Metronidazole effectively reduces pain in patients after hemorrhoidectomy: Study

Metronidazole effectively reduces pain in patients after a hemorrhoidectomy, suggests a new study published in BMC Surgery.

Pain is a significant issue in post-hemorrhoidectomy. Metronidazole is being explored as an adjunctive pain management option. This meta-analysis of randomized controlled trials (RCTs) assesses metronidazole’s effectiveness and safety compared to a placebo post-hemorrhoidectomy, aiming to provide evidence-based pain management guidance. They conducted a systematic search of the Cochrane Library, Embase, PubMed, Web of Science, and ClinicalTrials.gov for RCTs comparing metronidazole to placebo after hemorrhoidectomy, covering the period from database inception to July 21, 2024. After screening per inclusion/exclusion criteria, study quality was assessed using Cochrane Handbook’s risk of bias tool (version 5.1.0). The meta-analysis was conducted using RevMan 5.3 software, the quality of outcome indicators was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and trial sequential analysis (TSA) was employed to verify the adequacy of the sample size. Results: A total of 9 RCTs were included. The meta-analysis results showed that the pain scores on the first day post-operation, the second day post-operation, the seventh day post-operation, and the fourteenth day post-operation in the metronidazole group were lower than those in the placebo group. Additionally, the rate of additional analgesia was reduced. No statistically significant differences were found between the metronidazole and placebo groups in terms of the overall incidence of complications and time to return to normal activities. Sensitivity analysis indicated that the results for pain scores on the first day post-operation were unstable. High heterogeneity was observed in pain scores on the first, second, seventh, and fourteenth days post-operation and in the time to return to normal activities. The TSA indicated that the sample size for the primary outcome measures had achieved the required information size (RIS), supporting the strength and dependability of the meta-analysis findings. Metronidazole may be effective and safe in reducing postoperative pain in patients undergoing hemorrhoidectomy. However, due to the limitations of this study, further verification is needed from future large-sample, multi-center, well-designed high-quality RCTs.

Reference:

Dong, H., Chen, WX., Li, YJ. et al. Efficacy of metronidazole in reducing pain after hemorrhoidectomy: a meta-analysis of randomized controlled trials. BMC Surg 25, 92 (2025). https://doi.org/10.1186/s12893-025-02819-7

Keywords:

BMC Surgery, Metronidazole, pain, patients, hemorrhoidectomy, Dong, H., Chen, WX., Li, YJ.

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‘Inflammatory’ diet during pregnancy may raise child’s diabetes type 1 risk

A diet high in foods with the potential to promote low grade inflammation during pregnancy may raise that child’s risk of developing type 1 diabetes, suggests Danish research published online in the Journal of Epidemiology & Community Health.

This dietary pattern was associated with a 16% heightened risk for every unit increase in a dietary measure of inflammatory food intake, the findings show.

Type 1 diabetes is an autoimmune disorder characterised by the destruction of insulin-producing β-cells in the pancreas, necessitating lifelong insulin treatment.

New cases of type 1 diabetes have been rising steadily, increasing by an average of 3-4% every year, especially in developed nations, strongly suggesting a major role for environmental factors, note the researchers.

And since the immune system develops and establishes in early life, and to a certain degree before birth, there is a strong case for exploring the role of the mother’s diet during her pregnancy, especially as mounting evidence suggests that diet is a modifiable contributory factor to low grade systemic inflammation, they explain.

To explore this further, the researchers drew on pregnant women in The Danish National Birth Cohort (DNBC) (January 1996 to October 2002).

They calculated a score based on the inflammatory potential of the mother’s usual dietary intake (EDII score) in mid-pregnancy from a comprehensive food frequency questionnaire, covering 38 food groups (360 separate items), which was completed at around 25 weeks of pregnancy.

Foods that are often reported to have inflammatory properties include: red/processed meats; sugar sweetened drinks: commercial baked goods; refined grain products, such as white bread and pasta; deep fried foods; foods high in added sugar; and trans fats found in non-dairy creamers and some margarines.

In all, 67,701 mother-child pairs were included in the final analysis.

Information on type 1 diabetes diagnoses in the children was obtained through registry linkage to the Danish Registry of Childhood and Adolescent Diabetes. Some 281 (nearly 0.5%) developed the condition during an average tracking period of 17 years. Their average age at diagnosis was 10.

