今日の臨床サポート

爪白癬

著者: 常深祐一郎 埼玉医科大学 皮膚科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2020/05/14
参考ガイドライン:
  1. 日本皮膚科学会:日本皮膚科学会皮膚真菌症診療ガイドライン2019(https://www.jstage.jst.go.jp/article/dermatol/129/13/129_2639/_pdf/-char/ja)
患者向け説明資料

概要・推奨   

  1. 爪白癬の診断に際しては鏡検を行うことを強く推奨する(推奨度1)
  1. 爪白癬の患者には経口抗真菌薬による治療が強く勧められる(推奨度1)
  1. 爪白癬の患者にはテルビナフィン内服またはホスラブコナゾール内服による治療が強く勧められる(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
常深祐一郎 : 講演料(エーザイ株式会社,科研製薬,佐藤製薬,鳥居薬品,マルホ)[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1. わが国の皮膚真菌症のガイドラインが改訂され、皮膚真菌症診療ガイドライン2019になったことにあわせて、内容を一部改訂した。ただし、基本的な方針に変わりはない。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 爪白癬は爪甲への白癬菌の感染症である。
  1. 「爪水虫」とも呼ばれる。
  1. わが国では人口の約10%が罹患しているとされ、年齢とともに罹患率が増加する。
  1. 爪甲の混濁や肥厚を来す疾患は爪白癬以外にも多数あり、臨床像のみからでは判断が難しいことが多い。
  1. 自覚症状がないため、放置している患者が多い。
  1. 爪白癬は繰り返す足白癬の原因となる。
  1. 爪白癬は足白癬と並び、体部白癬など他の部位の白癬の原因となる。爪甲の肥厚が高度になると、歩行時に疼痛を来したり、足趾にあたって褥瘡をつくることもある。
  1. 厚い爪甲は爪切りがしにくいため、放置されていたり、無理に切ろうとして皮膚を損傷することもある。
  1. 治療には一部の病態、重症度の症例を除き、経口抗真菌薬が第1選択であるが、不適切に外用薬のみで治療されている症例も多い。
問診・診察のポイント  
  1. 爪白癬の臨床像は爪甲の混濁や肥厚、爪甲下の角質増殖である。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: M Ameen, J T Lear, V Madan, M F Mohd Mustapa, M Richardson
雑誌名: Br J Dermatol. 2014 Nov;171(5):937-58. doi: 10.1111/bjd.13358.
Abstract/Text
PMID 25409999  Br J Dermatol. 2014 Nov;171(5):937-58. doi: 10.1111/bjd・・・
著者:
雑誌名: J Am Acad Dermatol. 1996 Jan;34(1):116-21.
Abstract/Text
PMID 8543680  J Am Acad Dermatol. 1996 Jan;34(1):116-21.
著者: Shinichi Watanabe, Ichiro Tsubouchi, Akihiro Okubo
雑誌名: J Dermatol. 2018 Oct;45(10):1151-1159. doi: 10.1111/1346-8138.14607. Epub 2018 Aug 29.
Abstract/Text Fosravuconazole L-lysine ethanolate (F-RVCZ) is a prodrug of ravuconazole, a novel triazole antifungal agent, exerting broad and potent antifungal activity. The efficacy and safety of F-RVCZ, compared with a placebo, were investigated in a multicenter, double-blind, randomized study of Japanese onychomycosis patients with 25% or more clinical involvement of the target toenail. Subjects (n = 153) were randomly assigned to receive F-RVCZ (100 mg RVCZ, n = 101) or placebo (n = 52) p.o. once daily for 12 weeks. The primary end-point was the rate of complete cure (clinical cure [0% clinical involvement of the target toenail] plus mycological cure [negative potassium hydroxide examination]) at week 48 (36-week post-treatment visit). Secondary end-points were changes over time in the efficacy and mycological effect of F-RVCZ. Safety was also evaluated. The complete cure rate at week 48 was significantly higher with F-RVCZ (59.4%, 60/101) than the placebo (5.8%, 3/52) in the full analysis set (P < 0.001). The mycological cure rate at week 48 was also significantly higher with F-RVCZ (82.0%, 73/89) than the placebo (20.0%, 10/50, P < 0.001). Regarding safety, adverse events were observed in 83.2% (84/101) and 80.8% (42/52), and adverse drug reactions (ADR) in 23.8% (24/101) and 3.8% (2/52) of F-RVCZ and placebo subjects, respectively. ADR were mild to moderate in severity, with none being serious. F-RVCZ (equivalent to 100 mg ravuconazole) administrated once daily for 12 weeks was more effective than placebo and tolerable in patients with onychomycosis, suggesting it to be a promising drug for onychomycosis treatment.

