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DOI 10.1515/pjvs-2016-0067
Original article
Efficacy of topical therapy with newly developed
terbinafine and econazole formulations
in the treatment of dermatophytosis in cats
M. Ivaskiene
1
, A.P. Matusevicius
1
, A. Grigonis
2
, G. Zamokas
2
, L. Babickaite
2
1
Laboratory of Experimental and Clinical Pharmacology, Department of Non-Infectious Diseases,
Lithuanian University of Health Sciences, Veterinary Academy, Tilzes 18, LT-47181 Kaunas, Lithuania
2
Dr. L Kriauceliunas Small Animal Clinics, Lithuanian University of Health Sciences, Veterinary Academy
Abstract
In the field of veterinary dermatology dermatophytosis is one of the most frequently occurring
infectious diseases, therefore its treatment should be effective, convenient, safe and inexpensive. The
aim of this study was to evaluate the efficacy of newly developed topical formulations in the treatment
of cats with dermatophytosis. Evaluation of clinical efficacy and safety of terbinafine and econazole
formulations administered topically twice a day was performed in 40 cats. Cats, suffering from the
most widely spread Microsporum canis-induced dermatophytosis and treated with terbinafine hydro-
chloride 1% cream, recovered within 20.3±0.88 days; whereas when treated with econazole nitrate 1%
cream, they recovered within 28.4±1.14 days. A positive therapeutic effect was yielded by combined
treatment with local application of creams and whole coat spray with enilconazole 0.2% emulsion
„Imaverol”. Most cats treated with econazole cream revealed redness and irritation of the skin at the
site of application. This study demonstrates that terbinafine tended to have superior clinical efficacy
(p<0.001) in the treatment of dermatophytosis in cats compared to the azole tested.
Key words:cat, terbinafine, econazole, cream, dermatophytosis
Introduction
Dermatophytosis, also known as tinea or ring-
worm, is a disease caused by superficial fungal infec-
tion of the skin with a propensity to attack hair shafts
and follicles. It is caused by fungi of the genera Micro-
sporum,Trichophyton and Epidermophyton. Besides
humans, it may affect rodents, dogs, cats, horses,
cattle and swine. Dermatophytes are classified as zo-
ophilic, mainly found in animals, but can be passed to
humans. Anthropophilic dermatophytes are mainly
Correspondence to: M. Ivaskiene, e-mail: marija.ivaskiene@lsmuni.lt, tel.: +370 69934060
found in humans and are passed to animals rarely.
Geophilic dermatophytes are found mainly in soil,
where they feed on decomposing hair, feathers,
hooves and other sources of keratin. They infect both
humans and animals. Dermatophytosis is very con-
tagious and spreads extremely quickly among humans
and animals. This disease is the most commonly oc-
curring dermatological zoonosis. Over 90% of feline
dermatophytosis cases worldwide are caused by
Microsporum canis (Seebacher et al. 2008, Frymus et
al. 2013).
Polish Journal of Veterinary Sciences Vol. 19, No. 3 (2016), 535–543
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Today dogs and cats have become the most popu-
lar pets in the world, and suit our lifestyle perfectly.
As a result, it is common for people to be in close
contact with pets, who often happen to suffer from
zoonosis. There is an increasing amount of publica-
tions focusing on the superficial and invasive mycosis
that spread among people (Skerlev and Miklic 2010).
Microsporum canis is the most common agent in
Europetocausetineacapitisinchildren(Seebacher
et al. 2008).
Pets are frequently blamed for the transmission
of dermatophytes between animals and humans.
Transmission between hosts usually occurs by direct
contact with a symptomatic or asymptomatic host, or
direct or airborne contact with its hairs or skin scales.
Infective spores in hair and dermal scales can remain
viable from several months to years in the environ-
ment. Skin lesions in both humans and animals are
usually characterized by inflammation that is the
most severe at the edges, with erythema, scaling and
occasionally blister formation. Lesions can be localiz-
ed or generalized, usually pruritic in humans, not
animals, with burning sensation. Dermatophytes that
are acquired from animals or soil generally cause
more inflammatory lesions in humans than an-
thropophilic dermatophytes (Ameen 2010). Al-
though, dermatophyte infections may be self-limiting
in the individual with a strong immune system and
good living condition, the treatment helps to ex-
pedite the resolution of the disease and minimize the
risk for infected spores to spread into the environ-
ment (Scott et al. 2001). Topical therapy is intended
for animals with dermatophytosis, and may be the
sole therapy for local, non-diffuse lesions (Moriello
2004).
Although mycoses are widespread, for a long
time there was a limited choice of effective and
non-toxic antifungal agents used for treatment (Van-
den Bossche et al. 2003). Polyenes and pyrimidine
derivatives were available for the treatment of my-
coses; however, their limited antifungal spectrum
and toxicity to mammalian cell diminished their use
(Maertens 2004). The continued search for new and
less toxic antifungals led to the discovery of the
imidazoles, the modification of which led to the de-
velopment of more potent triazoles and bistriazoles.