The mothers’ average EDII scores ranged from −5.3 to 4.1, with higher scores indicating higher dietary intake of inflammatory foods.

Higher EDII scores were associated with younger maternal age, lower alcohol consumption, shorter breastfeeding period, and less favourable socioeconomic circumstances. They were also associated with higher BMI (weight) and a tendency to smoke beyond the first 12 weeks of pregnancy.

There was no significant difference in total energy intake between those women with the highest and lowest EDII scores. But higher daily intake of red meats, dairy low fat, pizza, margarine, potatoes, low energy drinks, French fries, and savoury snacks was reflected in higher EDII scores.

On the other hand, higher daily intake of alliums (onions and garlic), tomatoes, whole grains, coffee, green leafy vegetables, fruit juice, dark meat fish, tea, and fruits was reflected in lower EDII scores.

The risk of a child’s type 1 diabetes was associated with their mother’s EDII score, rising by 16% for each unit increase in score up to the age of 18, after accounting for potentially influential factors. Put simply, 1 unit of EDII, which is one standard deviation of the distribution of EDII, corresponds approximately to going from the bottom 3rd to the top 3rd of the population.

This risk wasn’t affected by the child’s sex or weight at birth, but it did seem to be affected by the mother’s intake of gluten, and whether she smoked during her pregnancy.

A 10 g increase in estimated intake of gluten was associated with a 36% increase in risk.

This is an observational study, and as such, can’t establish cause and effect. And the researchers weren’t able to account for the child’s diet.

But they write: “A low-grade inflammatory state secondary to an altered immune cell profile, which triggers pro-inflammatory pathways, is increasingly acknowledged as a critical early-life factor influencing offspring health.”

They caution: “The precise mechanisms by which diet modulates the immune response remain elusive, although some clues can be offered for specific dietary components.”

They add: “Of particular note is the fact that three factors during mid pregnancy, a pro-inflammatory dietary pattern, gluten, and smoking, seemed to independently predict the child’s risk of type 1 diabetes. This suggests that mid-pregnancy may be a critical period during which the fetus is particularly susceptible to maternal lifestyle influences in relation to the individual’s later risk for developing type 1 diabetes during childhood or adolescence.”

Reference:

Noorzae R, Bjerregaard AA, Halldorsson TI, et alAssociation between a pro-inflammatory dietary pattern during pregnancy and type 1 diabetes risk in offspring: prospective cohort studyJ Epidemiol Community Health Published Online First: 01 July 2025. doi: 10.1136/jech-2024-223320

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Telangana MBBS interns allege colleges threaten NEET PG future over stipend row

Hyderabad: MBBS interns from several private medical institutes in Telangana have alleged receiving threats from college managements with academic repercussions if they continued to raise concerns over unpaid or delayed stipends.

It has been alleged that the private medical colleges have warned of denying internship completion certificates to the MBBS interns. Without the internship certificates, these interns will not be able to appear in the National Eligibility-Entrance Test Postgraduate (NEET-PG) 2026 examination. 

Medical Dialogues had earlier reported that the intern doctors at the private medical colleges in Telangana had been protesting against the non-payment of the rightful stipend for the last three months.

As per a 2023 Government Order, the MBBS interns across both private and government medical colleges in Telangana need to be paid Rs 25,906 per month. Medical Dialogues had earlier reported that recently, the Telangana Government announced a 15 per cent stipend hike for MBBS interns and doctors pursuing post-graduate and super-speciality courses in medicine and dentistry in government institutes across Telangana.

Due to the new Government Order issued on June 28, 2025, the monthly stipend for the house surgeons (medical and dental) was increased from Rs 25,906 to Rs 29,792. However, the MBBS interns at the private medical colleges in Telangana have been alleging that the institutes have been paying them meagre stipend- as low as Rs 2,000 per month.

Also Read: Medical College Suspends 64 MBBS Interns who protested Against Non-Payment of Stipend

Earlier, the authorities at the Chalmeda Anand Rao Institute of Medical Sciences (CAIMS), a private medical college based in Karimnagar, Telangana, had suspended 64 MBBS interns at the medical college for a week for allegedly blocking the vehicles during a protest on the campus. While the medical college alleged that the action was taken based on the findings by a disciplinary committee, the students had claimed that it was a retaliatory move against the protest.

