499 Chin J Integr Med 2011 Jul;17(7):499-504
Epidemiologic studies have shown that the prevalence of
dermatophytoses is 20%- 25% worldwide(1). Combined topical
treatment is an effective shortcut for improving the efficacy of
drugs against pathogenic fungal infection, but currently the common
treatment strategy is to use two or more antifungal agents of
different structures, or corticosteroids and antifungal agents
together(2-4). The addition of a safe agent that enhances the
efficacy of antifungal agents would represent a breakthrough.
Previously, we demonstrated that the bisbenzylisoquinoline
compound, tetrandrine (TET), which is extracted from the natural
medicinal plant, fourstamen stephania root, could significantly
increase the susceptibility of fungi to azole drugs in vitro and in
experimental animals and volunteers. The mechanism is related to
the inhibition of the system, which is responsible for drug efflux
in fungi(5-13). In this study, we examined the clinical efficacy
and safety of the
combined topical use of TET and ketoconazole (KCZ) cream in
volunteers with dermatophytoses.
METHODS
Volunteers with dermatophytoses (tinea corporis and/or tinea
cruris, tinea pedis and/or tinea manuum) who sought medical
treatment at the Department
ORIGINAL ARTICLE
Synergistic Effects of Tetrandrine on the Antifungal Activity of
Topical Ketoconazole Cream in the Treatment of
Dermatophytoses: A Clinical Trial
SHI Jian-ping ()1,2, ZHANG Hong ( )1, ZHANG Zhi-dong ()1, ZHANG
Ge-hua ()3, GAO Ai-li ()1, and XIANG Shou-bao ()1
The Chinese Journal of Integrated Traditional and Western
Medicine Press and Springer-Verlag Berlin Heidelberg 2011Supported
by the National Natural Science Foundation of
China (No. 30972660), Foundation of Science and Technology
Planning Project of Guangdong Province, China (No. 2009B030801015
and No. 2008B030301350)1. Department of Dermatology, the First
Affiliated Hospital, Jinan University, Guangzhou (510632), China;
2. Department of Dermatology, Shajing People's Hospital, Shenzhen,
Guangdong Province (518104), China; 3. The Third Affiliated
Hospital, Sun Yat-sen University, Guangzhou (510095),
ChinaCorrespondence to: Prof. ZHANG Hong, Tel: 86-20-85224053, Fax:
86-20-85220032, E-mail: [email protected] DOI:
10.1007/s11655-010-0782-3
ABSTRACT Objective: To evaluate the synergistic effects of
tetrandrine (TET) on the antifungal activity of topical
ketoconazole (KCZ) in the treatment of dermatophytoses. Methods:
The minimum inhibitory concentrations (MICs) for KCZ and combined
KCZ and TET were compared in vitro. A randomized, double-blind
trial was conducted among 97 patients with dermatophytoses who
were assigned to 3 groups and received:
treatment with combination of 2% KZC and 2% TET cream (KCZ + TET
group), or only 2% KZC cream (KCZ
group), or 2% TET cream (TET group). Patients with tinea
corporis and/or tinea cruris were treated for 2 weeks,
separately. The patients with tinea pedis and/or tinea manuum
were treated for 4 weeks. Results: Compared with KZC alone,
combined use of KZC and TET showed lower MICs against clinical
isolates of dermatophytes
(P
500 Chin J Integr Med 2011 Jul;17(7):499-504
of Dermatology in our hospital from October 2006 to January 2008
were included in this study. The diagnostic criteria have been
previously described(14,15). To be included, patients must have
fulfilled the following criteria: positive microscopic findings and
fungal culture results of skin lesion smears; no use of any topical
antifungal agents or corticosteroids within 2 weeks before the
study or oral antifungal agents within the previous month. The
patients signed an informed consent, and their participation in the
study and follow-up was voluntary. We excluded the patients with
severe combined local bacterial infection or other skin diseases
that might interfere with the treatment, patients with diabetes
mellitus or severe heart, liver, or kidney disease, patients who
could not cooperate with the treatment, or patients who were
allergic to TET or KCZ.
The randomized, double blind clinical trial included a total of
120 patients with dermatophytoses. Six patients were lost during
the study, 13 terminated the treatment early, and 97 completed the
study. The patients with tinea corporis and/or tinea cruris and the
patients with tinea pedis and/or tinea manuum were randomly
assigned to 3 groups by means of a random number table and received
combined therapy with 2% TET cream and 2% KCZ cream (KCZ + TET
group), with 2% KCZ cream only (KCZ group), or with 2% TET cream
only (TET group) separately. There were no significant differences
in age, sex, course of disease, pretreatment clinical symptoms, or
physical sign scores among the groups (P> 0.05, Table 1).
Mycologic Examination The results of pretreatment
microscopic
examination and fungal culture were positive in all the
patients. The KANE/FISHER dermatophyte identification method(16)
was used in combination
with microscopic morphologic analysis. The isolated pathogens in
the KCZ + TET group, KCZ group, and TET group were Trichophyton
rubrum (30, 21, and 19 strains in the 3 groups, respectively),
Trichophyton mentagrophytes (4, 4, and 3 strains in the 3 groups,
respectively), Epidermophyton floccosum (4, 4, and 2 strains in the
3 groups, respectively), and Microsporum canis (4, 4, and 2 strains
in the 3 groups, respectively). The 2 test (Fisher's exact test)
revealed no significant differences among the 3 groups
(P>0.05).
Determination of Minimum Inhibitory ConcentrationsThe
experimental strains were clinical isolates
of dermatophytes. The methods described in the CLSI M38-A
program(17) were used to determine minimum inhibitory
concentrations (MICs), and the final concentrations of KCZ and TET
were 16-0.03 g/mL and 40 g/mL, respectively, according to our
previous report(11).
