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It seems like such a basic topic, yet I cant seem to find a thread covering this issue in particular.
My question is...What is your gold standard fungal nail treatment? and what are success rates like?
It is understood, each patient is a different case depending on if there little Betty the 87 year old with poor kidney function or Bob the healthy 35 y.o.
My experience of practice is minimal and over this time I fid myself questioning whether my management is up to norm of the larger podiatry population.
My General treatment plan is of topical treatment with undecenoic acid and chloroxylenol in oil based tincture (brand withheld) as first line treatment,
If this is unsuccessful, and depending on patients health I may request with GP a script for oral antifungal treatment.
I have a number of patients who have been trying for 1,2,3 years and still have no success and I wonder what others are managing these apatients with.
One particular patient is a 11 y.o boy, who noticed change in nail at a school camp about 9 maonth ago.
I saw him for the first time last week and his entire nail (except for a tiny distal fragment attached to the nail bed, has gone. This includes the matrix tissue, I can put a blacks file in the space it has left under the eponychium.
The GP had previously recomended topical treatments, and oral medications are contraindicated in children.
As no debridement is possible....where too? Maybe something else going on?
I'm with mimipod, I think that heavy debridement of the infected nail is important as the acive spreading fungal elements will be at the junction between infected and uninfected nail tissue. Quite often I then recomment daily tea tree oil, and if that goes no where I'll refer to the phamacist for a topical preparation. In some cases I'll consult with the GP for scrapings and oral therapy, but not that often. In the case of your 11 year old boy, I'd be treating it topically to make sure there are no fungal elements left as the new nail grows back.
Personally I like the tea tree oil because it's natural, and everyone seems to have some the bathroom cupboard. Did see some interesting results at a conference a couple of years ago regarding the antifungal properties of lavender oil, seems it works quite well not directly applied, but as an aromatic, i.e. put a couple of drops on a cotton wool ball and put it at the end of the shoe and the aroma will penetrate through the footwear and feet, and into the infected nail/skin, helping to kill the fungus.
Treating onychomycosis is such a difficult task, and takes such a long time, makes it difficult with patients.
Good luck!
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Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
Onychomycosis is such a common condition that it deserves a closer look. I have changed treatment regimens several times throughout the years. Two treatments that I have adopted in the last couple of years are providing very decent results.
1) Nail debridement plus application of Naftin 1% gel. The patient is asked to rub the gel into not only the nail but the posterior nail fold. A significant number of patients demonstrate clearing of the nail, that is, the new nail growth emanating from the matrix. It appears that the application of the Naftin gel to the posterior nail fold is what is effective, significantly more than the nail plate itself. Naftin cream does not work, only the gel form. I assume that the penetration characteristics differ.
2) Oral meds. The persisting issues with the "official" onychomycosis medications remains high cost, the need for liver function tests, care to monitor drug reactions, battling with insurance carriers, etc. A relatively inexpensive broad spectrum and highly effective antifungal is Diflucan (fluconazole). It has the same potential issues with the other oral meds but the dose needed to cure onychomycosis is only one 150 mg. capsule once a week. At that low and infrequent dose, I have run into no problems. Additionally, the cure rate is high because of Diflucan being a broad spectrum antifungal. Patients in the US need be advised that this is an "off-label" indication by the FDA.
There are a paucity of good studies on this. The relatively low cost of Diflucan compared to other oral antifungals may fail to provide an impetus for more thorough studies in my opinion.
The link is to an article that must first be purchased to be read. Please summarize the article or provide a version that does not require a fee.
Ed Davis, DPM
I agree with several of the submitters that extensive (heavy) debridement is the key to any possible success. Over the years (41 or more) I tried just about everything (topically & systemically); and in the end, found that extensive debridement, vinegar solution soaking, scrubbing with a fairly stiff brush and an anti-microbial scrub/soap/solution, thorough drying, and finally applying vinegar (it doesn't seem to matter what kind - white or cider) directly with an eye dropper has produced the best results.
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I'm not convinced that any topical really has any SIGNIFICANT efficacy on a consistent basis, and I believe debridement is the only palliative treatment with any real success. As Dr. Davis pointed out, the oral antifungals such as terbinafine and Diflucan are oral agents with success when indicated, but as previously stated, I can't say I've had any real "luck" with any of the plethora of topicals available.
OK, OK this is my first response.
Onychomycosis is very frustrating and hard to treat. I read all the responses and agree that aggressive debridement is essential. I think first in order to know what you are treating you need to do a nail fungal test. Many of these come back as onychodystrophy. Theses nails will not get better and treatment of these with oral medications not only lowers effectiveness rate published and is contraindicated. Many of the patients I see have this condition and have been treated by primary care with 2-3 rounds of oral medications with obviously no success.
Oral lamisil, which is my treatment choice went generic about three months ago and so the cost of treatment has gone down to about $25.00/month.
Over the years I have tried ALL the topical treatments....tinctures, vinegar, Penlac etc. to limited success rates. The newer topical medications are homeopathic and include camphor, menthylateum, etc. Vick's vaporub also includes many of these and I have started using this for topical care of onychomycosis. It is essential for aggressive debridement weekly. This works as good as the expensive topical treatments out there.
Sorry for rambling. MJS
The link is to an article that must first be purchased to be read. Please summarize the article or provide a version that does not require a fee.
Ed Davis, DPM
Ed,
The Chocrane data base is free to those in countries whose governments subscribe (this includes at leaset Australia and the UK)
abstract Below
Quote:
Abstract
Background
Fungal infections of the feet normally occur in the outermost layer of the skin (epidermis). The skin between the toes is a frequent site of infection which can cause pain and itchiness. Fungal infections of the nail (onychomycosis) can affect the entire nail plate.
Objectives
To assess the effects of topical treatments in successfully treating (rate of treatment failure) fungal infections of the skin of the feet and toenails and in preventing recurrence.
Search strategy
We searched the Cochrane Skin Group Specialised Register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane LibraryIssue 1, 2005), MEDLINE and EMBASE (from inception to January 2005). We screened the Science Citation Index, BIOSIS, CAB - Health and Healthstar, CINAHL DARE, NHS Economic Evaluation Database and EconLit (March 2005). Bibliographies were searched.
Selection criteria
Randomised controlled trials (RCTs) using participants who had mycologically diagnosed fungal infections of the skin and nails of the foot.
Data collection and analysis
Two authors independently summarised the included trials and appraised their quality of reporting using a structured data extraction tool.
Main results
Of the 144 identified papers, 67 trials met the inclusion criteria. Placebo-controlled trials yielded the following pooled risk ratios (RR) of treatment failure for skin infections: allylamines RR 0.33 (95% CI 0.24 to 0.44); azoles RR 0.30 (95% CI 0.20 to 0.45); ciclopiroxolamine RR 0.27 (95% CI 0.11 to 0.66); tolnaftate RR 0.19 (95% CI 0.08 to 0.44); butenafine RR 0.33 (95% CI 0.24 to 0.45); undecanoates RR 0.29 (95% CI 0.12 to 0.70). Meta-analysis of 11 trials comparing allylamines and azoles showed a risk ratio of treatment failure RR 0.63 (95% CI 0.42 to 0.94) in favour of allylamines. Evidence for the management of topical treatments for infections of the toenails is sparser. There is some evidence that ciclopiroxolamine and butenafine are both effective but they both need to be applied daily for prolonged periods (at least one year). The six trials of nail infections provided evidence that topical ciclopiroxolamine has poor cure rates and that amorolfine might be substantially more effective but more research is required.
Authors' conclusions
Placebo-controlled trials of allylamines and azoles for athlete's foot consistently produce much higher percentages of cure than placebo. Allylamines cure slightly more infections than azoles and are now available OTC. Further research into the effectiveness of antifungal agents for nail infections is required.
Plain language summary
Creams, lotions and gels (topical treatments) for fungal infections of the skin and nails of the foot
We found lots of evidence to show fungal skin infections of the skin of the feet (athlete's foot or tinea pedis) are effectively managed by over the counter topical antifungal creams, lotions and gels. The most effective topical agent was terbinafine. Other topical agents such as azoles, ciclopiroxolamine, butenafine, tolnaftate and undecanoate were also effective in curing athlete's foot.
Evidence for the management of topical treatments for management of dermatophyte infections of the toenails was sparser and the studies are small. There was some evidence that ciclopiroxolamine and butenafine are both effective but they both needed to be applied daily for prolonged periods (at least one year).
__________________ Stephen Tucker Calvary Health Care
2) Oral meds. The persisting issues with the "official" onychomycosis medications remains high cost, the need for liver function tests, care to monitor drug reactions, battling with insurance carriers, etc.
FYI, generic terbinafine is now available. Costco charges $22 for a 30-day supply. Bi-Mart, Fred Meyer, and Rite-Aid charge $4 for a 30-day supply. That's right, $4!
The patient can pay out of pocket (i.e, no insurance hassles) for less than the typical insurance co-pay.
Availability of generic changed the game completely.
My 2 cents worth: aggressive debridement, pure Tea Tree Oil daily (avoiding the surrounding skin due to risk of sensitivity reaction) and metho. or surgical spirit sprayed liberally after ANY and ALL moisture exposure (multiple times daily eg: after showering/bathing and when removing socks), also treat any skin infection (eg: full-strength Whitfield's) whilst treating nails and disinfect socks (eg: Canesten Hygiene rinse).
Since when is Tea Tree oil a "gold standard", especially in the context of the lack of evidence and there was talk of the EU banning it over safety fears!
Can i ask a (stupid) question? When you talk of `heavy debridement` are we talking total nail avulsion here or reduction with bur/scalpel?
I agree...
Quote:
Since when is Tea Tree oil a "gold standard", especially in the context of the lack of evidence and there was talk of the EU banning it over safety fears!
I have copied what i posted on a VP thread....
There is an interesting study in the Australasian Journal of Dermatology (Rutherford et al, 2007) which highlights the incidence of reactions to oxidized TTO as being relevant enough to warrant appropriate warnings (banning) on TTO products. It also states that the antimicrobial effect of TTO against bacteria, fungi and virus (herpes simplex only) has only been demonstrated in in vitro studies and that no clinical studies have revealed superiority of TTO over existing licensed pharmacological tx.
Another good read is Aberer, 2007. `Contact allergy and medicinal herbs`. This addresses the misconception that unlicensed herbal remedies are `harmless` or `gentle` drugs, as many contain active ingredients and/or toxic substances, which are not only capable of producing reactions such as contact dermatitis, anaphylaxis and photosensitivity, but can also adversely interact with other prescribed medication. It also discusses reaction to marigold therapy
Cheers,
Bel
Ref:
Rutherford T, Nixon R, Tam M and Tate B. Allergy to tea tree oil: retrospective review of 41 cases with positive patch tests over 4.5 years. Australasian Journal of Dermatology (2007) 48; 83-87
Aberer W. Contact allergy and medicinal herbs. Journal of the German Society of Dermatology (2008) 6; 15 -24
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Since when is Tea Tree oil a "gold standard", especially in the context of the lack of evidence and there was talk of the EU banning it over safety fears!
Hi,
I use Tea Tree Oil because it is readily available, inexpensive, is accepted by the Australian public, is easy to use and I have only seen reactions to it when patients apply too much on the skin ( that's why I emphasise to apply it to the nail/nailbed only). I know there is little evidence regarding its efficacy, but what topical agents have good evidence for "gold standard" treatment of onychomycosis?
Thanks for the link Craig, I noticed SotonPod (clever fella) made the pertinent point...
Quote:
The main problem in onychomycosis is not cure, drugs will do this, but its relapse and reinfection.
Whilst i cannot point to any recent evidence of a Gold Standard for topical therapy alone in OM, I advise pts to apply Amorolfine 5% (Loceryl or Curanail) twice weekly after I have reduced the nail, because in addition to its antimycotic activity, the lacquer provides a physical barrier thus preventing reinfection.
Obviously, combination therapy with an oral fungicidal (such as terbinafine) will produce better results, but as a derivative of morpholine, Amorolfine is a member of a class of compounds that also have application as a fungicidal (in addtion to fungistatic activity) against dermatophytes.
Not sure if it applies in Australia, but Griseofulvin is the only approved oral anti-fungal therapy in the UK....nasty side effect of flactulence though
On the topic of debridement I notice the majority in this thread are pro drilling onychomycosis (as am I) and some are using tungsten drill bits others are using diamond burrs.
In my experience when I was studying, onychomycosis was a no go zone with a drill in your hand, it was banned .
Did others have similar experiences? Do you have procedures in place for using the drill with onychomycosis to reduce the risks? Such as planned ventilation, debridement of the majority with clippers and blade (as much as possible) drill bit type etc.
Like most of you I appreciate the need to debride the nail in order to apply topical treatments to improve effectiveness, I am just interested about how people go about this.
On the topic of debridement I notice the majority in this thread are pro drilling onychomycosis (as am I) and some are using tungsten drill bits others are using diamond burrs.
In my experience when I was studying, onychomycosis was a no go zone with a drill in your hand, it was banned .
Did others have similar experiences? Do you have procedures in place for using the drill with onychomycosis to reduce the risks? Such as planned ventilation, debridement of the majority with clippers and blade (as much as possible) drill bit type etc.
Guess i can weigh in a little on this topic. In my final year of study i did a research proposal on the exposure to particle matter from the mechanical drilling of nails. The facts are that the majority of nail dust that is produced from the drilling of nails are in the smaller classification (PM 2.5) and are of course more dangerous (ability to track to alveoli). Based on the research on the efficiencies of drill dust extractors (published largely by the producer of the drill) the rates of dust removal is between 20-90%, with water units giving about 90% effective aerosol reduction. If you have a look at the total dust produced from an average drilling (10 nails) and compare the daily exposures to the WHO guidelines there appears to be a significant over exposure to particle matter, even when reducing it by the 90% that dust extraction claims to.
I think its important to maintain airflow within the clinic (open windows, air purifiers etc), maintain the drills (replacing dust bags regularly & servicing) and the use of adequate personal protective equipment (goggles, dust mask (not queen charlot)).
Thanks for the information it appears it may not be such a good idea, although either is riding a motorbike if you look at it that way!
Was your study just using nails with no clinical evidence of onychomycosis?
Quote:
Originally Posted by gush_horn
I think its important to maintain airflow within the clinic (open windows, air purifiers etc), maintain the drills (replacing dust bags regularly & servicing) and the use of adequate personal protective equipment (goggles, dust mask (not queen charlot)).
hope this helps a little
After gaining these results do you still use the drill regularly in everyday practice and with onychomycosis.
Thanks for the information it appears it may not be such a good idea, although either is riding a motorbike if you look at it that way!
Was your study just using nails with no clinical evidence of onychomycosis?
After gaining these results do you still use the drill regularly in everyday practice and with onychomycosis.
I mainly focused on particles in terms of size. However, if you do look at the issue of mycosis then the drilling of infected nails can lead to an aerosol of 'active' particles that have more of an effect when they penetrate the lungs. Cant remember the exact figures but there are a high number of podiatrist that have active antibodies to these types of particles.
I know that some public health services in Australia do not allow drills to be utalised. Hard to say the exact risk but high exposure to fine particles has been solidly linked to a number of serious morbidities
Last edited by gush_horn : 19th February 2009 at 07:08 PM.
Aggressive debridement/reduction of the infected nail is a must in my opinion. Also, twice weekly appl of Amorolfine....but the cost of this can be prohibitve....daily Tea Tree Oil to the nail is my alternative to Amorolfine....but I find this tends to contain the infection rather than treat it. I don't recommend TTO for elderly patients because I don't want them to get it on to the surrounding skin. ie mobility and vision obstacles.
Had a pt in yesterday with OM affecting entire plate and matrix. She had been advised to apply TTO by a practice nurse. After 6 months of application and recurring discomfort and erythema (Read; Contact dermatitis) to the PNF the GP prescribed AB (which she hasn`t taken) to "deal with the redness". There was no infection present, other than the OM
As far as tea tree oil goes I usually recommend this to patients who are not candidates for oral antifunguals (ie risks/ drug inteactions/side effects)
I only recommend a 30% concentration as 100% can burn the skin and surround (which is definitely no good in your diabetic patients). I also suggest monitoring closely and using it every day or every 2nd day. When pts tell me they have some tea tree at home it sends the alarm bells ringing( as this is usually 100% conc. and used in industrial cleaners also)- you often notice if the pt is using it too strong as it starts to eat at the nail so it all crumbles off completely...
I had a colleague who instructed a pt to use it on his nails and he somehow ended up getting the wrong end of the stick and applied it DAILY between his toes- which created nasty skin breaks!!
what concentrations are other people using?
Whats your Gold Standard for onychomycosis?
When you talk of `heavy debridement` are we talking total nail avulsion here or reduction with bur/scalpel?
. 
. There was no infection present, other than the OM
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