Compounded Medications for Podiatrists

Podiatrists may have many needs for compounded medications:

Onychomycosis – nail fungus

Commercial products to treat onychomycosis include griseoflulvin, itraconazole, Terbinafine and circlopirox 8% nail lacquer (Penlac). Griseofulvin has reported poor cure rates and requires 10 – 18 months of use. Oral therapy with itraconazole and Terbinafine also present problems with drug interactions and liver toxicity. A patient with compromised liver function or a GERD patient on a PPI will not be a candidate for oral itraconazole. For patients who cannot use antifungals, Penlac is the only commercial topical treatment available. However, Penlac reportedly has only a 14% cure rate after several months of use. Having a compounded prescription medication may overcome these problems and avoid the need for extensive liver monitoring. We can dissolve an antifungal in dimethylsulfoxide (DMSO) that has superior nail penetration and it is able to deliver an antifungal to the site of infection. Examples of antifungals that can be compounded in DMSO are azole antifungals and terbinafine.

Possible formulas:

Itraconazole 1%/Ibuprofen 2% in DMSO nail polish
Itraconazole 1%/Undecylenic Acid 17% in Tea Tree Oil-DMSO nail polish
Itraconazole 1%/Undecylenic Acid 17%/Salicylic Acid 10% in Tea Tree Oil-DMSO nail polish
Ketoconazole/Tea Tree Oil/DMSO Antifungal Solution
Terbinafine 1.67% Topical Solution

Warts

The classic treatment for warts is salicylic acid used topically. There are some unique treatments for warts that can be prepared by a compounding pharmacist involving the drugs Cimetidine, trichloroacetic acid, and 5-fluorouracial. Cimetidine at doses of 40mg/kg orally has been used to treat recalcitrant multiple warts.

Possible formulas:

Cimetidine 5%/DDG 0.2%/Tea Tree Oil 10%/Ibuprofen 2% transdermal
Salicylic Acid 40% Ointment
Salicylic Acid Compound Collodion
Salicylic Acid 28% Polymeric Substrate
Trichloroacetic Acid 2%/Salicylic Acid 60%

Non-Surgical Nail Removal

There is a compounded preparation that will allow for non-surgical nail removal that may be required for non-dermatophytic fungal infections.

Possible formula:

Urea 40% ointment

Diabetic Neuropathy

There are numerous medications that are commercially available to treat diabetic neuropathy and help return sensitization. Some of the drugs used to treat diabetic neuropathy are amitriptyline, baclofen, ketamine, gabapentin, and clonidine. Diabetic patients can benefit from topical combinations of these medications that are not commercially available. Combinations of topical medications have the advantage of fewer adverse effects as well as using one medication rather than several.

Possible formulas:

Baclofen 5%/Ketoprofen 10%/Lidocaine 5%/Gabapentin 5% transdermal
Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Lidocaine 2% transdermal
Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Nidedipine 2% transdermal
Gabapentin 6%/Clonidine 0.2% transdermal
Clonidine 0.2%/Gabapentin 6%/Ketamine 10% transdermal

For additional information on diabetic care see our diabetic page.

Hyperhidrosis of the Feet and Foot Odor

Many of the commercial products prepared for hyperhidrosis feet contain the drugs aluminum, atropine or scopolamine, formaldehyde, methenamine and glycopyrrolate. Methenamine is a pro-drug that is converted to the active drug formaldehyde. Aluminum chlorohydrate is a common ingredient found in many over-the-counter antiperspirants.

Possible formulas:

Methenamine 5% Clear Lotion/Gel
Methenamine 5% Deodorant Stick
Methenamine 5%/Benzalkonium Chloride 2%
Aluminum Chlorohydrate 5% and 10% Topical Antiperspirant Cream
Aluminum Chlorohydrate 5% Topical Powder
Aluminum Chlorohydrate 7.7% Topical Paste
Formaldehyde Roll-on Deodorant
Glycopyrrolate 0.25%/Tea Tree Oil 2.5% Deodorant/Antipersirant

Inflammation and Pain

Most topicals for inflammation and pain due to sprains and strains can be made from various NSAIDs in PLO containing ketoprofen. Of all the medications used topically in podiatry, NSAIDs probably have the most clinical data behind their use. The NSAIDs can be combined with a muscle relaxer or topical anesthetic if desired.

Possible formulas:

Ketoprofen 10%/Cyclobenzaprine 1-2% transdermal
Ketoprofen 10%/Lidocaine 5%/Bupivacaine 2% transdermal

Wound Healing and Circulation Improvement

Nifedipine has been used in concentrations of 0.2% to 10% PLO gel in an effort to enhance circulation in areas of ischemia. Higher concentrations are used by pharmacists, but the lower doses are a better starting point due to the hypotensive properties of this drug. The same vaso-dialation properties that make it work well orally in diseases such as hypertension, angina pectoris, and Raynaud’s syndrome could also make it work well as an agent to rub on areas around diabetic ulcers and in ischemic areas to aid in blood flow. Transdermal nifedipine PLO should be dispensed in an amber bag because of its light sensitivity. The patient should be monitored for decreased blood pressure while using the preparation, and the wound should be monitored for signs of healing (skin becoming more pink, vascularized and skin dryness around the wound. For more diabetic formulations, click here.

Possible formulas: