Whats your Gold Standard for onychomycosis?

Hi, I agree, but when I suggested a patient ask GP for a prescription for Loceryl, the GP declined because he felt that it would be ineffective if the fungal infection had spread to all toenails as in my elderly patient's case. As a Podiatrist I would like to apply Loceryl after debridement but am diffident because of the cost involved.

So many of my patients have severe onychomycosis that cutting the toenail sometimes tends to lift it. I haven't debrided with a blade but some of the threads advocate that approach

 

Ohh Fungus! Don't you just love it?! It makes our days interesting...

I have typically found TTO to be ineffective for nails. I do, however, commonly advise it for Tinea Rx interdigitally in a diluted form and advise they stop use immediately if they have any allergic reactions. I tend to recommend Clonea, Canesten or the chemist-made generic brand for the plantar surfaces.
I tend to think the use of AF creams or powders interdigitally keeps the skin too macerated and promotes a moist wound environment that keeps perpetuating itself. When treating the skin, I really emphasise the treatment of all shoes/socks/bathroom surfaces concurrently, if they're really going to knock it out effectively.

As for nails, the only topical tinctures I've seen that appear to have any success are Gordochom and Loceryl. Daktarin seems to form a thick black film that doesn't even penetrate the nail.
Considering the cost of Loceryl, I tend to advise my patients to use Gordochom, at a 1/3 of the cost. I also agree that heavy debridement is essential.

I usually recommend oral medication when more than half the nails are infected or when no topical has shown any significant healthy nail growth within 6mths.

I had a new pt recently who bought a tincture overseas from a beauty salon that surprisingly helped resolve her chronic fungal nail (not that surprising that the nail salon was very familiar with fungus) . The active ingredient was Thymol (the oil from Thyme) in an alcohol base.
I haven't been able to find any information on the efficacy of thyme oil. Anyone heard of its use in any clinical preparations?

 

Not quite right, Bel: GPs are also prescribing Lamisil when requested to.

 

That may be so, Charlie. I know many GPs do. However, as far as i am aware the MHRA only approves of Griseofulvin for children.

Cheers,
Bel

 

bumping an old, but worthy, thread...

Any new ideas on treatment? What works best for your patients?

How many of you (Docs) think oral anti-fungual meds as the best treatment?

I've heard/read that time spent without shoes and socks helps, but doesn't that spread fungus spores around the house that may infect other family members?

What about shoes? Do they need to be treated if they are only worn with socks (no bare feet)? If so, how does one 'treat' shoes so they are not a source of infection?

I heard/read that the fungi responsible for O/M is ubiquitous?!?! If so, to what degree? Is it everywhere?

 

Combination (oral & topical) therapy is without doubt one of the most effective. However, each patient is treated individually, according to their expected outcomes, medical history, previous treatments, concordance, ability to self treat, predisposing factors, underlying systemic conditions, secondary infection, etc.

With regard to cross and re infection, you may find the attached useful;

View attachment concomitant-fungal-contamination.pdf

You could always zap footwear with "nano technology"......

http://www.youtube.com/watch?v=WtElYlNxmOw

Cheers,
Bel

 

From Bel's linked article:

"An additional study demonstrated that the fungi still remained viable in hosiery
even after laundering."

Throw the socks and stockings away at the end of each day???

 

You could. But the fungus will still remain in the surrounding environment. The point of the study was to demonstrate that re infection can largely be attributed to spores in footwear and communal areas.

It is necessary to explain the nature of onychomycosis to patients seeking a cure. That is, the main problem in OM is not cure, drugs will do this, but its relapse and reinfection. A strict hygiene regime consisting of drying carefully interdigitally after bathing and using anti-fungal sprays or powder in footwear will help to reduce the likelihood of re-infection, but not eliminate it.

I was going to post a pic of me and mine white water rafting in Colorado here...but it appears that I have deleted that folder. Which river do you ride?

 

We did a study some years ago where we impregnated new socks with spores, laundered half of them and microwaved the other half. The laundered half still grew pretty patterns when we cultured them, the microwaved ones didn't. Sorry if I'm not using the right technical speak, fungus ain't my ****. Nuke your socks?

C(k?)lense machine????

 

Dear Delia,

For how long did you microwave them?

You can pick up Klenz machines on ebay for around £50.

 

Can I be the first to say euuewwww!

 

Can't remember, I'll find out if you're really interested. It was seconds as oppose to minutes- maybe 10- 20. Cotton socks from M&S. You see that bit of rubbish information I can remember - doh.:bash:

BTW, I'm more a soft-focused Nigella man myself. Better cup-cakes and more food based innuendo's; her recipes are rubbish though.

 

Just thinking here...

Wash in hot water with soap+bleach.
Dry with high heat setting.

Hard to imagine viable spores making it through that cycle.

I ride my bike along rivers (rather than rafting on the rivers). Although I do enjoy a rafting trip once in a while.

 

Its an interesting problem. We use a cloth to dry the feet and now the cloth becomes a fomite for the spores. We wash the cloth but the spores remain on the cloth and they are likely transfered to other items in the washer.

Spread those spores around!