© 2018 The Authors. The Journal of Dermatology published by John Wiley & Sons Australia, Ltd on behalf of Japanese Dermatological Association.
PMID 30156314  J Dermatol. 2018 Oct;45(10):1151-1159. doi: 10.1111/134・・・
著者: A Y Sergeev, A K Gupta, Y V Sergeev
雑誌名: Skin Therapy Lett. 2002;7 Suppl 1:6-7.
Abstract/Text Onychomycosis is a common disease, and there are a number of factors that may affect the duration and dosage of treatment including the type of onychomycosis, the area and thickness of nail involvement, the age of the patient, and the location of the digit that is affected. We report a composite index, the Scoring Clinical Index for Onychomycosis (SCIO) that combines these factors to give an index of the overall severity of onychomycosis. The use of the SCIO may have treatment implications; by matching patients with similar SCIO scores, it may be possible to better compare the clinical response to therapy.

PMID 12432424  Skin Therapy Lett. 2002;7 Suppl 1:6-7.
著者: R B Odom, R Aly, R K Scher, C R Daniel, B E Elewski, N Zaias, R DeVillez, M Jacko, N Oleka, B L Moskovitz
雑誌名: J Am Acad Dermatol. 1997 Feb;36(2 Pt 1):231-5.
Abstract/Text BACKGROUND: Onychomycosis is the most frequent cause of nail disease and represents 30% of all mycotic infections of the skin.
OBJECTIVE: Our purpose was to compare the effectiveness and tolerability of intermittent dosing of itraconazole ("pulse therapy") with placebo in fingernail onychomycosis.
METHODS: Seventy-three patients with clinically and mycologically diagnosed fingernail onychomycosis were randomly selected to receive itraconazole, 200 mg twice daily, or placebo for the first week of each month for 2 consecutive months; patients were observed for 19 weeks. Seventy-one patients received the study medication and were included in the safety analysis. Efficacy of treatment was evaluated in 46 patients.
RESULTS: A significantly greater proportion of itraconazole-treated patients than placebo-treated patients achieved clinical success (77% vs 0%), mycologic success (73% vs 13%), and overall success (68% vs 0%). No itraconazole-treated patient had a clinical or mycologic relapse during the follow-up period. Ten itraconazole-treated patients (28%) and nine placebo-treated patients (26%) had adverse events. Three patients discontinued treatment for safety reasons.
CONCLUSION: Pulse therapy with itraconazole for 2 consecutive months produces significantly greater clinical, mycologic, and overall success than placebo. Short-term itraconazole pulse therapy for fingernail onychomycosis is effective and well tolerated.

PMID 9039174  J Am Acad Dermatol. 1997 Feb;36(2 Pt 1):231-5.
著者: L A Drake, N H Shear, J P Arlette, R Cloutier, F W Danby, B E Elewski, S Garnis-Jones, J M Giroux, D Gratton, W Gulliver, P Hull, H E Jones, M Journet, A L Krol, J J Leyden, S C Maddin, J B Ross, R C Savin, R K Scher, G R Sibbald, N H Tawfik, N Zaias, M Tolpin, S Evans, J E Birnbaum
雑誌名: J Am Acad Dermatol. 1997 Nov;37(5 Pt 1):740-5.
Abstract/Text BACKGROUND: Onychomycosis is an increasing problem with limited therapeutic options.
OBJECTIVE: We evaluated the safety and efficacy, of oral terbinafine, a new fungicidal antimycotic, in patients with toenail onychomycosis.
METHODS: A North American multicenter, double-blind, placebo-controlled study evaluated the mycologic and clinical efficacy of oral terbinafine 250 mg/day for 12 or 24 weeks in 358 patients with toenail onychomycosis.
RESULTS: A total of 74% of patients treated with 12 or 24 weeks of terbinafine achieved a successful clinical outcome. Approximately 11% of terbinafine responders showed evidence of relapse 18 of 21 months after cessation of treatment. Terbinafine was well tolerated; most adverse events were transient and mild to moderate in severity.
CONCLUSION: The results of this study confirm that oral terbinafine is a safe and effective therapy for the treatment of onychomycosis.

PMID 9366820  J Am Acad Dermatol. 1997 Nov;37(5 Pt 1):740-5.
著者: R Baran
雑誌名: Br J Dermatol. 2001 Oct;145 Suppl 60:15-9.
Abstract/Text OBJECTIVE: This open randomized study examined the efficacy of a combination of oral terbinafine and topical amorolfine in the treatment of severe dermatophyte toenail onychomycosis with matrix area involvement.
PATIENTS/METHODS: A total of 147 patients were randomized to one of three treatment groups: 15 months of once-weekly topical amorolfine lacquer in combination with 6 weeks (Group AT6) or 12 weeks (Group AT12) of oral terbinafine, 250 mg once daily: or terbinafine monotherapy for 12 weeks (Group T12). Patients were followed for a total of 18 months. The primary efficacy variable was the result of mycological examination after 3 months of therapy; secondary efficacy variables were mycological and clinical examination at 3-monthly intervals, with an additional clinical evaluation at 18 months. Safety and tolerance were also assessed.
RESULTS: Negative mycological results, assessed at 3 months, were recorded for 14 of 40 patients (35%) in Group AT6, 11 of 44 (27.5%) in Group AT12 and 7 of 41 (17.1%) in Group T12. At 18 months, the global response (mycological and clinical cure) was seen in 22 of 50 patients (44%), 34 of 47 (72.3% and 18 of 48 (37.5%) in the AT6, AT12 and T12 groups, respectively.
CONCLUSIONS: These results suggest that a combination therapy regime with oral and systemic treatment is superior in efficacy to monotherapy with a systemic drug alone in the treatment of severe onychomycosis. In addition, the cost per cure ratio was better in the combination groups.

