43 (74.1) 44 (68.8)
Nondermatophyte 2 (3.6) 6 (10.3) 9 (14.1)
Candida spp. 2 (3.6) 2 (3.4) 1 (1.6)
Mixed infection 4 (7.3) 3 (5.2) 2 (3.1)
Number of subjects who completed the study 50 52 61

nail discoloration, nail plate hardening, and crumbling ter in the solvation shell and specifically binding to amide
and hyperkeratosis of the nail bed, resulting in decreased units), compromising the hydrogen bonds and softening
quality of life for people with the condition [2, 3]. The the nail by hydration, thus reducing its tensile strength
most common treatment for the disease is systemic anti- and enabling its mechanical removal [11–13]. AGISPOR
fungal drugs with a 24–69% failure rate, with certain ONYCHOSET is a marketed ointment containing urea
treatments having hepatotoxic side effects and drug inter- 40% and the antifungal bifonazole 1%. According to the
actions [4, 5]. Topical antifungals are therefore some- ointment’s standard treatment protocol, the patient is re-
times preferred due to localized activity; however, they quired to soak the nail in warm water for 10 min, trim and
must be applied for a minimum of 12 months for toenails, scrape fungally infected portions of the nail, apply the
due to slow growth of nails and limited penetration of the ointment, and seal it with a bandage. The following day,
drug through the nail [6]. the bandage is removed and the nail is soaked again, fol-
The nail plate is predominantly composed of α-keratin lowed by scraping of fungal debris and reapplication of
proteins which are organized into a structure mainly sta- the ointment and bandage. This process is repeated daily
bilized by hydrophobic connections, hydrogen bonds, [14]. In a previous randomized, double-blind compari-
and di-sulfide bonds [7]. While onychomycotic nails are son study with topical bifonazole-urea ointment mono-
less dense and more porous than healthy nails, the hydro- therapy and in combination with oral griseofulvin, we no-
phobic connections remain, preventing most topical ony- ticed that patients who performed these actions less fre-
chomycosis therapies comprised of large, hydrophobic quently achieved earlier removal of the nail [15]. Similar
molecules, from penetrating to the sites of fungal infection results were seen in our clinic, which led us to believe that
[8]. Therefore, chemical removal or avulsion of a maxi- better sealing leads to earlier chemical avulsion.
mum amount of infected nails prior to antifungal treat- Therefore, we decided to test our hypothesis that a
ment allows for higher healing rates in both systemic and lower frequency of treatment administration and longer
topical treatments, due to reduced fungal load and in- application time of 3 days or 1 week with a new sealing
creased penetration through the nail bed and plate [9, 10]. technique would lead to better and quicker results in the
Urea is a keratolytic agent which is used in the chemi- treatment of onychomycosis. We treated patients with a
cal avulsion of fungally infected nails. The compound combination therapy that included maximal sealing of
damages the structure of the proteins in the nail by de- the nail using a new sealing technique with lower fre-
creasing the hydrophobic effect (due to displacing of wa- quency of treatment administration.

Nail Removal in Onychomycosis Skin Appendage Disord 2020;6:304–308 305

DOI: 10.1159/000508926
Table 2. Summary of multiple regression analysis (N = 160)

Color version available online

30 p < 0.001
Variable B SE β

Constant 14.092 1.869 25

Age 0.128 0.041 0.220a
Gender −0.441 0.965 −0.032 20
Diabetes −0.808 1.380 −0.041
Treatment regimen −7.393 1.007 −0.504b 15

Gender is for males compared to females. Treatment regimen

10
is for alternate regimens (every 3 days and weekly) compared to
daily. B, unstandardized regression coefficient; SE, standard error
of the coefficient; β, standardized coefficient. a p < 0.01. b p < 0.001. 5