During the last decades, a new group of allylamines
has been synthesized. The antifungal action of al-
lylamines is mediated by inhibition of ergosterol bio-
synthesis at a site much earlier in the pathway than
the azole antifungal drugs (Matusevicius et al.
2008a,b). Allylamines are highly selective for the
fungal enzyme and have a minimal effect on mam-
malian cholesterol synthesis, thus are more effective
and less toxic to mammalian cell than azoles. Over
the past years, there have been a variety of trials
evaluating use of topical terbinafine addressing dif-
ferent pharmaceutical formulations. Terbinafine is
very well tolerated in any topical pharmaceutical for-
mulation and also has high efficacy as a cure for der-
matophytosis in humans, irrespective of type of phar-
maceutical formulation, treatment duration and fre-
quency of application (Korting et al. 2007). Recently,
econazole and terbinafine are widely used in antifun-
gal preparations for human mycoses, however these
agents are not licensed for use in animals. Although
terbinafine is prescribed for the treatment of my-
coses in humans, it is increasingly being used in vet-
erinary patients (Sakai et al. 2011). In Lithuania,
available topical formulations for use in pets are
Surolan
®
,Malaseb
®
(miconazole) and Imaverol
®
(enilconazole), which contain antifungals of first
generation imidazole, that are fungistatic, have nar-
row spectrum of activity and the development of re-
sistance to these antifungals has become increasingly
apparent.Theuseofaneffectiveandsafeantifungal
therapy, which decreases the time of treatment and
owner’s exposure to the disease, is important in vet-
erinary medicine.
Materials and Methods
Newly developed formulations
The Laboratory of Experimental and Clinical
Pharmacology in Veterinary Academy of Lithuanian
University of Health Sciences has prepared two topi-
cal formulations, E-1 and T-1, to treat pets infected
with dermatophytosis. Both topical formulations in
the form of cream are developed on the basis of ho-
mogeneous oil-in-water emulsion. The vehicle of for-
mulations contains chemical substances, which are
safe and commonly used in topical preparations.
These substances are: salicylic acid, mono-
ethanolamine and chloralhydrate. The formulation
E-1 contains antifungal active agent belonging to
imidazole group – econazole nitrate (1%); T-1 for-
mulation contains agent belonging to allylamine
group – terbinafine hydrochloride (1%). Formula-
tions have to spread easily and dry rapidly on ani-
mal’s skin, leaving no detectable residue and adher-
ing to the treated area without being tacky, having
optimal pH and being non-irritating to the skin, as
well as having no unpleasant texture or odour, but
having keratolytic and moisturizing effect on skin.
The aim of this study was to determine the clinical
efficacy of newly designed topical formulations E-1
and T-1.
M. Ivaskiene et al.536
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Animals
Scientific research was conducted according to the
Act No. B1-639 of the Republic of Lithuania, dated
18/12/2008, Regarding Animal Care, Storage, Main-
tenance and Use („Valstybes zinios”, 22/01/2009, No
8). The treatment was performed by the pet’s owner
upon signing the consent. Effectiveness and safety of
experimental creams were assessed in 40 cats (random
age and gender) with M. canis naturally induced der-
matophytosis that had from one to five clearly ex-
pressed skin lesions with a diameter of less than 5 cm.
Microsporum canis was identified in 86 damaged skin
sites. The majority (n=45; 52.3%) of damaged skin
sites was determined in the head and muzzle areas.
Limb area of damaged skin amounted to 33.7%
(n=29), body area amounted to 11.6% (n=10) and
tail area amounted to 2.3% (n=2).
Animal treatment
The cats were divided into 4 experimental groups
(A, B, C, D), each containing 10 animals. The cats had
similar intensity of infection – extensive damage to the
skin, erythema, crusting, ulceration, loss of hair.
Group A was treated with cream T-1 only, group
B was treated with cream E-1 only, group C and
D were treated with experimental creams – T-1 and
E-1, respectively and additionally with enilconazole
0.2% emulsion „Imaverol” spray every 3 days until the
end of clinical changes.
A pea-sized portion (average 25 mg) of experi-
mental cream was used for one application. Skin
lesions were treated with experimental creams two
times a day, in the morning and in the evening, by
rubbing it gently into the affected area before the
feeding time, or Elizabethan collars were used to pre-
vent cats from grooming. The lesions were visually
examined daily throughout the experiment to deter-
mine the severity and recovery of lesion. The animal
was considered to have recovered completely, when
the hair in the damaged area had fully grown back,
there were no signs of infection and the mycological
test result was negative.
