Exploring Treatment Approaches To Various Cases

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.

Should You Pursue A Culture
When Treating Children?
Dr. Malkin: What about laboratory diagnosis and confirmation on a child?
Dr. Mozena: I think there are multiple studies on this in the dermatology literature. For example, Fuchs just came out and said that 32 percent only had tinea uncultured.24 Then you look at all the different studies saying that cultures are less than 50 percent effective.25 The understanding with these studies is talking about false negatives that can occur.
After 20 years of practice, I think I have a pretty good handle on what is a fungal infection and what is not. When I treat onychomycosis, if I’m giving a topical medication, then I won’t call for a PAS, which is the most effective means of getting a diagnosis. However, if I am considering an oral medication, I want to try to get a better diagnosis. However, with a topical, I don’t feel it is necessary because of the risk-advantage ratio.
I also want to point out that many of my colleagues have talked to me about a particular nail problem and they’ll say, “Well, they have psoriasis so I don’t know if I need to worry about that.” If you look at this a little bit closer, why can’t that nail also have onychomycosis?
Also keep in mind concerning Dr. Malkin’s case with the 13-year-old patient that she may have trauma to the nail. However, when we’re looking at a traumatic event and probable nail deformity, there may be a secondary problem of onychomycosis as well. When talking about patient expectations, we need to tell patients that although they may be cured of the fungus, they may still have problems from the trauma and deformity of the nail.

Dr. Malkin: Before treating a 13-year-old child, I will almost always get a culture and KOH in order to get laboratory confirmation. If the laboratory confirmation is negative, I will still treat this as onychomycosis. However, I like the idea of getting laboratory confirmation on what I would consider sort of an atypical situation, not necessarily for a patient with a history of tinea pedis or concomitant tinea pedis, but just an isolated nail that appears to be fungal.
Dr. Mozena: We need to recognize the fact that the negative culture does not preclude treatment. There is data showing that there are problems with culturing.24-25 As podiatrists, we can use our clinical experience and we have all seen the clinical response in our patients showing that using medication on patients empirically does work well.
Dr. Malkin: Aside from debridement, I think this is what separates a specialist from a generalist. This is why a patient comes to a person who is supposed to be an expert on the disease—a dermatologist, a podiatrist—as opposed to their family practitioner, and taking that extra step gives us a leg up on treatment.
Dr. Malay: That’s why the general practitioner sends them to us.
Dr. Joseph: That’s a good point. Now would you do cultures before starting treatment or would you take the culture, start the treatment and then wait?
Dr. Malkin: If I’m using a topical for treatment, I feel comfortable starting the topical treatment without a definitive culture. Based on its safety profile in adults, ciclopirox lacquer is considered safe for use in children 12 years and older. When considering an oral medication, I will wait to get a culture result. Although I said I may treat clinically, even with a negative culture, I just feel it is prudent to have the laboratory study before providing an oral medication. Usually at the first encounter, I order baseline work and fungal cultures and KOH. I also tell the patient I’ll call him or her on the phone after the lab results are in and mail them two things: the prescription for a second set of interim lab work and a prescription for the oral agent. Then I will see these patients back in seven weeks from when they start the oral medication. I want to make sure they are taking the pill as directed and that things are going well with no adverse effects.
Dr. Mozena: One of the reasons we can initially treat with ciclopirox is because it is a broad spectrum antifungal, and that gives us the ability to specialize the treatment once we get the culture back.