As per the latest media report by The Hindu, the MBBS interns at several private medical colleges in Telangana have alleged being threatened with academic repercussions if the students continued to protest over the stipend issue. At Patnam Mahender Reddy Institute of Medical Sciences, students claimed that the college had warned them not to pursue the stipend issue further.

Commenting on the matter, an intern from the medical college told The Hindu, on the condition of anonymity, “They told us that if we raise it again, we will not be given our internship completion certificate when we pass out. Without that, we cannot appear for NEET PG.”

Even though the college recently credited Rs 28,500 to the accounts of the intern doctors (Rs 25,500 as stipend for three months and Rs 3,000 as reimbursement for scrubs), the students said that the stipend amount of Rs 8,500 per month was never officially acknowledged by them. The students are also uncertain about the future payments.

At Chalmeda Anand Rao Institute of Medical Sciences, the current batch of MBBS interns has not received any stipend since the commencement of their internship on April 21.

While previous batches received Rs 2,000 per month, the students claimed that management did not made any payments and did not clarify regarding a revision as well. 

Speaking to the Daily, an intern, who was among the 10-15 students to submit a written complaint to the State Vigilance Committee, said, “They asked us to open bank accounts, but have not credited a rupee.”

“I have paid ₹3 lakh over five years as an ‘A’ category student, in addition to ₹5,000 per year towards a ‘stipend fee’ that was collected along with tuition. Still, we are being denied any stipend,” an MBBS intern from Hyderabad said.

As per the Daily, some private medical colleges have reportedly agreed to hike stipends to Rs 7,000 to Rs 10,000 per month. However, the implementation remains patchy.

Meanwhile, taking note of the complaints from students, the State government has initiated a State-wide vigilance inquiry into these private medical colleges, The Hindu has reported.

Confirming this, a senior Health Department official said that the decision was prompted by internal assessments revealing that over half of the 29 private medical colleges in the State had submitted fabricated information in response to official notices. 

Issuing these notices, the State sought detailed explanations on 17 parameters, including stipend disbursement, patient care quality, faculty, availability, clinical infrastructure, biometric attendance systems, and the constitution of key regulatory committees within institutions.

Commenting on this, the official said, “Only four colleges were found to be compliant with the prescribed norms.” Further, the official added that responses received from the remaining colleges were found to be unsatisfactory and misleading.

According to the official, the findings reflected a broader pattern of institutional neglect, where both undergraduate and postgraduate students are being denied stipend and the students are being made to train in substandard clinical environments.

Some of the PG students deposed before vigilance authorities highlighting troubling revelations. In one such instance, an inspection at a private medical college in Suraram exposed severe discrepancies in stipend disbursal and academic governance, prompting the State to widen the probe and initiate raids across other private medical colleges.

Following this, the State issued directions to Kaloji Narayana Rao University of Health Sciences (KNRUHS) to begin formal proceedings against defaulting institutions. The probe revealed that several medical colleges failed to adhere to the National Medical Commission (NMC) norms. Further, it revealed that mandatory bodies such as anti-ragging committees, internal complaints committees to address sexual harassment, hospital infection control teams, and standard diagnostic services, including X-rays, CT scans, MRIs and lab facilities, were either absent or non-functional in many institutions.

Meanwhile, the NMC Chairman, during a recent visit to Hyderabad, reiterated that stipend payment is non-negotiable and binding for all institutes. 

Commenting on these developments, the health department official warned, “If colleges are found guilty of persistent violations, they could face cancellation of their affiliation certificates by KNRUHS, and the Essentiality Certificates granted by the State. This, in turn, could prompt the NMC to withdraw their operational licences entirely.”

Also Read: Telangana Stipend row: Medicos allege retaliatory suspensions, doctors body seeks NMC intervention

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This artificial sweetener could make cancer treatment less effective: Study

Sucralose is a popular sugar substitute for people who are cutting calories or managing blood sugar levels, but new research by the University of Pittsburgh and UPMC Hillman Cancer Center suggests that the artificial sweetener may not be the best choice for patients undergoing cancer immunotherapy.

Publishing today in Cancer Discovery, a publication of the American Association for Cancer Research, the study found that patients with melanoma and non-small cell lung cancer who consumed high levels of sucralose had worse response to immunotherapy and poorer survival than those with diets low in the artificial sweetener.

