A Guide To Treatments For Onychomycosis

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Continuing Education Course #111 — August 2003

I am very pleased to introduce the latest article, “A Guide To Treatments For Onychomycosis,” in our CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Obviously, onychomycosis is a common condition that you see in your practice. It is also a condition that has become increasingly more prevalent in older patient populations. In this article, Dr. John Mozena reviews the etiology and diagnosis of the condition, and explores the various treatment options for onychomycosis, including combination therapy of topical and oral medications.

At the end of this article, you’ll find a ten-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 61 and successfully answering the questions on pg. 68. Use the postage-paid card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Mozena has disclosed that he is a member of the Speaker’s Bureau for Dermik Laboratories.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: August, 2003.
EXPIRATION DATE: August 31, 2004.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss how to diagnose a fungus infection in the nail;
• explain the principles of debridement and chemical avulsion in treating nail fungus infections;
• describe the mechanism of action for ciclopirox;
• differentiate between the oral medications griseofulvin, itraconazole and terbinafine; and
• discuss the rationale of employing combination therapy to treat onychomycosis.

This article is supported by an educational grant from


Take note of the superficial white onychomycosis (SWO) of the third and fourth toenails. SWO is the second most common type and accounts for 10 percent of onychomycosis. (Photo courtesy of Aditya Gupta, MD)
Here is severe onychomycosis with onycholysis and subungual debris. (Photo courtesy of Aditya Gupta, MD)
Here is a view of onychomycotic nails irritating plantar aspects of toes in a patient who has diabetes. (Photo courtesy of Jeffrey Page, DPM)
The above patient, a fire chief, presented with an approximately half-infected medial border.
The above patient, a fire chief, presented with an approximately half-infected medial border.
After three months of treatment with ciclopirox lacquer and terbinafine, the patient’s nail showed signs of clearing and the infection was resolving.
After three months of treatment with ciclopirox lacquer and terbinafine, the patient’s nail showed signs of clearing and the infection was resolving.
By John Mozena, DPM

Onychomycosis is the number one diagnosed and treated disease by podiatrists today. While the disease was first recognized in the United States in 1928, it has only recently been brought under control with drugs that have been introduced in the last 10 years. With the advent of safer oral and topical medications, there has been a renewed focus on increasing efficacy rates. The current research seems to be centered on synergistic activity of oral and topical medications as well as different vehicles to add additional penetration of the medication.
Onychomycosis is present in 2 to 3 percent of the population with the most common source of contamination coming from the patient’s own skin. Currently, 70 percent of the population has fungus recovered from the feet. Fifteen to 20 percent of people between the ages of 40 and 60 have onychomycosis, 32 percent of 60- to 70-year-olds have nail fungus and approximately 50 percent of those over 70 are afflicted.

A 1965 U.S. study stated fungus can also be contagious throughout the patient’s own body and can also spread among individuals. In a study of 963 children cultured for onychomycosis, 263 (30.74 percent) were positive. The number of cases rose quickly with the age of the child, with only 25 percent of the patients being below the age of six.
The question of treatment is always present due to the fact that onychomycosis has been considered a cosmetic problem in the past. This has led many physicians to falsely believe that this infection should be monitored and not treated. However, recent evidence shows this is not the case. Seventy-five percent of the people who have this infection exhibit psychosocial concerns. These people face the dilemma of not being able to go to the swimming pool, public shower areas or even wear open-toed sandals. More important is the fact that 48 percent of the people with onychomycosis have pain. The pain is intense enough to have these patients miss 1.8 days of work on average over a six-month period.1,2,3

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