Patients with wounds can be especially challenging when they develop fungal infections. These panelists discuss fungal treatment options, whether they get cultures to direct treatment and address innovative fungal treatments.
Do you treat fungal skin and nail disease in patients with lower extremity wounds?
Kazu Suzuki, DPM, CWS, treats fungal skin and nail disease aggressively, especially in patients at high risk for limb loss, including those with diabetes, peripheral arterial disease (PAD) and those on dialysis. He has seen many cases in which severe fungal infections directly led to foot and leg amputations in his patient populations.
Tracey Vlahovic, DPM, FFPM, RCPS (Glasg), says she does not wear “blinders” in honing in on the wound itself. She also considers the state of skin on both legs and around the wound, wherever that might be.
As Marc Brenner, DPM, emphasizes, patients with wounds require daily special effort and meticulous care of skin and nails at all times. “There is never such a thing as ‘routine foot care’ when dealing with wound care patients,” he notes.
Do you get a fungal culture when treating fungal skin and nail diseases?
Drs. Vlahovic and Brenner always get cultures when treating fungal diseases. Dr. Vlahovic says cultures help her determine what species she is dealing with. She has also started using polymerase chain reaction (PCR) to analyze fungal infections.
In contrast, Dr. Suzuki feels a fungal culture is not mandatory before treating fungal skin and nail infection. Dr. Suzuki believes one should not delay an initiation of antifungal treatment because fungal culture may take time or may be a false negative. He does caution that some side effects from chemotherapy drugs and disease processes such as psoriasis may mimic fungal skin and nail infections.
What is your fungal treatment of choice in patients with wounds?
If he is treating fungal skin infection such as tinea pedis, Dr. Suzuki may start with oral terbinafine (Lamisil, Novartis) 250 mg once a day for two weeks. He may combine this oral therapy with a topical antifungal cream, such as terbinafine cream, or some kind of azole cream like clotrimazole or econazole cream. There are numerous prescription topical antifungals that he may use if his patient fails to respond to the first topical agent.
For Dr. Vlahovic, the answer depends on the patient’s concomitant disease, current medications and the amount of nail involved. She also considers if patients will not or cannot take an oral (or are taking too many orals), and if they can bend down to apply a topical. She does use various products for nails and tinea pedis.
Dr. Brenner also cautions that some patients, especially the elderly, refuse to take more orals and instead choose topicals, avulsion, laser debridement and/or all of the latter. As Dr. Brenner notes, patients with diabetes have multiple factors they must deal with daily. Although oral antifungals have great success rates, he says orals at times come with black box warnings that may preclude their use with several statins, which most patients with diabetes are taking. Dr. Brenner uses orals, when possible, in conjunction with several well-known topicals. He stresses the importance of foot hygiene and advises that one must always treat the skin in order to adequately address nail fungus.
For fungal nail infection, Dr. Suzuki debrides the infected nails and then uses the same regimen as with tinea pedis of oral terbinafine 250 mg once a day for two weeks. He may then see patients a month later for a physical exam and have the patient refill the prescription once a month. As Dr. Suzuki notes, this is a variation of many pulsed terbinafine therapies that appear to work well in his experience. He also cites another pulsed therapy method with one week of oral terbinafine therapy every three months, noting that this may be similarly effective.1 Dr. Suzuki says the study shows that one 250 mg tablet daily for seven days, repeated at three months intervals (total of 28 250 mg doses annually), is virtually as effective as 90 day continuous dosing.
Fluconazole is another option for PO antifungal if the patient does not respond to terbinafine, according to Dr. Suzuki. He notes the dosage varies depending on the severity of fungal infection.
Efinaconazole (Jublia, Valeant Pharmaceuticals) is a new topical solution for fungal nail infection that Dr. Suzuki has started using recently. He says efinaconazole appears to work reasonably well as a monotherapy and notes it may be even more effective if one combines it with oral antifungal therapy.
Are there any innovative technologies that hold promise for fungal infections in patients with wounds?
Although many manufacturers of laser therapies claim their devices supposedly treat fungal nail infections, Dr. Suzuki has yet to see convincing data to make him want to purchase a laser device and offer this therapy to his patients.
“As far as I am concerned, the burden of proof is on the device makers to show that the laser really treats and controls the fungal disease in a meaningful way from our patients’ perspective,” says Dr. Suzuki.
Dr. Brenner acknowledges newer and better lasers as well as new and improved topicals such as Formula 3 (Tetra Corporation) and oral medications.
Dr. Vlahovic says there are “very exciting” products on the horizon that could simplify the treatment of fungal infections in patients with wounds.
Do you have any additional clinical pearls on treating fungal infections in patients with wounds?
One should assure the patient that total cures are rare, notes Dr. Brenner. He says safe debridement of nails with proper vacuums, masks and personal protection is mandatory. Dr. Brenner also notes that debulking the nail promotes easier penetration for topicals and creates a better cosmetic appearance, facilitating patient satisfaction.
Dr. Vlahovic and Dr. Brenner advise being proactive and treating both the nails and the skin if infections are present.
Patient education may be the key, according to Dr. Suzuki. On a daily basis, he sees patients with severe fungal skin and nail infection who believe it is normal or just part of the “aging process” to have dry skin, and thick and dystrophic nails.
“I believe it is up to us to educate them that it is not okay to leave a infectious process untreated as it may lead to skin breakdown, infected ingrown nails and toe, foot and/or leg amputations,” asserts Dr. Suzuki.
Dr. Brenner is the CEO and Director of the Institute for Diabetic Foot Research in Glendale, NY, and is on the medical/surgical staff of North Shore Hospital in New York City. He is a Fellow and Past President of the American Society of Podiatric Dermatology. Dr. Brenner is also the past Co-Director of the Wound Care Division of the New Cardiovascular Horizons and the Veith Symposium.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .
Dr. Vlahovic is an Associate Professor and J. Stanley and Pearl Landau Fellow at the Temple University School of Podiatric Medicine. She writes a monthly blog for Podiatry Today. Readers can access Dr. Vlahovic’s blog at www.podiatrytoday.com/blogs/556 .
1. Zaias N, Rebell G. The successful treatment of Trichophyton rubrum nail bed (distal subungual) onychomycosis with intermittent pulse-dosed terbinafine. Arch Dermatol. 2004; 140(6):691-5.