Strikingly, supplements that boosted levels of the amino acid arginine mitigated the negative effects of sucralose on immunotherapy in mice, an approach that could now be tested in clinical trials.

“It’s easy to say, ‘Stop drinking diet soda,’ but when patients are being treated for cancer, they are already dealing with enough, so asking them to drastically alter their diet may not be realistic,” said lead author Abby Overacre, Ph.D., assistant professor in the Department of Immunology at Pitt and UPMC Hillman. “We need to meet patients where they are. That’s why it’s so exciting that arginine supplementation could be a simple approach to counteract the negative effects of sucralose on immunotherapy.”

Senior author Diwakar Davar, M.D., associate professor of medicine at Pitt and a medical oncologist and hematologist at UPMC Hillman, collaborating with Overacre and their team, used mouse models to show that the negative impacts of sucralose are driven by disruption to gut bacteria.

Sucralose shifted the composition of the mouse gut microbiome, increasing bacterial species that degrade arginine, which reduced levels of this amino acid in the blood, tumor fluid and stool.

Immune checkpoint inhibitor immunotherapies such as anti-PD1 work by ramping up T cell activity so that they can more effectively kill cancer cells. Arginine is essential for T cell function, especially in cancer.

“When arginine levels were depleted due to sucralose-driven shifts in the microbiome, T cells couldn’t function properly,” said Overacre. “As a result, immunotherapy wasn’t as effective in mice that were fed sucralose.”

In mouse models of adenocarcinoma and melanoma, adding sucralose to the diet inhibited anti-PD1 therapy, leading to larger tumors and poorer survival. But when the researchers gave sucralose-fed mice arginine or citrulline, which is metabolized into arginine in the body, the effectiveness of immunotherapy was restored.

To assess the relevance of these findings for humans, the researchers looked at 132 patients with advanced melanoma or non-small cell lung cancer who received anti-PD1 therapy alone or in combination with chemotherapy. Patients filled out detailed diet history questionnaires that included questions about how often they consumed artificial sweeteners in coffee, tea and diet soda.

“We found that sucralose impeded the effectiveness of immunotherapies across a range of cancer types, stages and treatment modalities,” said Davar. “These observations raise the possibility of designing prebiotics, such as targeted nutrient supplementation for patients who consume high levels of sucralose.”

The researchers hope to launch a clinical trial investigating whether citrulline supplements — which boost arginine levels more than arginine itself — affect the gut microbiome and anti-tumor immune response in patients.

They are also interested in looking at how other sugar substitutes, such as aspartame, saccharin, xylitol and stevia, impact the immune system and response to immunotherapy.

Reference:

Kristin M. Morder, Madison Nguyen, Sucralose consumption ablates cancer immunotherapy response through microbiome disruption, Cancer Discovery, https://doi.org/10.1158/2159-8290.CD-25-0247.

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Plastic pollution is an underrecognized threat to health, experts warn

Ahead of the expected finalization of a UN global plastics treaty, a group of international experts calls for a greater focus on health impacts when considering plastic pollution. The Health Policy published in The Lancet reviews the current evidence on how plastics—including microplastics and plastic chemicals—impact health and announces the launch of a new project tracking these impacts: the Lancet Countdown on Health and Plastics.

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How leukemia virus stays hidden in the body—and a key to future treatments

A research team from Kumamoto University has made a new discovery that reveals how the human T-cell leukemia virus type 1 (HTLV-1) silently persists in the body. Their finding potentially lays the foundation for new therapeutic approaches. Their study, published in Nature Microbiology, identifies a previously unknown genetic “silencer” element that keeps the virus in a dormant, undetectable state.

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Bacterial cellulose-based dressing offers rapid bleeding control for burn wound care

In a study published in Advanced Materials, a research team developed an innovative bacterial cellulose (BC)-based hemostatic dressing that enables rapid and sustained bleeding control.

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Two-Thirds of Indian Children With Lupus Develop Nephritis Early, Registry Finds

India: A recent study from India has revealed that kidney involvement is highly prevalent among children diagnosed with systemic lupus erythematosus (SLE), with nearly two-thirds developing lupus nephritis (LN) either at diagnosis or within five years. These findings are part of the first report from the Indian Pediatric Lupus Nephritis (pLN) Registry and were published in Clinical Rheumatology by Dr. Sanjukta Poddar and colleagues from the Institute of Child Health, Kolkata.