PMID 11777260  Br J Dermatol. 2001 Oct;145 Suppl 60:15-9.
著者: Boni E Elewski, Phoebe Rich, Richard Pollak, David M Pariser, Shinichi Watanabe, Hisato Senda, Chikara Ieda, Kathleen Smith, Radhakrishnan Pillai, Tage Ramakrishna, Jason T Olin
雑誌名: J Am Acad Dermatol. 2013 Apr;68(4):600-608. doi: 10.1016/j.jaad.2012.10.013. Epub 2012 Nov 20.
Abstract/Text BACKGROUND: Onychomycosis is a common nail infection, often resulting in nail plate damage and deformity. Topical lacquer treatments have negligible efficacy. Oral treatments, although more efficacious, are limited by drug interactions and potential hepatotoxicity.
OBJECTIVE: We investigated the safety and efficacy of efinaconazole 10% solution (efinaconazole), the first triazole antifungal developed for distal lateral subungual onychomycosis.
METHODS: Two identical, multicenter, randomized, double-blind, vehicle-controlled studies were conducted in patients with toenail distal lateral subungual onychomycosis (20%-50% clinical involvement [study 1: N = 870, study 2: N = 785]). Patients were randomized (3:1) to efinaconazole or vehicle, once daily for 48 weeks, with 4-week posttreatment follow-up. Debridement was not performed. The primary end point was complete cure rate (0% clinical involvement of target toenail, and both negative potassium hydroxide examination and fungal culture) at week 52.
RESULTS: Mycologic cure rates were significantly greater with efinaconazole (study 1: 55.2%, study 2: 53.4%) compared with vehicle (P < .001). The primary end point, complete cure, was also significantly greater for efinaconazole (study 1: 17.8% vs 3.3%, study 2: 15.2% vs 5.5%, P < .001). Treatment success (percent affected target toenail [0%-≤10%]) for efinaconazole ranged from 21.3% to 44.8% in study 1 and from 17.9% to 40.2% in study 2, compared with 5.6% to 16.8% and 7.0% to 15.4%, respectively, with vehicle. Adverse events associated with efinaconazole were local site reactions (2%) and clinically similar to vehicle.
LIMITATIONS: A period of 52 weeks may be too brief to evaluate a clinical cure in onychomycosis.
CONCLUSIONS: Once daily topical efinaconazole appears to be a viable alternative to oral treatment options for onychomycosis.

Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.
PMID 23177180  J Am Acad Dermatol. 2013 Apr;68(4):600-608. doi: 10.101・・・
著者: Shinichi Watanabe, Hiroshi Kishida, Akihiro Okubo
雑誌名: J Dermatol. 2017 Jul;44(7):753-759. doi: 10.1111/1346-8138.13816. Epub 2017 Mar 23.
Abstract/Text Onychomycosis is a highly prevalent and intractable disease. The first-line treatment agents are oral preparations, but an effective topical medication has long been desired. The objective was to investigate the efficacy and safety of luliconazole 5% nail solution, an imidazole antifungal agent, for the treatment of patients with onychomycosis. A multicenter, double-blind, randomized phase III study was conducted in Japanese patients with distal lateral subungual onychomycosis affecting the great toenails, with 20-50% clinical involvement. Patients were randomized (2:1) to luliconazole or vehicle once daily for 48 weeks. The primary end-point was the complete cure rate (clinical cure [0% clinical involvement of the nail] plus mycological cure [negative results on direct microscopy]). The adverse event incidence was monitored to evaluate safety. The complete cure rate significantly favored luliconazole (14.9%, 29/194 subjects) versus vehicle (5.1%, 5/99) (P = 0.012). Similarly, the negative direct microscopy rate was significantly higher with luliconazole (45.4%, 79/174) than with vehicle (31.2%, 29/93) (P = 0.026). There were no serious adverse drug reactions. We conclude that once daily topical luliconazole 5% nail solution demonstrated clinical efficacy and was confirmed to be well tolerated.

© 2017 Japanese Dermatological Association.
PMID 28332720  J Dermatol. 2017 Jul;44(7):753-759. doi: 10.1111/1346-8・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから