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Hi all, I have a patient who has presented today with a slightly tricky problem.
He is a male, aged 55 and has chronic OM in all toenails and fingernails (this has been confirmed by lab test), and his nails are yellow, white, green and black, and thick on all areas. This has been present for 2 years. Previous treatment given at other clinics was the removal of all his nails, topical antifungals which have contained turbinafine, and another with itraconazole. Also natural antifungals which have contained oils such as lavender, teatree ect.

After using these every day for months at a time there has been no improvement, and according to the patient and his wife they have been very compliant with treatment.

The reason why this one is tricky is that at the same time this happened to all his nails, he also developed a "nose cold" which has been present for 2 years also, with a green yellow discharge on a daily basis. He has been to ENT clinics, had antibiotics, his sinus drained ect ect.. but no improvement. He also has had a few verrucae appear around the similar time, which he has never had before, and also said that he has tinea pedis 80% of the time. He also said that he seems to get sick very easily also.

He has had general bloods done, nothing has shown up. I am assuming there must be some sort of immune issue. Any thoughts?

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I think your're right to suspect immune issue, but if nothing is showing up on blood tests, I don't see what you can to except keep it under review and keep doctor informed.

I believe it is possible to have a hayfever like allergy to fungal infections which may explain the coincidental "nose cold"- the best way of finding out is to clear to fungal infection and see if this improves!

Given the level of OM/TP I'm surprised that topical antifungals were tried at all- especially if this was not along side debridement or similar to the nails. I seem to recall that most of the study data shows this is almost bound to fail. Unless there is a reason that oral antifungals are contraindicated (ie allergy, poor liver function), this is the way to go.

Yep, if he's fit and healthy and you can get a Doctor on board I would try oral Terbinafine, take a picture before you start and then each time you debrided, as often clients "cant see any improvement" it also will give you a baseline.

And obviously routine bloods for LFTs after being on terbinafine for about 6 - 8 weeks, to exclude liver toxicity

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Well I feel chipper and confident enough enough to say that if terbinafine ends up being a no go you could also suggest that he consider looking into PinPointe Footlaser treatment. Nails and fingers can be treated. I know because I have done it and had success. Sadly I guess he would have to travel to USA or the UK at present, so in all events unlikely.

Hi Hamish,
Do you have a pin pointe footlaser? I did look into it but the cost was prohibitive to a small practice like mine. How effective have you found it?
liz

Has OM been confirmed as there are obvously other causes if discoloured / damaged nail that should be consider unless infection has been confirmed.

see above

I have a number of thoughts about this case.
Firstly, what was the identity of the fungus grown in the nails if identified by mycology testing? There are some obscure fungi and those which are not classically
Dermatophytes. The nail infection could be secondary to an underlying nail condition.

What profession/hobbies is the patient involved with? There are occupational possibilities?

This type of extensive infection and the rhinitis could indicate an immune abnormality. Simple FBC ESR etc are unlikely to identify this.

Terbinafine may be effective but consider dermatophytoma. Probably need an extended treatment although the finger nails are likely to respond more quickly than the toe nails.

Regards Mike Staineshttp://www.podiatry-arena.com/podiatry-forum/gfx_v3BrownGold/icons/icon7.gif

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