Why It's Essential To Treat Onychomycosis As An Infection

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Here is a view of interdigital tinea pedis. As Dr. Joseph points out, onychomycosis initially starts as tinea pedis and proceeds to get under the toenails. He says it’s important to manage both conditions as they are “inexorably linked.” (Photo courtesy o
Here one can see chronic fungal onychomycosis and paronychia with osteomyelitis of the distal phalanx. Dr. Joseph says onychomycosis can lead to serious local and systemic sequelae. (Photo courtesy of Gary Dockery, DPM)
“Unless patients are properly 
managed, everybody who has onychomycosis and was treated will get it back.” 

—Dr. Joseph
“It is important to recognize onychomycosis affects a very broad age range of patients.”

— Dr. Malay
9

Dr. Joseph: The fact that onychomycosis is an infection is often overlooked. It is a fungal infection of the nail and the nail bed stratum corneum. There is no other infection anywhere on the body that we think twice about treating, but for some reason, this is an infection that we’ve always been reluctant to treat.
Just to give you an example, one of my kids came home once with a case of ringworm on his arm. The school nurse sent a note saying that he was not going to be allowed back in school unless he had a note from the doctor saying the ringworm of his arm was under active treatment. Ringworm of the arm is basically a fungal infection of the skin caused by the exact same organism that causes the fungal infection of the skin of the toes. It is a T. rubrum fungal infection. It’s tinea corporis.

When the infection is on a visible part of the body, it causes great consternation and concern. As soon as you hide it in a shoe and a sock, people just don’t seem to care about it. This is going to become especially important for our diabetic population. What infection in a diabetic don’t we treat immediately? Yet for some reason, people don’t think this is important enough to treat.
As an infection, onychomycosis can progress. We know it can start in one part of one toenail and spread throughout that toenail. It can jump from one toenail to another. It can move from skin to a toenail to other parts of the body, and it can actually move from one patient to another. As an infection, onychomycosis can also recur following treatment. It can lead to serious local and systemic sequelae.
Onychomycosis causes major quality of life issues, embarrassment, sexual dysfunction and pain. Approximately 50 percent of patients have pain with this disease.1 We should also be aware of the potential complications for patients with diabetes and the whole concept that onychomycosis acts as a reservoir for infection. In other words, there is a nasty cycle going on here. The bottom line is this is a disease that needs to be treated.

What Statistics Reveal
About The Gaps In Diagnosis And Treatment
Dr. Joseph: We know onychomycosis is a common disease. It has been estimated that 35 million patients in the United States have onychomycosis but only 6.3 million people have actually been diagnosed with onychomycosis because they are the ones who have come to physicians’ offices and actually had the condition diagnosed.2 That tells you there are approximately 29 million people walking around out there with onychomycosis who have never been seen by a physician for onychomycosis and never been formally diagnosed with onychomycosis.
In regard to the 6.3 million patients who have been diagnosed with the condition, they account for about 11 million office visits.2 This tells us the average patient is seen about twice a year by doctors when they have this disease. In short, onychomycosis is an extremely common and under-diagnosed infection that really needs to have more attention paid to it.
We know onychomycosis increases with age. About 60 percent of patients with onychomycosis are 55 or older. Even if you look at these numbers, you will see that 20 percent of patients diagnosed with onychomycosis are between 30 and 45 years of age. That’s incredibly young. Another 22 percent of these patients are between 65 and 74 years of age.2 These are still the active elderly years for many patients so we do need to aggressively treat these patients and try to cure their onychomycosis.
If you look at prescribing habits that are out there, the numbers are truly amazing to me. For the aforementioned patients who are between 30 and 45, about 85 percent of them receive some sort of prescription for onychomycosis. That number starts dropping precipitously as the age of the patient goes up. In the 46 to 54 age group, only about 75 percent of patients receive any prescription.2 That means 25 percent of these patients are leaving their podiatrists or their physician’s office without having any active treatment for this disease. I really think we can do better.

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