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Is Onychomycosis A Medical Or Cosmetic Condition?

In my opinion, onychomycosis is a cosmetic concern. Rarely does a patient with nail fungus have pain. Most often, patients with nail fungus present to the office with the concern of a thickened and discolored nail that is unsightly, or patients are concerned the fungus will spread.

However, what adverse effects does nail fungus have on a person's overall health? While onychomycosis is by definition an infection, in my clinical experience, I don’t see serious adverse effects resulting from this condition. Yet, for years, we have treated nail fungus with potentially harmful and toxic oral medications that have limited success rates.

In my opinion, in the vast majority of cases I have seen, toenail fungus is cosmetic. If onychomycosis goes untreated and left alone, what happens? The nail gets worse. It becomes thicker and crumbly with more discoloration, and the emergence of lysis. I have never heard of a patient getting seriously ill or dying from onychomycosis. If people want to go through life with a thickened and discolored toenail, that is up to them. If someone wants to attempt to get a clear nail, we are here to help.

During the initial consultation for onychomycosis, I break down the condition by severity and type of fungus. To simplify it, I categorize the condition into three levels: mild, moderate or severe. Mild nail fungus includes superficial white onychomycosis but one should not confuse this with nail dehydration. The mild category would also include fungus that only occupies less than 20 percent of the nail. Moderate nail fungus involves a thicker, discolored nail that occupies 20 to 60 percent of the nail. I note the presence of minimal lysis and subungual debris. Patients who present with severe nail fungus have 60 to 100 percent nail involvement extending to the matrix, lysis, subungual debris and malodor. 

My treatment protocol for mild nail fungus includes a nail polish holiday until the condition has cleared and topical antifungal medication (efinaconazole (Jublia, Ortho Dermatologics), ciclopirox or Formula 3 (Tetra). You can also use your own compounded agent with formulations and a home remedy protocol. The home remedy protocol I recommend includes topical tea tree oils, hydrogen peroxide soaks and cleaning shoes and socks with bleach. With these treatments, onychomycosis typically goes away within one month. If it does not, I add one or two laser treatments. Avoidance of a nail salon is critical.

For moderate and severe nail involvement, I utilize a treatment program. I do not believe there is one modality that will eradicate the condition. Nail fungal involvement has high rates of resistance and recurrence. Therefore, a comprehensive program is indicated. This program includes everything I discussed in the treatment protocol for mild onychomycosis as well as the introduction of a home program, oral medication or lasers. The home program includes having the patient remove the topical medication twice a week; filing the top and tip of the nail (dipping the file in bleach or discarding it when done); soaking their nails in one of the aforementioned home remedy solutions; and subsequently reapplying the medication.

Patients need to address the home by cleaning the shower and moist surfaces with bleaching agents, discarding any bath mat and cleaning the carpet with terbinafine and Lysol (Reckitt Benckiser). I have patients discard their home slippers or any shoes that they wear daily and that are contributing to the condition. What good is it to treat the foot when the patient is going to walk barefoot on a bath mat that is infested with fungus and mold? 

When choosing between oral medication and laser treatments, I discuss the pros and cons with the patients, and let them decide. A lot of patients come into the office and immediately state that they do not want anything that can potentially harm their organs, and nothing that will interfere with other medications they are taking. Patients do not want blood work and they are not interested in oral medication. These patients are perfect for laser treatments.   

After using lasers to treat nail fungus for over ten years, here are my conclusions. Lasers do work with the right patient selection. It is best to use lasers as a part of a program with combination therapies of topical agents and nail debridement. I believe a few sessions are required over a six-month period and the strength of the laser is important. Anything less than a Class IV laser cannot provide enough heat energy to the target tissue and will be insufficient. 

For severe nail fungus, I immediately indicate to the patient that it is often difficult to provide a long-term clinical cure but I can help to greatly improve the overall appearance of the nail. The treatment program is similar to treatment for the moderate nail fungus group. However, in this subset of patients, I use a course of oral medication, extensive nail debridement, laser treatments and a home treatment program. Often, a patient requests to have the nail removed and we will start the treatment of the nail fungus two weeks after taking the nail off. 

I have grown weary of the nail culture. With the high incidence of false negative results, I rarely culture. With the popularity of owning and operating a pathology lab, more physicians are obtaining nail fungal cultures, but do cultures really change your course of treatment? If you are certain the nail contains a fungus, you will likely treat nails with your protocol. Of course, there is a small percentage of doctors who get the culture, get the exact organism and pick the medication in a targeted fashion. On the contrary, the majority of practitioners utilize one or two medications and have a standard protocol regardless of what the culture shows. Interestingly, I have found that many times when the cultures are negative, the nail is traumatized and hypertrophic, and I treat it with topical agents, nail debridement and laser, the patient outcomes are positive.


 

Comments

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I agree mostly with what Dr. Schoenhaus-Gold states about the low morbidity of onychomycosis, except in the setting of diabetes, PVD, neuropathy, and immunodeficiency. In otherwise healthy patients, of course, the morbidity is very low. However, the prescribing of an oral agent or FDA-approved topical agent, or the application of a laser to a toenail without the benefit of laboratory confirmation of the infection is not up to standard in either the podiatric or dermatology community. The fact that it is an all too common occurrence is regrettable, not acceptable. Any adverse reaction to oral medication or topical laser treatment without confirming diagnosis prior to treatment exposes the practitioner to significant litigation risk. Dermatology payouts are as high as orthopedic surgery cases. In addition, prescribing an FDA-approved topical at a cost of $5-6,000.00, even with a prevalence rate of 85% using eyeball diagnosis, still exposes the system to an unacceptable cost for the 15% who do not have the disease.
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