Candidiasis is one of the most common oral fungal infections in humans. This is an opportunistic infection, often affecting individuals who are debilitated by another disease. Oral candidiasis affects 65-93 % of elderly patients wearing dentures. Localized oral candidiasis should be managed initially with local treatment confined to the site of involvement before systemic antifungal drugs are used. Recognition of the potential risk and early treatment of oral candidiasis may prevent serious morbidity in high-risk patients. A study evaluated the efficacy of fluconazole mouthrinse compared to clotrimazole mouthpaint in the treatment of oral candidiasis.

  

   43 patients were treated with fluconazole mouthrinse (Group A) and 46 patients were treated with clotrimazole mouthpaint (Group B). Group A used a suspension of 2 mg/ml of fluconazole in distilled water (with no sweetness and flavor) which was prepared by a hospital pharmacist, stored in brown bottles and kept refrigerated. Each patient in this group was instructed to rinse 5 ml of the treatment solution for 2-3 minutes and then swallow. Mouthrinse was used three times daily for two weeks. Patients were instructed to avoid consuming water and food for at least two hours after rinsing, and to maintain their oral hygiene. Group B patients were treated with commercially available clotrimazole 1% mouthpaint (Candid Mouthpaint 1%, Glenmark Pharmaceuticals) which was dispensed in small amber-colored bottles. Patients were advised to apply the mouthpaint to affected areas with the index finger three times daily for two weeks.

  

   The clinical resolution rates in Group A and Group B were 96% and 78%, respectively. More fluconazole-treated patients remained disease-free during the 15 day follow-up than those treated with clotrimazole. Both treatment regimens were well tolerated. Only one patient in Group A reported mild gastrointestinal discomfort three days after ingesting the rinse; the discomfort resolved spontaneously and did not require any medical intervention.

  

   The advantages of mouthrinses over other type of applications are as follows:

• In patients with dry mouth, tablets given to dissolve in the mouth may be poorly soluble. Epstein reported that fluconazole is detected in saliva two hours after systemic administration. On the other hand, fluconazole mouthrinse enhances the drug exposure to the oral mucosa immediately, and lasts for four hours, compared with the same dose administered systemically. Because the pathogenic microorganisms in oral candidiasis are usually in the superficial layers of the oral mucosa, the effectiveness of this mouthrinse may be attributed to the temporarily higher concentration at the affected site, resulting in improved efficacy.
• Mouthrinses may reduce the risk of systemic adverse effects and drug interactions.

  Although the number of patients in the present study was small, the outcome was promising. Additionally, the dose of fluconazole used per day was only 30 mg, which is less than one-third of the standard oral dose of fluconazole (100 mg).

  

Note: Mouthrinse and mouthpaint may not be effective in the treatment of widespread severe oral candidiasis in immuno-compromised patients.

  

    Using pharmaceutical grade bulk powders as a source of active ingredients (antibiotics, anesthetics, etc.) to compound mouthrinses offers numerous advantages versus the common practice of combining commercially available products:

• Palatability - Compounded preparations do not contain multiple groups of excipients (such as preservatives and suspending agents) that may not be compatible and can create a chalky or unpleasant feel when multiple preparations are combined.
• Flavor (different products have different flavors, which may not taste good together)
• Dyes used to color liquid preparations may stain the oral mucosa and can be removed when the preparation is compounded.

   Compounding allows multiple active ingredients to be incorporated into customized dosage forms such as mouthrinses, gels, lozenges, etc. For example, antibiotics can be formulated as a mouthrinse or added to an oral adhesive paste to treat periodontal disease. We can compound medications that are sugar-free to reduce cariogenic potential and for diabetic patients.

  

    In the treatment of onychomycosis, compliance, drug interactions and the potential for adverse events associated with antifungal therapy are important considerations. Diabetic patients frequently take concomitant medications, and therefore, topical therapy may be preferred. Most antifungal medications are not used topically and are not commercially available as topical preparations due to concerns about lack of penetration. However, we can solve this problem by dissolving the preferred antifungal agent in pharmaceutical grade DMSO (a penetrant enhancer). Because topical therapy results in lower systemic blood levels of medications, topical therapy reduces the potential for serious adverse events associated with oral antifungal therapy.

  

   At the Nail Disease Centre, Cannes, France, 13 patients with onychomycosis, aged 25-78 years, most with involvement of the matrix region, were treated with a solution of 1% fluconazole and 20% urea in a mixture of ethanol and water, applied once daily at bedtime. In four patients there was complete resolution of the condition; four patients who had involvement of one nail only demonstrated a 90% improvement. Of the four patients who had presented with involvement of both big toenails, two showed 50% improvement bilaterally and in the remaining two patients there was a 90% improvement in one nail and a 50% improvement in the other.

  

   A randomized, double-blind study enrolled 70 patients with onychomycosis of the finger and toenails and compared treatment regimens of fluconazole 1% and fluconazole 1% with urea 40%. These results indicated topical treatment of onychomycosis with a combination of fluconazole 1% and urea 40% was more effective (82.8%) than fluconazole 1% (62.8%) nail lacquer alone. Fluconazole was well tolerated and side effects were negligible. At the end of therapy and the end of the 6-month follow-up, fluconazole 1% and urea 40% demonstrated statistically significant superiority in clinical and mycological responses.