0
1 3 7
Application regimen, days
Methods

We conducted a retrospective cohort study on patients (18 to Fig. 1. Time to chemical avulsion. ** p < 0.001.
>60 years of age) visiting the “LEY HAYASMIN” clinic in Netanya,
Israel, during the years 2009–2018. We screened 15,000 patients
suspected of having moderate to severe toenail onychomycosis (25 layer of paper leukoplast tape around the toe which seals the mid-
to ≤75% of target nail involvement with thick, coarse toenails). dle of the toe and the nail, leaving the distal skin of the toe bare.
These patients were subjected to a medical interview and a clinical Strict adhesion to the treatment protocol was expected of the pa-
evaluation of the infected nail(s), followed by laboratory confirma- tients until there were no more soft infected parts of the nail left to
tion with KOH microscopy and/or fungal culture. Exclusion crite- be trimmed and scraped: this process is known as chemical avul-
ria included patients sensitive to urea/bifonazole agents or the sion. The duration to complete avulsion of all infected portions of
plaster, and pregnant women. Of all included patients diagnosed the nail in each group, patient compliance to the treatment, and
with onychomycosis (n = 177), the most common etiological any discomfort or side effects were asked to be reported to the con-
agents were dermatophytes (120, 67.8%), nondermatophyte molds sulting dermatologist.
(17, 9.6%), and Candida spp. (5, 2.8%). Mixed infections were ob- A one-way ANOVA was used to compare the time to reach
served in 9 (5.1%) patients. Nail samples taken from 13 (7.3%) pa- chemical avulsion with each of the 3 treatment regimens. χ2 tests
tients were KOH microscopy positive, but culture was negative. were used to determine if there were differences between the treat-
However, they were deemed as confirmed cases of onychomycosis ment regimens for patient characteristics. A multiple regression
and considered for treatment with the AGISPOR ONYCHOSET was performed to determine whether treatment regimen, age, gen-
ointment. Of the 177 patients with onychomycosis, 115 were male der, and presence of diabetes predicted time to chemical avulsion.
(65.0%) and 62 were female (35.0%). Twenty-two of 177 (12.4%) Analyses were performed using SPSS Statistics 20 (IBM) with sig-
had a coexisting condition such as diabetes. Patient characteristics nificance set to α = 0.05.
at baseline are summarized in Table 1.
Treatment was applied to trimmed nails after soaking in warm
water for 10 min and scraping of the distal portion with a scraper
provided along with the ointment kit. This study had 3 treatment Results
groups which were created based on patients’ reported ability to
adhere to the specific treatment protocol. Group 1 had 55 patients,
of whom 5 dropped out (thus, 33 males and 17 females completed There were no differences between treatment groups
the study); group 1 subjects were instructed to apply the urea 40% in patient characteristics (Tables 1, 2) and compliance to
and bifonazole 1% ointment once a day and wrap the nail with a the treatment. Analyses were conducted on subjects who
plaster provided along with the ointment kit, leaving the plaster on completed the study (i.e., drop outs were excluded from
until the next application. Group 2 had 58 patients, of whom 6
dropped out (thus, 32 males and 20 females completed the study), analyses). The average time to complete avulsion (±SD)
and group 3 had 64 patients, of whom 3 dropped out (thus, 40 in group 1 with daily application of the urea 40% and bi-
males and 21 females completed the study) who were instructed to fonazole 1% ointment was 18.68 days (±6.81 days), group
apply the urea 40% and bifonazole 1% ointment once every 3 days 2 with application once every 3 days was 12.73 (±6.17
and once a week, respectively, again leaving the plaster on until the
days) days, and group 3 with application once a week was
next application. Both groups 2 and 3 had to wrap the nail follow-
ing ointment application with a new sealing technique proposed 11 days (±4.46 days) (p < 0.001). Figure 1 shows the time
by the dermatologist, that is, covering the nail with the plaster pro- in days that was required for chemical avulsion for each
vided along with the ointment kit followed by wrapping another treatment regimen. A one-way ANOVA was performed