Clinical evaluation
Changes in lesion scaling, erythema, ulceration or
alopecia were examined and recorded daily. To evalu-
ate the clinical efficacy, the methodology described by
Ghannoum et al. (2009) was used. The infected area
was divided into four equal quadrants. Each quadrant
was scored on a scale from 5 to 0 as follows: 5 – exten-
sive damage to the skin, redness, crusting, ulceration,
loss of hair; 4 – erythematous skin, loss of hair, scal-
ing; 3 – slightly erythematous skin, moderate scaling,
hair starts to re-grow, few bald patches; 2 – no
erythema, no swelling, hair re-grows over entire lesion
site, little scaling; 1 – no erythema, no scaling, hair is
half length long; 0 – absence of lesion, no signs of
infection, hair is fully re-grown. These scores were
summed for the four sites on each animal and were
used to compare the efficacy of different treatments.
Treatment efficacy in percents was calculated using
the following equation: Efficacy = 100 – (T*100/C),
where T – the total score of treated lesion in each
animal; C – the score of 20 for the unhealed lesion.
The total score for any group denotes the average
clinical score from different animals in the same
group.
Mycological examination
Cats infected with Microsporum canis were identi-
fied at admission via physical examination and pres-
ence of skin lesions. Visual diagnosis was approved by
performing standardised mycological test. Damaged
hairs were plucked with sterile tweezers from the de-
marcation zone between healthy and damaged skin,
scabs and dandruff were collected. The sample from
each animal was divided into two parts. One part was
cultivated under aerobic conditions in a thermostat at
28
o
C, another part was cultivated under aerobic con-
ditions in a thermostat at 37
o
C. Samples were placed
on the Sabouraud Dextrose Agar in Petri dishes, incu-
bated for up to 7 days and examined daily. Fungal
identification was based on cultural morphology and
microscopic examination of hyphae, microconidia and
macroconidia. Lactophenol Cotton Blue Solution was
used as mounting medium and staining agent in the
preparation of slides for microscopic examination of
fungi. Mycological test was repeated after clinical
signs of infection disappeared. MacKenzie’s tooth-
brush technique was also used to ensure spores had
not remained on the coat.
Data and statistical analyses
Statistical analysis of data was performed using
SPSS statistical package (version 15, SPSS Inc.,
Chicago, IL). Mean total (±SE) (SE – standard error)
of treatment days was calculated for each treatment
group. The groups were compared by a time-to-event
analysis (survival analysis). The Log Rank
(Mantel-Cox) test was used to compare the survival
time. Student test Independent Samples T Test was
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Fig. 1. Clinical efficacy of tested formulations.
Fig. 2. Distribution of healing time according to the treatment used.
M. Ivaskiene et al.538
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applied to evaluate the differences between effective-
ness of treatments. P value <0.05 was considered sig-
nificant.
Results
Figure 1 shows comparative clinical percent effi-
cacy of each tested formulation. First signs of recovery
were seen on the second day of treatment in animals
of group A and C, while group B and D showed recov-
ery signs on the third day of the treatment. Cats, suf-
fering from Microsporum canis-induced derma-
tophytosis, when treated with cream T-1 (group A),
have recovered in 20.3±0.88 days (15-24 d.); whereas,
when treated with cream E-1 (group B), they have
recovered in 28.4±1.14 days (23-33 d.). During this
research, two groups of cats with localized skin lesions
were treated with experimental creams and ,Imaverol`
solution. Such a combined treatment of local applica-
tion of cream T-1 and whole coat spray with
„Imaverol” solution (group C) yielded positive thera-
peutic effect in 21.8±1.15 days (16-28 d.), whereas lo-
cal application of cream E-1 and whole coat spray
with „Imaverol” solution (group D) yielded positive
therapeutic effect in 28.1±0.97 days (24-34 d.). The
difference between mean treatment time of groups A,
C and B, D was statistically significant (p<0.01). The
probability of recovery over the time is shown in Fig.
2. Treatment with the cream T-1 reached the prob-
ability 1 faster (all treated animals recovered). This
was followed by the combined treatment of cream T-1
and „Imaverol” spray, cream E-1 and ultimately by
combined treatment of cream E-1 and „Imaverol”
spray. Treatment with T-1 and „Imaverol”, E-1 and
„Imaverol” demonstrated clinical efficacy after
6.6±1.5 and 8.7±1.2 applications, respectively. This
study demonstrates that treatment with the cream T-1
influence the healing rate statistically significantly
(p<0.001) compared to the treatment with cream E-1
and combined treatment with cream E-1 and
„Imaverol” solution. During observational period of
12 months, all the cats did not show disease recur-
rence. Figures 3-8 show the lesions on the right cheek
and the right side of the neck of the 2 year old cat
treated with the cream T-1 and recovered in 15 days.
Discussion
Over the past decade, the effectiveness and tolera-
bility of terbinafine were actively investigated in the
treatment of animal dermatomycoses (Bechert et al.
