Exploring Treatment Approaches To Various Cases

Start Page: 27
Here one can see 100 percent relapse of onychomycosis 18 months after a course of terbinafine. Prevention of relapse medication had been discontinued when the patient became pregnant. (Photo courtesy of Kenneth Malkin, DPM)
Here one can see 20 percent proximal clearing two and a half months after the second course of terbinafine and daily ciclopirox. (Photo courtesy of Kenneth Malkin, DPM)
“I feel
comfortable starting the
topical treatment without a
definitive
culture.”
— Dr. Malkin
30

Dr. Malkin: The first case I will present centers around a 36-year-old female with a non-contributory medical history who presented with a totally dystrophic isolated hallux nail that had 100 percent involvement. I treated this patient with oral medication and at one point, she had approximately 75 percent proximal clearing of the nail.
Then the patient became pregnant and could not use any topicals or orals at all. She came back about 18 months later with 100 percent relapse of her nail. This case illustrates how fast onychomycosis can either recur or relapse.
In this case, I feel the benefit-risk ratio for a pregnant woman is not there so I would not treat onychomycosis in a pregnant woman.
Dr. Joseph: I don’t think I would treat a pregnant woman with just about anything either. It’s too risky, even though we know with ciclopirox lacquer, you are looking at like a nanogram of absorption. Still, it is an absorption that I don’t even want to start playing with for these patients. I certainly would not use itraconazole.
Dr. Malay: I would fall back on mechanical debridement and stay on top of it that way.

Case Study: A Teenager
With Hallux Nail Involvement
Dr. Malkin: I had a couple of hypothetical case studies that I would like to propose to the group. These would be hypothetical patients who might come into your office.

A 13-year-old patient presents with 15 percent distal subungual onychomycosis of a hallux nail. She is athletic and has no contributing medical history but there is a family history of onychomycosis.
How would the group treat this patient?
Dr. Malay: I would be inclined to make sure this youngster does not have some type of immunopathy that has not been identified. She may be having a cell mediated type of infection that tends to be chronic and indolent as compared to just a flare-up of tinea pedis.
Dr. Malkin: This case brings up the notion of dermatologists telling us there is no such thing as onychomycosis in young children. In reality, we see it, and I think the reason why we see it is increased athletic activity and trauma to the nails.
Dr. Cervantes: I would ask how many members in the family have this type of infection and what is the patient’s lifestyle? Is she in athletics or swimming every day?
Dr. Malkin: She is an athletic woman and both her mother and father have onychomycosis.
Dr. Joseph: If the patient is a soccer player, then you know she wears cleats and is getting her feet stepped on. All you need is the trauma to break that seal between the hyponychium and the nail for the fungus to get in there. In that case, I wouldn’t necessarily think immune compromise.
Now if I have a young patient come in — of course, a young patient in the VA is 50 — and he or she happened to have significant involvement of eight or 10 toenails, then I start thinking of some genetic problem or some immune deficiency. However, if a physically active soccer player comes in with some onychomycosis distally, I am going to treat that differently.

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