Treating Fungal Infections In Patients With Wounds

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   “If ethically promoted this way, and not as a ‘zap’ cure or described as the ‘most effective’ treatment, only then will its true value be realized and the degree of efficacy be determined,” he cautions.

   Likewise, Dr. Suzuki feels the burden is on the laser device companies to provide a large-scale randomized controlled trial to establish clinical evidence and determine if the treatment is “vastly superior” over placebo or a control group.

   Dr. Suzuki cites the advantages of having lasers as an alternative therapy to systemic antifungal therapy, which may interact with other medications or potentially cause liver injury. Furthermore, Dr. Haverstock acknowledges that lasers have a much better safety profile than oral medication, particularly in patients with chronic wounds. Such wound care patients usually have multiple medical problems and are on a number of medications, according to Dr. Haverstock. He says adding an oral antifungal agent to an already compromised patient has a risk that he believes is not worth the potential outcome.

   Dr. Suzuki feels laser onychomycosis therapy would take off if it had its own CPT code or even a partial insurance reimbursement.

   “At this moment, I have referred many patients for laser therapy to my colleague in my institution, but many of my patients seem to have second thoughts when they hear that the treatment is still cash-only and is neither quick nor a permanent ‘cure’ of fungal nails,” notes Dr. Suzuki.

   Dr. Mozena also acknowledges several questions on lasers for antifungals. Is the dual wavelength or single wavelength treatment best? Is the pulse duration or cavitations critical in killing the fungus? Is 1064 nm the right wavelength? Is spot size or the number of passes the most important factor? Can combination therapy prove more efficacious for fungus treatment?

   “All these factors need to be explored before we dismiss or proceed with this exciting new technology,” says Dr. Mozena.

Q:

Do you have any additional clinical pearls on treating fungal infections in patients with wounds?

A:

Dr. Haverstock supports performing routine debridement of the nails when treating nail fungal infections. He prefers using a nail drill to allow deep penetration of the medication. As he notes, the results are “much more impressive” when one debrides the nails every three to four weeks.

   Dr. Markinson advises podiatrists never to start oral or laser therapy for onychomycosis without absolute laboratory confirmation of a dermatophyte infection.

   “Although many do not agree and feel they can diagnose clinically, the legal ramifications of an adverse event with either therapy without laboratory confirmation are simply and unequivocally indefensible,” he says.

   Dr. Suzuki recommends using a free drug database that is available to you and your assistant at all times. He uses Epocrates (http://www.epocrates.com ) software, which is available on iPhones and online. With that free app, he says one can check for the correct dosing and drug-to-drug interactions as well as adverse reactions, pricing and pill pictures. He also recommends Medscape (http://www.medscape.com ), which also has a similar drug database and a smartphone app that is free of charge.

   Dr. Mozena says fungal disease is a constant battle between the nail trying to grow out and the fungus progressing inward. In order to address a dynamic disease, Dr. Mozena says the treatment approach should be equally dynamic.

   “We should keep an open mind to new treatment options and encourage the scientific proof of their efficacy,” he says.

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