2010, Sakai et al. 2011, Williams et al. 2011, Wang et
al. 2012). After a number of studies in animals, scien-
tists have proved that orally administered terbinafine
is effective in the treatment of cats suffering from ex-
perimentally induced or naturally occurring derma-
tophytosis (Castanon-Olivares et al. 2001, Kotnik
2002, Kotnik and Cerne 2006, Foust et al. 2007). Re-
cently topically applied terbinafine showed superior
effectiveness in the treatment of experimental M. can-
is infection in guinea pigs (Ivaskiene et al. 2011).
In the present study, treated cats had a similar
level of infection intensity; but the time of the disap-
pearance of the clinical symptoms varied. It was no-
ticed that lesions began recovering rapidly after crusts
and infected hairs, both of which are the food source
of dermatophytes, were removed. Presumably this
happened due to everyday moisturizing effect on skin,
which speeds up the cleansing of the lesion and helps
to recover skin barrier properties. It was noticed that
after the crust is gone and the hair had fallen off, it is
easier for the pharmacological formulation to reach
the stratum corneum and the microscopic fungi pres-
ent within. Therefore, after such „cleansing” the
lesion heals and the hairs start to grow back.
During the research most cats treated with cream
E-1 revealed redness and irritation of the skin at the
site of application. The animals have been starting to
scratch the patch of skin, which the cream was applied
to, immediately after application; however, the irrita-
tion would disappear after couple of hours. It is
known that azoles used in topical formulations may
cause side effects, such as skin itching, redness and
burning sensation (Sheppard and Lampiris 2007).
According to printed sources, dermatophytosis is
a common infectious skin disease among small ani-
mals. Dermatophytosis is highly contagious and
zoonotic; therefore its treatment has to be effective,
convenient, safe and inexpensive. When treating
cutaneous fungal infections in pets, topical drugs are
often preferred to oral drugs. The efficacy of a topical
drug depends on the nature of the vehicle and the
physicochemical properties of its active substance.
A higher oral dose usually needs to be administered
to achieve the same local concentration of a drug,
which increases the risk of side effects (Ozcan et al.
2009). The preferred form for a topical administration
of an active substance is cream and lotion, which are
usually homogeneous oil-in-water emulsions, or „van-
ishing creams” that have a continuous aqueous phase
containing oily globules. Oil-in-water emulsions in-
tensely hydrate the skin. Increased skin hydration
opens the structure of the superficial layers of the
skin, which in turn increases the penetration of active
agents (Benson 2005). The evaporation of water pro-
vides a cooling effect on the skin (Williams 2003).
It is a common knowledge that emollients, moist-
urizers and keratolytic agents are central to the topi-
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Figs. 3, 4, 5. Lesions on the first day of treatment with cream T-1.
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Figs. 6, 7. Lesions after 7 days of treatment with cream T-1.
Fig. 8. Skin recovered after 15 days of treatment with cream T-1.
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cal treatment of the skin diseases. They are supple-
mentary to classic treatments and help normalize bar-
rier function of the stratum corneum; they suppress
anti-inflammatory effects and make the epidermis
more resistant to external stress factors. Salicylic acid
is generally used in ointments and solutions because
of its antiseptic, keratolytic and antipruritic proper-
ties; it increases hydration and softens the stratum cor-
neum by decreasing its pH. Topical salicylates im-
prove the absorption and productiveness of other
topical medications (Yosipovitch et al. 2001). More-
over, the pH of creams was adjusted to 6.2, because
reduction in skin pH suppresses the reproduction of
pathogenic microbiota (Matousek et al. 2003).
The present results concur with those of previous
studies, which demonstrated high effectiveness of
topical terbinafine formulations in the treatment of
experimental dermatophytosis in guinea pigs (Ghan-
noum et al. 2004, 2009, 2010).
Allylamines and azoles are lipophilic drugs; they
usually accumulate in the stratum corneum and hair
follicles, and persist there at concentrations above the
MIC for several weeks after a short-term therapy (Jes-
sup et al. 2000, Foust et al. 2007). Absorption of
lipophilic drugs into the bloodstream is very low after
topical application (Schafer-Korting et al. 2008). Pre-
sumably that was the reason the mycological test and
toothbrush technique results were negative to all the
cats at the end of the treatment after all clinical signs
of infection disappeared.
This study demonstrated that terbinafine tended
to have superior clinical efficacy compared to the
azole tested. This apparent superiority may be due to
the fungicidal activity and non-skin irritating proper-
ties of terbinafine compared to the fungistatic and ir-
ritating effect of the econazole. The inhibiting fungi-
cidal activity of terbinafine, keratolytic and hydration
effect of newly designed oil in water formulation allow
reaching fast results of treating dermatophytosis in
cats.
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