Treatment Methods TET (batch No. Cac0205; purity 99.6%;
China
Aroma Chemical Co., Ltd., Hangzhou) and KCZ (Nanjing Second
Pharmaceutical Factory, China; purity 99%) were dissolved in
dimethyl sulfoxide simultaneously, post-condensation cream matrix
was added, and the sample was mixed continuously until it became
coagulated. The cream containing KCZ, or TET, or both was applied
on the affected skin twice per day, once in the morning and once in
the evening, at the indicated dose. The duration of treatment was 2
weeks for tinea corporis and/or tinea cruris, and 4 weeks for tinea
pedis and/or tinea manuum. Symptoms, physical signs, and laboratory
parameters were observed weekly during treatment and at 2 weeks and
4 weeks after drug withdrawal; the efficacy and safety were also
evaluated.
Table 1. General Characteristics of the Three Groups of Patients
with Dermatophytes before Treatment
Group Case Male FemaleAge
(Year, s )Course
(Day, s ) Overall scores ( s )
Tinea corporis and /or tinea cruris
KCZ+TET group 16 12 4 29.818.40 14.6914.10 6.632.06 KCZ group 15
12 3 26.678.69 14.8714.99 6.402.13 TET group 12 9 3 28.289.43
14.4120.24 6.252.05Tinea pedis and /or tinea manuum
KCZ+TET group 24 18 6 34.9612.65 34.4619.80 5.331.37 KCZ group
20 16 4 33.0511.59 33.9013.41 5.351.60 TET group 10 7 3 34.2012.80
34.3016.18 5.801.87
503 Chin J Integr Med 2011 Jul;17(7):499-504
stool tests, ECG, or tests for liver and kidney function. No
serious adverse events occurred.
DISCUSSION
We had previously shown that TET could significantly enhance the
susceptibility of a variety of fungi to azole drugs in vitro and in
experimental animals(5,6,8,11-13), and this effect was directly
related to the inhibition of the mRNA expression levels of the drug
efflux pump(7-9). The main purpose of this study was to explore
whether the synergistic activity of TET on the activity of azole
drugs had any clinical significance.
The results of this study demonstrated that, compared with
monotherapy with KCZ cream, the use of combined TET and KCZ cream
increased the rates of clinical cure, fungal clearance, and overall
efficacy among patients with tinea corporis and/or tinea cruris and
patients with tinea pedis and/or tinea manuum. However, 2% TET
cream did not show any therapeutic effects on the aforementioned
dermatophytoses, suggesting that TET could synergistically enhance
the clinical efficacy of topical ketoconazole cream in the
treatment of dermatophytoses.
In recent years, with the wide application of azole drugs,
resistant strains have gradually emerged, but resistance has shown
an obviously increasing trend. Failure of treatment of infections
with resistant
strains has increased greatly. For example, among the 1 219
clinical isolates of Aspergillus examined by Snelders, et al(21),
2.6% were resistant to itraconazole. Wroblewska, et al(22) examined
851 clinical isolates of Candida albicans and found that 37.2% of
them were resistant to fluconazole and 47.6% of them were resistant
to itraconazole. Theoretically, improving the efficacy of azole
drugs for the treatment of fungal infections can be carried out
with the following methods: standardizing drug indications,
adjusting dose and duration of treatment, developing new antifungal
agents, and using drug combinations. The first two approaches need
to be gradually improved during clinical practice, and new drug
development is a lengthy process. Therefore, combined drug use may
be an effective shortcut. Currently, the combined treatments for
fungal infection usually adopt two or more antifungal agents with
different structures(23). There are no clinical trials that have
used drugs without inherent anti-fungal activity as antifungal drug
synergists, and tested whether the fungal drug resistance could be
counteracted by that type of combination. After all, no safe and
effective antifungal agent synergist with a defined functional
mechanism has been found until now.
TET is a bisbenzylisoquinoline alkaloid, the molecular formula
of which is C33H42N2O6. Currently, it is formulated as tablets and
injections, which are mainly used for anti-fibrosis and
anti-inflammatory
Table 4. Comparison of the Overall Efficacy among the Three
Groups of Patients
with Dermatophytes during Follow-up after Drug Withdrawal
(Case)
Groups Case
Two weeks after drug withdrawal Four weeks after drug
withdrawal
Cured Effective Improved Not effective
Cure rate (%)
Cured Effective Improved Not effective
Cure rate (%)
Tinea corporis and/or tinea cruris KCZ+TET 16 12 2 2 0 75.00 13
1 2 0 81.25
KCZ 15 5 2 8 0 33.33 5 0 10 0 33.33
TET 12 0 0 0 12 0 0 0 0 12 0
P1 0.032 0.011Tinea pedis and/or tinea manuum KCZ+TET 24 16 2 6
0 66.67 18 1 5 0 75.00
KCZ 20 7 2 11 0 35.00 8 0 12 0 40.00
TET 10 0 0 0 10 0 0 0 0 10 0
2 4.39 5.53P2 0.036 0.019
Note: P1 and P2 are the 2 test values of the patients with tinea
corporis and/or tinea cruris and patients with tinea pedis and/or
tinea manuum in the KCZ + TET group and KCZ group during follow-up,
respectively
504 Chin J Integr Med 2011 Jul;17(7):499-504
treatment. The commonly used dosage ranges between 200-300 mg
per day(24). It is a non-selective calcium channel blocker(25).
The results of this study and our previous clinical(10) and
laboratory(5-9,11-13) studies showed that TET was a natural and
safe synergist of azole antifungal drugs, with a low toxicity,
extensive drug sources, and potential for clinical application.
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