What About Treating Children
Who Have Multiple Nail Involvement?
Dr. Cervantes: What if a 12-year-old patient comes in with 10 nails involved? How would you treat this patient?
Dr. Malkin: If the patient is young and has mild to moderate disease, I feel a topical prescription antifungal is the appropriate way to go in this particular scenario.
Dr. Cervantes: To change the scenario, let us say that the patient is 12 years old and has severe onychomycosis and immune compromise. Let’s say the labs are fine and the culture is positive. How will you treat this young patient?
Dr. Malkin: Dr. Joseph will tell you that terbinafine has been used in children for tinea capitis, but I have very little experience with terbinafine in children myself. I would not personally treat it that way.
Dr. Joseph: Terbinafine is not indicated in the pediatric population, but I also start looking at 13- and 14-year-olds differently than a 7-year-old or 5-year-old. If a 13-year-old has pretty significant involvement with eight, nine or 10 toenails involved, I have no problems going with an oral antifungal.
Dr. Malkin: Dr. Cervantes, have you seen these patients and presentations in your practice?
Dr. Cervantes: I have seen patients who come in with multiple nail involvement. They are non-diabetic. Obviously, the question is systemic involvement and immune compromise, but it’s an issue. We have patients who are young and our hands are tied.
Dr. Mozena: I also see children with onychomycosis and I will use terbinafine or fluconazole if the condition doesn’t first respond to the topical. Terbinafine and fluconazole are not indicated in the younger population but I have done it and I have found these medications to be successful. I am not afraid to use these medications as long as you do it by weight.
Dr. Malkin: You can’t really titrate terbinafine since you only have one tablet size, so you are cutting it in half?
Dr. Mozena: Yes.

Dr. Malkin: Perhaps the philosophy would be that you would use half a tablet if the patient is under a certain weight and a full tablet if the patient is over that weight.
Dr. Mozena: That is basically how I do it. I look at the body weight of the patient. If the patient is approximately 135 pounds or over, I use a full tablet. Otherwise I try to titrate it to their body weight.

Case Three: When There Is
Total Involvement Of Six Nails
Dr. Malkin: The next patient is a 39-year-old woman who has a non-contributory medical history and presents with 100 percent involvement of six toenails that is KOH positive. How would you approach therapy for this patient?
Dr. Malay: I would present the option of a course of topical therapy versus oral therapy with follow-up topical therapy. I’d be inclined to pursue the oral, thinking it will in all likelihood yield a better result initially. However, then it is up to the patient to take that information and determine which course she wants to pursue.
Dr. Joseph: I wouldn’t go with a topical on 100 percent involvement. I’d look at either an oral medication or combination therapy.
Dr. Malay: I would tell her that she is not likely to see results in her case with the topical, but the topical is still an option for her. If she is afraid or doesn’t want to do the oral therapy because she doesn’t want to have the liver function test, then the topical is another option.
Dr. Mozena: That’s the reality of practice. I agree with you 100 percent. I will tell my patients that the chances of curing it are very low, but a lot of patients are wary of the potential side effects of oral medications and they say, “Let’s do something else.” You can try the topical. You tell them if it is not successful, then we’ll probably have to advance to more aggressive modalities.
Dr. Malay:I am certainly coaching the patient that I think the more aggressive form would be more effective.
Dr. Cervantes: Again, there is an issue of risk involved with these oral antifungal medications. The patient needs to be aware of the potential side effects and the efficacy profile. When you present all the options, alternatives and the expectations, it might take perhaps a little longer to see improvement with topicals, but eventually, perhaps in six months, we might accomplish with a topical what you would accomplish in three months with orals.
Dr. Malkin: I think this is a classic case for me to use Dr. Gupta’s new regimen and prescribe terbinafine 250 mg daily for one month, one month off, and a third month of terbinafine at 250 mg daily, with the patient using ciclopirox daily the entire time. This is less expensive than 12 weeks of terbinafine 250 mg daily and appears to be almost equivalent. Certainly reducing the amount of terbinafine by one-third from the usual 12 weeks can only increase the safety.
Dr. Malay: That’s certainly what the literature says.

Case Four: Treating White
Superficial Onychomycosis
Dr. Malkin: For the last case, we have a 69-year-old diabetic patient who has white superficial onychomycosis.
Dr. Malay: I would use topical ciclopirox.
Dr. Joseph: When it comes to white superficial onychomycosis, topical therapy certainly is the hallmark of treatment because the fungus, which is usually T. mentagraphytes, is sitting on the superficial dorsal aspects of the nail. Because of that, I think curettage scraping of the top of the nail along with a topical antifungal certainly has been shown to be the best way to go with this presentation.

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