A Closer Look At Key Treatment Strategies

Dr. Mozena: When I present my treatment plan for onychomycosis to the patient, I always present a step-wise progression with six different options. We can ignore it, debride it, provide surgical treatment, use topical medications, use oral medications or employ combination therapy.
The first option is ignore it. What are the consequences of ignoring onychomycosis? Well, obviously, there are psychological concerns and there are pain issues to consider. Onychomycosis is not only contagious to ourselves, it’s contagious to others.
The second option is debridement. When we talk about debriding, I tell them we can decrease the fungal load and give them a better psychological benefit. We also can reduce pain by reducing the pressure on the nail. However, debridement is not treatment. I explain to my patients that when we debride, we are helping your condition but we are not actually treating it.

The third option is surgical treatment. Surgical treatment is one of the older therapies that we have. When we remove the nail, we have better access to the nail bed. However, are there any consequences to removing the nail? Nail avulsions have proven to be a problem over time. If you remove the nail, you’re actually removing the dorsal pressure so you are relieving the retrograde force on the bone itself. When you release the pressure on the bone, the distal dorsal tuft on the distal phalanx hypertrophies. As it hypertrophies, it stops the distal excursion of the nail over the hyponychium edge.
This leads to distal ingrown toenails, which are extremely difficult to deal with. We have done several exostectomies. We have done distal nail fold release and wedge resections. Often we have to do a total matrixectomy. For a small longitudinal striation, it can be devastating to have to go on to a total matrixectomy. I usually preach against any type of nail avulsion.
The next option is topical medication. Up until 1992, there was no topical medication that actually was able to treat onychomycosis. In 2000, ciclopirox 8% became the first FDA-approved medication for topical treatment of onychomycosis.
The next option is oral medication. From the first medication (griseofulvin) that was introduced in 1958 through the introduction of ketoconazole in the mid-‘80s and the triazoles of the ‘90s including itraconazole and fluconazole, we had some medications that seemed to be mildly effective. However, we had many side effects including liver problems that had to be addressed. The last drug group that came out was the allymines, which includes terbinafine. That particular medication seemed to be very effective. However, we obviously have not had complete efficacy or this would be the only drug we use.

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