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Research Article

Phase I Study of the Novel Antifungal Agent Dapaconazole (Zilt®) in Healthy Volunteers

T. Gagliano-Juca, A.M.M. Arruda, M.F. Sampaio, A.G. Lopes and G. De Nucci
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The study aims to evaluate the tolerability of multiple-dose topical dapaconazole tosylate, a new imidazole antifungal drug, in healthy volunteers. Twenty-four healthy volunteers (12 men) with skin pigmentation classified as I-III in the Fitzpatrick scale enrolled in this open-label, two-treatment study with daily application of 40 mg of dapaconazole for 14 consecutive days. Drug application was monitored by a physician and photographs were taken before and 1 h after application to evaluate possible dermatological reactions. Medical evaluations including physical examination, laboratory tests and electrocardiograms were performed to evaluate possible systemic adverse events. To evaluate systemic dapaconazole absorption blood samples were collected before and 2, 4 and 6 h after products application on the first day of treatment. The same occurred in days 7 and 13, but an extra 24 h sample was collected after application of the products. Dapaconazole plasma levels were measured by high-performance liquid chromatography coupled to tandem mass spectrometry. No volunteers had dermatological reactions to the formulations. Only one blood sample had detectable levels of dapaconazole (0.23 ng mL-1). One volunteer presented hypertriglyceridemia (424 mg dL-1) after the 14 days of treatment. Three months after the last dose triglycerides were back to normal range (151 mg dL-1). Dapaconazole 2% (Zilt®) showed a safe adverse event profile for topical application in daily doses of 40 mg for up to 14 days in healthy individuals.

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T. Gagliano-Juca, A.M.M. Arruda, M.F. Sampaio, A.G. Lopes and G. De Nucci, 2014. Phase I Study of the Novel Antifungal Agent Dapaconazole (Zilt®) in Healthy Volunteers. International Journal of Pharmacology, 10: 507-512.

DOI: 10.3923/ijp.2014.507.512

Received: June 26, 2014; Accepted: October 10, 2014; Published: November 28, 2014


From the beginning of the 20th century until shortly after the Second World War, potassium iodide was the standard treatment for cutaneous fungal infections like tinea and sporotrichosis (Dostrovsky et al., 1960; Urabe and Nagashima, 1969). In 1946, the first polyene antifungals were obtained from the fermentation of Streptomuces griseus, which later led to the development of nystatin and amphotericin B (Whiffen et al., 1946). Progress of antifungal drug development has since then lagged behind that of the antibacterial antibiotics. The main reason for this is that, before emergence of HIV/AIDS as a global disease, the incidence of fungal infections was believed to be very low, which prevented extensive investments in this research area (Ghannoum and Rice, 1999).

Until the discovery of the azole antifungal drugs, amphotericin B was the only treatment for disseminated fungal infections. Therefore, the antifungal azole compounds constituted a considerable advance in the treatment of superficial and systemic infections of fungal etiology. The first generation of azoles was developed in the late 1960s and included several imidazole compounds, such as miconazole, clotrimazole and ecoconazole (Botter, 1971; Buchel et al., 1972; Thienpont et al., 1975).

Nowadays, resistance to commonly used antifungals is a significant problem, especially in the nosocomial setting, either in invasive or superficial mycosis (Sternberg, 1994; Rodloff et al., 2011; Faller et al., 2011; Canton et al., 2011; Lockhart et al., 2012; Verweij and Warris, 2013). Thus, the emergence of drug-resistant fungal infections has generated the need for new antifungal drugs.

The compound dapaconazole, 1-(2-(2,4-dichlorophenyl)-2-(4-(trifluoromethyl)benzyloxy)ethyl)-1H-imidazole, CAS 1269726-67-1, is a novel imidazole derivative and exhibits interesting anti-fungal properties (Table 1) (Kepler et al., 2012). A dose finding study has already been performed in 33 healthy male volunteers.

Table 1: Minimum Inhibitory Cconcentration (MIC) of miconazole nitrate and dapaconazole tosylate against various fungal species
CFU: Colony formation units, Miconazole-N: Miconazole nitrate, Dapaconazole-T: Dapaconazole tosylate

Doses evaluated ranged from 0.5-250 mg (5 g of creams with concentrations ranging from 0.01-5%) applied in single doses to healthy skin. Only 8% of blood samples collected for bioavailability evaluation had detectable levels of dapaconazole. Detections ranged from 0.24-8.0 ng mL-1 (De Moraes et al., 2014). No volunteers had dermatological reactions to any cream concentration evaluated. The present study was designed to evaluate the safety and tolerability of chronic treatment (14 consecutive days) of 2 g of a 2% topical formulation (daily dose of 40 mg) of dapaconazole (Zilt®). The study was performed in healthy volunteers of both sexes.


Reagents: Cream containing dapaconazole tosylate 2.0% (Zilt®) and a formulation containing only vehicle were provided by Biolab Sanus Farmacêutica Ltda. (Brazil). The composition of the vehicle was as follows (w/w): Glycerol 5%, dimethicone 1%, methylparaben 0.18%, propylparaben 0.02%, edetate disodium 0.1%, octyl palmitate 10%, stearic acid 4%, glyceryl stearate/ PEG-100 stearate 14%, purified water 65%.

Human volunteers: Twenty-four volunteers (twelve men) participated in the study. Their median age was 32 years (19-46 years); mean body weight was 66.5 kg (44.0-93.0 kg), mean height was 165 cm (145-183 cm) and mean Body Mass Index (BMI) was 24.00 kg m-2 (19.63-27.60 kg m-2).

No volunteers had any significant cardiac, hepatic, renal, pulmonary, neurological, gastrointestinal or hematological diseases, as determined by their medical history, physical examination and routine laboratory tests (hematology, blood biochemistry and urine analysis) and had negative serology for HIV, hepatitis C and B (except for serologic scars). Women were negative for serum β-HCG. Because dermatological reactions are more easily evaluated in subjects with lighter skin pigmentation (Fitzpatrick scale I to III (Fitzpatrick, 1988)) and little body hair, volunteers with these characteristics were selected for the studies. Subjects were instructed to abstain from taking any drug including Over-The-Counter (OTC) medicines for 2 weeks prior to and during the study period. The study was performed according to the revised declaration of Helsinki for biomedical research involving human subjects (WMA., 2008) and the volunteers gave full informed consent. The protocol was approved by the Committee of Research Ethics of the State University of Campinas (UNICAMP), Campinas, Brazil (approval number 474.845).

Study design: The study had an open-label, two-treatments (vehicle and Zilt®) design. At first, twelve men were treated with Zilt® daily for 14 consecutive days. Treatments were performed by topical administration of 2 g of the cream on a fixed area (4×4 cm2) on the right superior region of the back. Concomitantly with treatments on the right side, volunteers received 2 g of the vehicle on an equivalent area on the left superior region of the back, as a control for possible dermatological reactions to the vehicle. The products were removed 1 h after application. After treatment in men, twelve women were treated with the same administration scheme.

Before enrolment volunteers were tested with the vehicle in order to evaluate any reactions to its components.

Dermatological evaluation: Application of the product was performed by a physician and photographic documentation was made of the sites where Zilt® (right upper back) and vehicle (left upper back) were applied. Photographs were taken daily before and immediately after the application of the products, as well as before and immediately after product removal (1 h after products administration).

Dapaconazole bioavailability: To evaluate systemic bioavailability of dapaconazole following topical application, venous blood samples (7 mL) were collected before and 2, 4 and 6 h after products application on the first day of the study. The same occurred in days 7 and 13, but an extra 24 h sample was collected after application of the products (days 8 and 14, before product administration). Collected blood samples were centrifuged at 2000 g for 10 min, plasma was separated and stored at -20°C until assayed, for pharmacokinetic studies.

Dapaconazole quantification: Plasma dapaconazole was quantified by high-performance liquid chromatography coupled to tandem mass spectrometry as previously described (De Moraes et al., 2014).


Twenty-four volunteers received treatment. There were no dermatological reactions, such as dry skin, itching, altered pigmentation or erythema after 14 days of daily exposure to 40 mg of dapaconazole (Fig. 1).

Only one sample of the 294 had detectable levels of dapaconazole (volunteer 14, sample of 6 h of day 13, 0.23 ng mL-1).

Two adverse events were detected:

Volunteer 16 presented hypertrigly ceridemia (424 mg dL-1) on the week following the end of the 14 days of treatment. Three months after the last dose triglycerides were back to normal range (151 mg dL-1)
Volunteer 20 presented low hematocrit (35%) after treatment. This adverse event was considered unrelated to therapy

Volunteers 8, 12 and 24 dropped out due to personal reasons.


The present study results demonstrated that chronic treatment with 40 mg day-1 of dapaconazole tosylate for 14 days applied to healthy skin can be considered safe in healthy volunteers. This conclusion was based on the absence of local dermatological reactions at the site of the application and the low systemic bioavailability after topical application.

Fig. 1(a-d):
Photographic documentation of possible dermatological reactions in volunteer 3 on day 14 of treatment. Figure show the back of the volunteer, (a) Before and (b) Immediately after the application of the 40 mg daily dose of Zilt® on the right side and placebo on the left side, 1 h after products administration, (c) Before and (d) After products removal

The common dermatological reactions to imidazole antifungals include erythema, dry skin, burning sensation, scaling and pruritus (Leiste et al., 1989; Jegasothy and Pakes, 1991; Suschka et al., 2002; Watanabe et al., 2007; Sharma et al., 2011). These adverse reactions are important factors in securing patient compliance with therapy, a major determinant of the success of the treatment of dermatomycosis (Ali et al., 2007; Weinberg, 2009).

A brief review of topical imidazoles available commercially today shows that these antifungal drugs have dermatological reactions as a common adverse event. In a study involving 250 patients with Tinea corporis comparing topical treatment with sertaconazole nitrate 2% cream or miconazole nitrate 2% cream twice a day for 2 weeks, the main dermatological reactions observed were: Burning in 3 (2.7%) patients receiving sertaconazole and in 2 (1.8%) receiving miconazole; pruritus in 2 (1.8%) patients of the sertaconazole group and in 3 (2.7%) of the miconazole group and dry skin in 2 (1.8%) patients receiving sertaconazole and in 4 (3.6%) individuals receiving miconazole (Sharma et al., 2011). In a similar study evaluating the safety of clotrimazole 1% cream once a day and ketoconazole 2% cream twice a day for four weeks in 106 patients (53 in each group) with Tinea pedis, dermatological reactions included burning after application of the product in one patient of each group (1.9%) and redness and scaling of one patient (1.9%) in the group receiving ketoconazole (Suschka et al., 2002). Another study evaluated the safety of the recently developed topical imidazole luliconazole in 224 patients with Tinea pedis. Patients received one of the 3 cream formulations evaluated (0.1, 0.5 and 1% luliconazole). The overall safety evaluation showed 2 cases of eczema (0.1 and 1%), 1 case of dermatitis (1%), 1 case of pruritus (0.5%) and 1 case of erythema (0.1%), all considered mild by the authors (Watanabe et al., 2007). In 955 patients treated with 1% oxiconazole nitrate in trials in the United States, the following adverse events were reported: itching (1.6%), burning (1.4%), irritation (0.4%), erythema (0.2%), maceration (0.1%) and fissuring (0.1%) (Jegasothy and Pakes, 1991). A study comparing 2% fenticonazole spray once daily versus 1% naftidine spray, once daily for 2-4 weeks, for dermatomycosis had 6% (3/50) of fenticonazole-treated patients reporting burning sensations after product application (Leiste et al., 1989). Daily occlusive patch applications of efinaconazole in concentrations up to 10% in healthy volunteers over a three-week period did not significantly change cumulative irritancy indices, when compared with vehicle and control-treated areas (Del Rosso et al., 2013).

Topical azole drugs have the therapeutic advantage of treating superficial fungal infections without generating high plasma levels of the drug, compared with orally administered azoles and thus show fewer drug interactions (Yu et al., 2005; Galatti et al., 2007; Alexandra et al., 2008; Wey et al., 2008; Broos and van Puijenbroek, 2010). A study with 2% miconazole nitrate cream in infants with diaper dermatitis showed that 80% had detectable levels of miconazole ranging from 5.2-7.4 ng mL-1 after 7 days of treatment with at least 5 applications per day. This study, however, did not specify the amount of cream (dose) applied at each intervention. No adverse events were noted in the infants with these plasma levels of miconazole (Eichenfield and Bogen, 2007). When administered intravaginally, a single-dose of an ovule containing 1200 mg of miconazole nitrate generated a mean maximum concentration (Cmax) of 10.7 ng mL-1 (Stevens et al., 2002). A single oral dose of 400 mg of posaconazole generated a mean Cmax of 611 ng mL-1 (Courtney et al., 2003). Oral fluconazole generates plasma levels of 2000 ng mL-1 after a 100 mg dose (Debruyne, 1997). Thus, dapaconazole plasma levels were much lower than those reported by several studies with topical miconazole nitrate, oral posaconazole or fluconazole.

There is no report in the literature of hypertriglyceridemia induced by treatment with topical antifungal azoles. However, orally administered azoles such as ketoconazole and itraconazole are both known to cause hypertriglyceridemia as a commonly reported but low incidence adverse event (Rollman et al., 1985; Tucker et al., 1990; De Lima Barros et al., 2011). Since the volunteer that had elevated triglycerides had no blood samples with a detectable level of dapaconazole, this systemic adverse event is unlikely to be related to the treatment.


Because of the absence of dermatological reactions to the formulation and the low systemic bioavailability, Zilt® showed a safe adverse event profile for topical application in daily 40 mg doses for up to 2 weeks in healthy individuals of both sexes. The lack of dermatological reactions also should improve patient compliance during the chronic treatment necessary for many fungal infections of the skin. This study gives support to efficacy evaluations of Zilt®.


This study was financially supported by Biolab Sanus Farmacêutica Ltda., Brazil. No authors had any financial relationship with any organizations that might have an interest in the submitted work in the previous 3 years or any other activities that could have influenced the submitted work.

Alexandra, J.F., E. Pautas, I. Gouin-Thibault, V. Siguret and M.A. Loriot, 2008. Over anticoagulation with coumarin and cutaneous azole therapy. Ann. Internal Med., 148: 633-635.
CrossRef  |  PubMed  |  

Ali, S.M., R.T. Brodell, R. Balkrishnan and S.R. Feldman, 2007. Poor adherence to treatments: A fundamental principle of dermatology. Arch. Dermatol., 143: 912-915.
CrossRef  |  Direct Link  |  

Botter, A.A., 1971. Topical treatment of nail and skin infections with miconazole, a new broad-spectrum antimycotic. Mykoses, 14: 187-191.
CrossRef  |  Direct Link  |  

Broos, N. and E.P. van Puijenbroek, 2010. Interaction between topical miconazole and coumarins. Eur. J. Clin. Pharmacol., 66: 1171-1172.
CrossRef  |  

Buchel, K.H., W. Draber, E. Regel and M. Plempel, 1972. [Synthesis and properties of clotrimazole and other antimycotic 1-triphenylmethylimidazoles]. Arzneimittelforschung, 22: 1260-1272, (In German).
PubMed  |  

Canton, E., J. Peman, G. Quindos, E. Eraso and I. Miranda-Zapico et al., 2011. Prospective multicenter study of the epidemiology, molecular identification and antifungal susceptibility of Candida parapsilosis, Candida orthopsilosis and Candida metapsilosis isolated from patients with candidemia. Antimicrob. Agents Chemother., 55: 5590-5596.
CrossRef  |  Direct Link  |  

Courtney, R., S. Pai, M. Laughlin, J. Lim and V. Batra, 2003. Pharmacokinetics, safety and tolerability of oral posaconazole administered in single and multiple doses in healthy adults. Antimicrob. Agents Chemother., 47: 2788-2795.
CrossRef  |  Direct Link  |  

De Lima Barros, M.B., A.O. Schubach, R.D.V.C. de Oliveira, E.B. Martins, J.L. Teixeira and B. Wanke, 2011. Treatment of cutaneous sporotrichosis with itraconazole-study of 645 patients. Clin. Infect. Dis., 52: e200-e206.
CrossRef  |  Direct Link  |  

De Moraes, F.C., S.F. Bittencourt, E. Perissutti, F. Frencentese and A.M.M. Arruda et al., 2014. Quantification of dapaconazole in human plasma using high-performance liquid chromatography coupled to tandem mass spectrometry: Application to a phase I study. J. Chromatogr., 958: 102-107.
CrossRef  |  PubMed  |  Direct Link  |  

Debruyne, D., 1997. Clinical pharmacokinetics of fluconazole in superficial and systemic mycoses. Clin. Pharmacokinet., 33: 52-77.
CrossRef  |  

Del Rosso, J.Q., B. Reece, K. Smith and T. Miller, 2013. Efinaconazole 10% solution: A new topical treatment for onychomycosis. Contact sensitization and skin irritation potential. J. Clin. Aesthetic Dermatol., 6: 20-24.
Direct Link  |  

Dostrovsky, A., F. Raubitschek, Z.E. Paz and B. Axelrad, 1960. The treatment of Tinea capitis with oral potassium iodide. J. Invest. Dermatol., 34: 347-349.
CrossRef  |  Direct Link  |  

Eichenfield, L.F. and M.L. Bogen, 2007. Absorption and efficacy of miconazole nitrate 0.25% ointment in infants with diaper dermatitis. J. Drugs Dermatol., 6: 522-526.
Direct Link  |  

Faller, M.A., S.A. Messer, G.J. Moet, R.N. Jones and M. Castanheira, 2011. Candida bloodstream infections: Comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-ICU settings in the SENTRY Antimicrobial Surveillance Program (2008-2009). Int. J. Antimicrob. Agents, 38: 65-69.
CrossRef  |  

Fitzpatrick, T.B., 1988. The validity and practicality of sun-reactive skin types I through VI. Arch. Dermatol., 124: 869-871.
PubMed  |  

Galatti, L., G. Mazzaglia, A. Greco, E. Sessa and C. Cricelli et al., 2007. Co-prescriptions with itraconazole and fluconazole as a signal for possible risk of drug-drug interactions: A four-year analysis from Italian general practice. Pharmacoepidemiol. Drug Saf., 16: 422-428.
CrossRef  |  PubMed  |  Direct Link  |  

Ghannoum, A.M. and L.B. Rice, 1999. Antifungal agent: Mode of action, mechanisms of resistance and correlation of these mechanisms with bacterial resistance. Clin. Microbiol. Rev., 12: 501-517.
Direct Link  |  

Jegasothy, B.V. and G.E. Pakes, 1991. Oxiconazole nitrate: Pharmacology, efficacy and safety of a new imidazole antifungal agent. Clin. Ther., 13: 126-141.
Direct Link  |  

Kepler, A.F., S.L. Sacurai, M.H. Zaim and C.E.C. Touzarim, 2012. Benzyl aralkyl ether compounds, method for preparing same, intermediate compounds, use of said compounds, method for treatment and/or prevention, pharmaceutical composition and medicament containing same. U.S. Patent Publication No. US20120196908 A1, August 2, 2012.

Leiste, D., W. Braun, W. Fegeler, K. Fegeler and A. Stary et al., 1989. A double-blind clinical trial of fenticonazole (2%) spray versus naftifine (1%) spray in patients with cutaneous mycoses. Curr. Med. Res. Opin., 11: 567-575.
Direct Link  |  

Lockhart, S.R., N. Iqbal, A.A. Cleveland, M.M. Farley and L.H. Harrison et al., 2012. Species identification and antifungal susceptibility testing of Candida bloodstream isolates from population-based surveillance studies in two U.S. cities from 2008 to 2011. J. Clin. Microbiol., 50: 3435-3442.
CrossRef  |  Direct Link  |  

Rodloff, A.C., D. Koch and R. Schaumann, 2011. Epidemiology and antifungal resistance in invasive candidiasis. Eur. J. Med. Res., 16: 187-195.
CrossRef  |  Direct Link  |  

Rollman, O., S. Jameson and H. Lithell, 1985. Effects of long-term ketoconazole therapy on serum lipid levels. Eur. J. Clin. Pharmacol., 29: 241-245.
CrossRef  |  

Sharma, A., D.G. Saple, A. Surjushe, G.R.R. Rao and M. Kura et al., 2011. Efficacy and tolerability of sertaconazole nitrate 2% cream vs. miconazole in patients with cutaneous dermatophytosis. Mycoses, 54: 217-222.
CrossRef  |  Direct Link  |  

Sternberg, S., 1994. The emerging fungal threat. Science, 266: 1632-1634.
Direct Link  |  

Stevens, R.E., J. Konsil, S.S. Verrill, P. Roy, P.B. Desai, D.H. Upmalis and F.L. Cone, 2002. Bioavailability study of a 1200 mg miconazole nitrate vaginal ovule in healthy female adults. J. Clin. Pharmacol., 42: 52-60.
CrossRef  |  

Suschka, S., B. Fladung and H.F. Merk, 2002. Clinical comparison of the efficacy and tolerability of once daily Canesten® with twice daily Nizoral® (clotrimazole 1% cream vs. ketoconazole 2% cream) during a 28-day topical treatment of interdigital tinea pedis. Mycoses, 45: 91-96.
CrossRef  |  

Thienpont, D., J. van Cutsem, J.M. van Nueten, C.J. Niemegeers and R. Marsboom, 1975. Biological and toxicological properties of econazole, a broad-spectrum antimycotic. Arzneimittelforschung, 25: 224-230.
Direct Link  |  

Tucker, R.M., Y. Haq, D.W. Denning and D.A. Stevens, 1990. Adverse events associated with itraconazole in 189 patients on chronic therapy. J Antimicrob. Chemother., 26: 561-566.
CrossRef  |  Direct Link  |  

Urabe, H. and T. Nagashima, 1969. Mechanism of antifungal action of potassium iodide on sporotrichosis. Int. J. Dermatol., 8: 36-39.
CrossRef  |  Direct Link  |  

Verweij, P.E. and A. Warris, 2013. Update on antifungal resistance in children: Epidemiology and recommendations. Pediatr. Infect. Dis. J., 32: 556-557.
Direct Link  |  

WMA., 2008. World medical association declaration of Helsinki-Ethical principles for medical research involving human subjects. World Med. J., 54: 120-124.
Direct Link  |  

Watanabe, S., H. Takahashi, T. Nishikawa, I. Takiuchi and N. Higashi et al., 2007. Dose-finding comparative study of 2 weeks of luliconazole cream treatment for tinea pedis-comparison between three groups (1%, 0.5%, 0.1%) by a multi-center randomised double-blind study. Mycoses, 50: 35-40.
CrossRef  |  

Weinberg, J.M., 2009. Increasing patient adherence in antifungal infection treatment: Once-daily dosing of sertaconazole. J. Clin. Aesthetic Dermatol., 2: 38-42.
Direct Link  |  

Wey, P.F., F. Petitjeans, C. Lions, M. Ould-Ahmed and J. Escarment, 2008. Laryngeal dyspnea in relation to an interaction between acenocoumarol and topical econazole lotion. Am. J. Geriatr. Pharmacother., 6: 173-177.
CrossRef  |  PubMed  |  Direct Link  |  

Whiffen, A.J., N. Bohonos and R.L. Emerson, 1946. The production of an antifungal antibiotic by Streptomyces griseus. J. Bacteriol., 52: 610-611.
Direct Link  |  

Yu, D.T., J.F. Peterson, D.L. Seger, W.C. Gerth and D.W. Bates, 2005. Frequency of potential azole drug-drug interactions and consequences of potential fluconazole drug interactions. Pharmacoepidemiol. Drug Saf., 14: 755-767.
PubMed  |  

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