Treating Onychomycosis

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Is drilling holes through the toenail to give topical solutions access to the nail bed a good idea if it is done with great care?

 

Hi Medvice,

:welcome: to the Arena!

I tend to drill through the nail plate, at the most proximal point of infection, to harvest active subungual tissue for culture to identify which dermatophyte/candida/yeast are actively involved in presenting OM, in order to implement pathogen specific treatment.

Mechanical debridement, ie reduction of fungal load, is essential prior to topical and/or combination therapy.

Cheers,
Bel

 

Hi Bel,

Thank you very much for your reply, please forgive me for asking a few questions:-

What size drill do you use?

How long will the culture survive i.e. how long can it be stored after harvesting?

What treatment do you use for OM?

If you had a device for drilling multiple holes safely through the nail plate, with complete confidence that it will only drill the nail plate and not cause damage or pain to the patient would you use it for; harvesting cultures and/or producing pathways for anti-fungal treatments through the nail plate?

How many patients do you treat for OM each year?

I am based in the South of England and very interested in cultural differences in treating OM, can I ask where you are based (roughly)?

Kind Regards,

Rolf

 

Rolf,

No need to apologise for asking questions. I have one for you, before I answer yours; what are you trying to sell us?

Bel

 

Hi Bel,

I'm developing a device that allows the Podiatrists to easily and painlessly make multiple micro pathways through the nail for treating OM.

I'm just doing some market research to try to understand Podiatrists current practices and how they might use such a device.

Sorry to be cryptic but the device is still in development and I'm trying to understand about current practices. If you prefer to communicate directly, then please feel free to use my email info@medvice.co.uk

Thank you again for your help.

Rolf

 

Why do I need to go "through" it when I can just get access through the distal separation? Regardless getting "through" the nail is the least of your concerns, its what the fungicidal agent is that you are delivering?

 

Has anyone had any experience using PACT, in preference to Nail lasers for fungal Therapy?
I'm interested in PACT because it seems to have the least risk in tissue damage due to heat build up and also clients may tolerate it better?
Thanks for any feedback.

 

What is PACT?

 

PACT is photodynamic light therapy, used in the dental field for years for anti microbial and antifungal therapy. Briggate medical have started retailing this PACT unit. Iam interested in anyone's experience or thoughts with this therapy. With my discussion with Briggate it seems it has the same success rate for clearance and would be much more reasonably priced for our clientele .

 

I'm afraid I don't agree with you on this point. It sounds like the sort of information that a Pharmaceutical Company would have us believe.

The anti fungal agents on the market are very effective, by example Lamisil Once will kill Athlete's Foot (the same infection) with a single application.

The problem with Onychomycosis it getting the treatment to the infection.

Please see this post below on the subject from another thread.

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Re: How important is debridement in onychomycosis?
Most funguses are saprophytic - they live on dead material. The nail is dead material, placed on digit ends for protection of the sensitive living material.

Nails are 'historical', have no blood supply and are thus readily invaded by fungal pathogens.

Most of our topical treatments fail because we treat only the historical material. We need to treat the germinal matrices where the nail is made, not the nail itself. Debriding/removing the nailplate reduces the reservoir of infection and gives access to the sterile matrix (nailbed). But only 10% of the nailplate is produced by the sterile matrix. The other 90% of the nail plate is generated by the germinal matrix on the dorsum of the distal phalanx, proximal to the nail.

To kill the fungus we need to target the germinal matrix and nail fold, i.e. paint over the matrix area, not the nail. Topical agents will penetrate better and deeper when applied in this region. Applying them to the nailplate is ineffective. The nailplate is composed principally of keratin and as such is effectively chemical-proof.

 

The germinal matrix lays under the skin at the proximal nail fold - how are you going to "drill" through that?

 

Rolf,

Are you a podiatrist?

 

Medvice,

I am quite concerned by your comment of "what size drill do you use?" Surely, it isn't the size of the drill that matters, but, the nature/type of attachment in the drill.

Also, I am sure that Ivan Bristow said that although bacterial samples don't last that long, fungus samples do!

Ivan Bristow, such a knowledgeable person. His knowledge in dermatology is fantastic, a huge asset to the profession!

I wander what he thinks to this thread!

 

On the same topic...i had a patient visit me on Saturday, having been advised by me several months ago,not to bother with "laser" treatment on most of his toes, all historically infected for "years "..... He has parted with£550 and has had four " very painfull" treatments.... He then comes to me " to cut the cutical back so the nail grows quicker" ....now hes obviously not the sharpest tool in the box, but I managed to stop myself reacting to incredulously....According to my notes there was not ANY improvement. Has anyone else come across this? Does anyone do laser treatment? Am I missing a point? Did he get it wrong/ make it up? Are these people actually qualified? ( Harley St address but ' clinic' in the suburbs)

 

Carol,

Why did you advise against laser treatment for OM? Have you read the thread below? There is some compelling evidence for this treatment modality, although I agree; the cost here in the UK is hard to justify.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22925&highlight=laser treatment

Cheers,
Bel

 

I advised him originally, purely for clinical reasons, every nail on both feet are badly damaged, he has had the condition, to my knowledge from our clinic history, for at least ten years. He has had some nails removed and they have just regrown the same. He is 70 years old. My main concern on Saturday, was that he came to me with verbal 'instructions', not just to soften and push back the cuticle, but to surgically cut it back. I am concerned that this person may not be as qualified as her fees would imply. Purely a gut feeling. If this person was a Podiatrist she wouldn't have told him to come to me. If she is not then why is she using lasers on clinical nail infections. She wasn't a Doctor, we established that.
Money was not really an issue, he can afford it, but I do think vanity and obsession have crept in. No fool like an old ( rich ) fool!
Just curious to whether anyone else as come across a situation like this.

 

Can`t say I have, Carol. Maybe you should contact the practitioner if she is suggesting shared care of your pt.

BTW, you should bear in mind that pts do read this forum....more than a few of mine contacted me for treatment after reading my posts here.

Cheers,
Bel

 

Unfortunately the gentleman would not share this information with me, which actually gave me good reason to refuse without causing any offence. I have said if she would like to write to me i would consider her recommendations. "provided they were within my professional boundaries" which is my stock answer for all verbal instructions via patients. Its no good up before HCPC Saying " he told me to"....And yes, I am quite aware patients read this, as do colleagues and bosses.

 

Fair enough.

So you don`t mind pts and colleagues seeing you refer to pts as `vain, obsessed and rich old fools`? Nevermind.

 

Oh come on Blinda.. Carol is permitted to have a giggle. She hasn't named anyone or referred to them personally. Enough!

 

OK, surfboy. Thanks for the reprimand.

I`m all for a bit of banter and light hearted fun between colleagues, but I receive a substantial amount of GP referrals and patients coming to see me because they have read posts on this forum. Something to bear in mind when we talk about our patients, IMO.