306 Skin Appendage Disord 2020;6:304–308 Shemer/Eshel/Gupta/Farhi/Haneke/

DOI: 10.1159/000508926 Daniel/Foley/Quinlan
to determine if there were significant differences between has more time to penetrate into the more porous mycotic
treatment regimens in the time to reach chemical avul- areas of the plate, resulting in higher keratolytic activity.
sion. There was a significant main effect of treatment reg- When the solution is removed every day, the amount of
imen (F (2,160) = 25.51, p < 0.001), with the alternative solution absorbed is minimal; fresh application does not
regimens of ointment application and sealing every 3 increase absorption in as meaningful a manner as main-
days or weekly producing chemical avulsion in signifi- taining the original application. The second reason is the
cantly less time than the standard of daily ointment ap- increased application time, along with the tighter sealing
plication and sealing (Tukey post hoc p < 0.001). There method, reduces evaporation of water resulting in a more
was no significant difference between treatment every 3 moisturized and thus softer nail plate, with reduced tensile
days and weekly (p = 0.259). strength that is removed more easily. The porous nail plate
A multiple regression was performed using the inde- with the diminished hydrophobic effect permits the urea
pendent variables of age, gender, treatment regimen, and bifonazole to be more readily absorbed, thus increas-
and presence of diabetes. For treatment regimen, the ing treatment efficacy. Application of urea over time loos-
alternate regimens of every 3 days and weekly were col- ens the nail keratin and improves nail hydration, which
lapsed and compared to the standard daily treat- ultimately softens the nail and loosens the firm attach-
ment regimen. The regression model was significant ment of the nail plate to the underlying nail bed, thus aid-
(F (4,155) = 15.06, p < 0.001, adjusted R2 = 0.261). Gen- ing in easy removal of the infected portion of the nail.
der and presence of diabetes did not significantly influ- Another finding that emerges from the results is that
ence the time to chemical avulsion (Table  2). An in- an increase in age of 1 year is associated with an increase
crease in age of 1 year is associated with increasing the in the time to chemical avulsion by 0.128 days. We also
time to chemical avulsion by 0.128 days (p < 0.01). found that patients aged 60 and over had longer treat-
Treatment regimen significantly predicted time to ment duration to complete chemical avulsion on average
chemical avulsion. Compared to daily application of in each of the treatment groups (group 1 = 19.42 days;
ointment and sealing, alternate applications (every 3 group 2= 18.83; group 3 = 12.85 days). These findings can
days and weekly) of ointment and sealing are associated be explained by the thickening of the toenails with aging,
with decreasing the time to chemical avulsion by ∼7.4 which may make it more difficult to remove them using
days (p < 0.001, Table 2). Mild dermal irritation was re- the ointment, difficulty bending and reaching the feet,
ported by 2 patients in group 3 who applied the oint- and difficulty cutting (and scraping) the thick toenails,
ment once every 7 days, which did not prevent them known phenomena among the elderly [16].
from completing the treatment. Due to these promising results, it is suggested that on-
ychomycosis patients treated with the urea 40% and bi-
fonazole 1% ointment apply the treatment to the affected
Discussion nail once a week for 1 week and cover the nail using the
new tight sealing method. This new treatment protocol is
The results of this study support our hypothesis that more efficacious and adequately tolerable (the only side
increased duration of urea 40% and bifonazole 1% oint- effect which was reported by 2 patients in the once a week
ment application before removing the plaster and reap- application treatment group was mild dermal irritation
plying the product leads to decreased overall treatment which did not prevent them from completing the treat-
time until chemical avulsion of the mycotic nail. While ment) and may improve patient compliance, as it requires
reapplying the treatment daily resulted in an average of less work from the patient with faster results. This is es-
18.68 days before chemical avulsion, this duration de- pecially true for patients with onychomycosis of the toe-
creased to 12.73 days for a reapplication of every 3 days nails who have difficulty bending, such as older or physi-
and decreased further to an average of 11 days for weekly cally disabled patients, or those who require assistance
reapplication. It appears that the efficacy of this treatment from caregivers. Although we did not find differences in
method begins to plateau between 3 and 7 days. treatment compliance between treatment groups, there
We hypothesized that the increased duration between may have been such that we were unable to detect due to
applications and the tighter sealing method lead to a great- follow-up that was not strict enough for precise adher-
er efficacy of chemical avulsion due to 2 main reasons. The ence to treatment protocol.
first reason is due to the increased time of contact between The purpose of the treatment with the urea 40% and
the urea preparation and the nail plate, the urea solution bifonazole 1% ointment is achieving mycological cure.