The Indian pLN Registry, which began in 2020, is the first prospective initiative of its kind in a low- and middle-income country (LMIC). It collects data from multiple centers across India to better understand the clinical characteristics, laboratory parameters, and renal biopsy findings in children (≤18 years) diagnosed with lupus and nephritis. The present report captures the initial clinical presentation of these children and highlights some stark patterns.

The following were the key findings of the study:

  • Of the 154 children enrolled in the registry by July 2024, 75% were female. The median age at diagnosis was 12 years.
  • Most children had kidney involvement at the time of lupus diagnosis, while others developed nephritis within five years.
  • Edema was present in 75% of the children.
  • Hypertension was in 54% of cases.
  • Proteinuria was detected in 98% of children, with nearly 70% exhibiting nephrotic-range protein loss.
  • Acute kidney injury (AKI) occurred in 43% of patients, with 20% having stage 3 AKI.
  • Low complement levels (C3, C4, or both) were in 94% of the cohort.
  • Anti-nuclear antibody positivity was seen in 96% of children.
  • Class IV lupus nephritis was the most common renal biopsy finding, affecting 45% of patients.
  • Class IV lupus nephritis was associated with significantly lower kidney function compared to Class V, indicating a more severe disease course.

The researchers noted that AKI, often overlooked in earlier studies due to retrospective data limitations, was found to be far more common when assessed prospectively. Given its independent link with increased morbidity and mortality, early identification and management of AKI in pediatric lupus is critical.

The report highlights the urgent need for better awareness, early diagnosis, and robust follow-up in managing pediatric lupus nephritis, particularly in resource-constrained settings. As children enrolled in the registry continue to be followed up, researchers hope to gain deeper insights into treatment responses and long-term outcomes, which could ultimately help refine care protocols and improve prognosis for affected children in LMICs.

The authors concluded, “The study emphasizes the value of prospective data collection in understanding disease burden more accurately and shaping more effective, evidence-based strategies for managing pediatric lupus nephritis.”

Reference:

Poddar, S., Dasgupta, D., Pradhan, S. et al. Clinical presentation of children with lupus nephritis from a low- and middle-income country (LMIC): an initial report from the Indian pSLE Nephritis Registry. Clin Rheumatol (2025). https://doi.org/10.1007/s10067-025-07576-9

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What are Key Predictors and Management Factors for Orthokeratology Effectiveness in Myopic Children? Study Finds Out

China: A new study published in BMC Ophthalmology has identified key factors influencing the success of orthokeratology (Ortho-K) in slowing axial elongation among children with myopia. Researchers found that age, spherical equivalent refraction (SER), and parental high myopia significantly affect treatment outcomes. Additionally, maintaining proper lens decentration without visual disturbances and adhering to regular follow-ups were shown to enhance the efficacy of myopia control.    

The retrospective analysis, conducted by Kai Wang and colleagues at the Institute of Medical Technology, Peking University Health Science Center, Beijing, reviewed 542 eyes from 300 myopic children fitted with Ortho-K lenses between January 2022 and December 2023. They evaluated Baseline ocular measurements, such as corneal parameters, anterior chamber depth, pupil size, and treatment zone characteristics. Researchers also incorporated genetic factors, parental myopia status, and lifestyle habits—including near-work duration, outdoor activity, diet, and follow-up compliance—collected through detailed questionnaires.

The findings revealed the following:

  • Children who started orthokeratology treatment at a younger age showed greater axial length elongation (ALE).
  • Patients with less baseline myopia experienced faster ALE progression.
  • High myopia in both parents was associated with increased ALE.
  • Larger treatment zone decentration, when without visual disturbances or complications, was linked to slower axial elongation.
  • Regular and consistent follow-up examinations were crucial for better control of myopia progression.

Researchers emphasized that the study’s strength lies in its comprehensive approach, integrating a wide range of ocular, genetic, and behavioral factors in a relatively large cohort. This holistic evaluation highlights the importance of combining precise clinical assessments with parental involvement and lifestyle management to optimize myopia control strategies.