Nail Removal in Onychomycosis Skin Appendage Disord 2020;6:304–308 307

DOI: 10.1159/000508926
Unfortunately, we did not have the information regard- Conflict of Interest Statement
ing this parameter as our research is retrospective, and
A.K. Gupta is a coordinating investigator for Moberg Pharma
this data was not collected. We suggest that future studies and Bausch Health Canada and a speaker for Bausch Health Can-
utilize our new treatment protocol to examine this pa- ada. The authors have no other relevant affiliations or financial
rameter, in addition to the time to chemical avulsion, in involvement with any organization or entity with a financial inter-
order to demonstrate that our new treatment protocol est in or financial conflict with the subject matter or materials dis-
achieves quicker chemical avulsion with similar myco- cussed in the manuscript apart from those disclosed. Other au-
thors have no conflicts of interest to declare.
logical cure rates. Another parameter that was not avail-
able to us and could have contributed to the results was
the thickness of initial toenails, as it could be included in
the multiple regression analysis to investigate if once Funding Sources
weekly application has the same efficacy in achieving
The authors did not receive any funding. Mediprobe Research
chemical avulsion of toenails of increased thickness. We Inc. is a not-for-profit, self-funded research organization.
suggest conducting a randomized control trial in the near
future that will examine the results of our study and in-
clude the parameters described above (mycological cure
Author Contributions
and toenail thickness).
Avner Shemer is the primary investigator and Yossi Eshel is
the primary researcher in this project. Aditya K. Gupta contrib-
Statement of Ethics uted to the conceptualization and writing of the manuscript. Re-
nata Farhi assisted in data collection from patient files. Eckart
We conducted the research in accordance with the World Med- Haneke and Ralph Daniel also helped in conceptualization. Kelly
ical Association Declaration of Helsinki. We had Helsinki approv- Foley contributed to the statistical analysis and interpretation of
al which was given to us by the Israeli Ministry of Health to conduct the data. Emma Quinlan contributed to the writing of the manu-
this retrospective cohort study in the “LEV HAYASMIN” clinic. script.

References
  1 Scher RK. Onychomycosis is more than a cos-   7 Elsayed MMA. Development of topical thera- 12 Jacobi A, Mayer A, Augustin M. Keratolytics
metic problem. Br J Dermatol. 1994 Apr; peutics for management of onychomycosis and emollients and their role in the therapy of
130(Suppl 43):15. and other nail disorders: a pharmaceutical psoriasis: a systematic review. Dermatol Ther.
  2 Gupta AK, Versteeg SG, Shear NH. Onycho- perspective. J Control Release. 2015 Feb;199: 2015 Mar;5(1):1–18.
mycosis in the 21st century: an update on di- 132–44. 13 Wang B, Yang W, McKittrick J, Meyers MA.
agnosis, epidemiology, and treatment. J Cu-   8 Baraldi A, Jones SA, Guesné S, Traynor MJ, Keratin: structure, mechanical properties, oc-
tan Med Surg. 2017 Dec;21(6):525–39. McAuley WJ, Brown MB, et al. Human nail currence in biological organisms, and efforts
  3 Gupta A, Mays R. The impact of onychomycosis plate modifications induced by onychomyco- at bioinspiration. Prog Mater Sci. 2016 Mar 1;
on quality of life: a systematic review of the avail- sis: implications for topical therapy. Pharm 76:229–318.
able literature. Skin Appendage Disord. 2018;4: Res. 2015 May;32(5):1626–33. 14 Ministry of Health, Israel. AGISPOR ONY-
208–16.   9 Seebacher C, Brasch J, Abeck D, Cornely O, Ef- CHOSET Prescribing Information [Internet].
 4 Beuscher T, Kelechi T. Onychomycosis: fendy I, Ginter-Hanselmayer G, et al. Onycho- 2014 [cited 2020 Mar 26]. Available from: https:
diagnosis, treatment, and prevention. J
­ mycosis. Mycoses. 2007 Jul;50(4):321–7. //www.old.health.gov.il/units/­p harmacy/
Wound Ostomy Cont Nurs. 2019 Aug; 46(4): 10 Hay RJ. The future of onychomycosis therapy trufot/alonim/Agispor_dr_1410796308211.
333–5. may involve a combination of approaches. Br pdf.
  5 Kaul S, Yadav S, Dogra S. Treatment of der- J Dermatol. 2001 Oct;145(Suppl 60):3–8. 15 Friedman-Birnbaum R, Cohen A, Shemer A,
matophytosis in elderly, children, and preg- 11 Zou Q, Habermann-Rottinghaus SM, Mur- Bitterman O, Bergman R, Stettendorf S.
nant women. Indian Dermatol Online J. 2017 phy KP. Urea effects on protein stability: hy- Treatment of onychomycosis: a randomized,
Oct;8(5):310–8. drogen bonding and the hydrophobic effect. double-blind comparison study with topical
  6 McAuley WJ, Jones SA, Traynor MJ, Guesné S, Proteins. 1998;31(2):107–15. bifonazole-urea ointment alone and in com-
Murdan S, Brown MB. An investigation of how bination with short-duration oral griseoful-
fungal infection influences drug penetration vin. Int J Dermatol. 1997 Jan;36(1):67–9.
through onychomycosis patient's nail plates. 16 Baran R. The nail in the elderly. Clin Derma-
Eur J Pharm Biopharm. 2016 May;102:178–84. tol. 2011;29(1):54–60.

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DOI: 10.1159/000508926 Daniel/Foley/Quinlan