Despite its robust design, the study acknowledged several limitations. Being retrospective, it relied partly on parental recall for lifestyle factors, which may have introduced memory bias. Approximately 10% of cases were excluded due to incomplete data or low-quality questionnaires, and the absence of a prospective design limits causal inference. Additionally, the complex etiology of myopia, influenced by environmental and behavioral factors, suggests that further research with prospective, multi-time-point data collection is necessary to validate these findings.

The authors concluded that understanding these predictive factors can help clinicians better tailor Ortho-K treatment plans. “Younger children, those with lower baseline myopia, and with both parents highly myopic require closer monitoring and possibly additional interventions to maximize treatment effectiveness,” they noted. Encouraging regular follow-ups and educating families on healthy visual habits were highlighted as essential steps to enhance myopia management and reduce trial-and-error in clinical practice.

By integrating personalized lens fitting, maintaining optimal decentration, and addressing genetic and lifestyle influences, the study suggests that orthokeratology can be a powerful tool in combating progressive myopia and its associated long-term visual complications in children.

Reference:

Deng, Y., Li, X., Zhao, M. et al. Critical factors to predict efficacy of orthokeratology in inhibiting axial elongation in myopic children. BMC Ophthalmol 25, 433 (2025). https://doi.org/10.1186/s12886-025-04265-8

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Efinaconazole 10% Proven Safe and Effective for Toenail Fungus in Older Adults: Study

A post hoc study published in Mycoses has confirmed that efinaconazole 10% solution is both effective and safe for treating toenail onychomycosis in adults aged 65 and older. Despite age-related nail changes, the treatment showed comparable results in older adults and the general population, supporting its use in elderly patients. The study was conducted by Shari R. and colleagues.

Onychomycosis, a fungal toenail infection, is particularly common in the elderly. Thicker nails and slower growth, both associated with aging, as well as comorbid medical conditions, contribute to making the infection more difficult to treat. Oral antifungals, while effective, carry risks including liver injury and drug–drug interactions that are particularly problematic in this age category. Topical treatments such as efinaconazole 10% solution, which can be applied locally to the nail with minimal absorption into the body, provide a safer option. Hitherto, there have been sparse data on their efficacy particularly among elderly populations.

This analysis employed data from two multicenter, randomized, double-blind, vehicle-controlled phase 3 trials (NCT01008033 and NCT01007708), involving once-daily use of efinaconazole 10% solution or vehicle for 48 weeks with a post-treatment follow-up period of 4 weeks. The analysis was applied to a subgroup of patients 65 years of age or older, with mild to moderate toenail onychomycosis, consisting of 162 patients who received efinaconazole and 56 patients treated with vehicle. The main outcome was 52-week complete cure, which was taken as 0% clinical involvement of the target toenail and mycologic cure (negative potassium hydroxide [KOH] microscopy and fungal culture). Secondary outcomes were mycologic cure and complete or near complete cure (≤5% nail involvement + mycologic cure). Safety was evaluated through treatment-emergent adverse events (TEAEs).

Results

• At week 52, 13.6% of the subjects between the ages of 65 and 71 years receiving efinaconazole had a complete cure, whereas only 3.6% in the vehicle group a statistically significant difference (p < 0.05).

• Complete or near-complete cure rate was significantly greater in the efinaconazole group as well at 19.1%, compared with 5.4% with vehicle (p = 0.01).

• Most significantly, 59.2% of the patients had a mycologic cure on efinaconazole, as compared to a mere 12.5% in the placebo group (p < 0.001).

• TEAEs due to treatment were low with efinaconazole at 6.0%, which was comparable to the rates experienced by the total study population.

• These results highlight the safety and efficacy of efinaconazole even among elderly patients, who often present with more recalcitrant nail conditions.

Efinaconazole 10% solution was both safe and effective in the treatment of toenail onychomycosis among adults aged 65 years and older. With notable improvement in cure rates and minimal adverse effects, efinaconazole is a worthwhile treatment option for older adults who are not candidates for systemic antifungal treatment.

Reference:

Lipner, S. R., Gupta, A. K., Joseph, W. S., Elewski, B., Guenin, E., & Vlahovic, T. C. (2025). Efficacy and safety of efinaconazole 10% topical solution for treatment of onychomycosis in older adults: A post hoc analysis of two phase 3 randomised trials. Mycoses, 68(5), e70069. https://doi.org/10.1111/myc.70069

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