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Advice please- 106 year old with onychomycosis

Discussion in 'General Issues and Discussion Forum' started by linda.j, Feb 19, 2013.

  1. linda.j

    linda.j Member

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    Hi All!
    Been lurking in the background and learning lots from the forum (thanks!) for the last while and now feel its finally time to get involved!

    I would appreciate advice on the following case...

    Im seeing a 106 year old lady, in a nursing home, who has severe onychomycosis affecting all nails. Incredibly she is on no medication and has no medical conditions aside from being partially sighted. However she has had 2 episodes of lower limb cellulitis in the last 2 months and is 'failing' alot since she has gone into care.

    I dont see any point in suggesting nail lacquers given the severity of the infection and potential issues getting the treatment applied. Probably just getting caught up on her age but is oral terbinafine the best option?
  2. Congratulating her on reaching the age she has reached is the way forward; gleaning the wisdom of her years with each encounter that you have with her and making a difference to her day. I really wouldn't worry too much about the onychomychosis, I'd bet she doesn't. Ask her how she would change the world and report back.
  3. Jonix

    Jonix Active Member

    What Simon says.. He's more eloquent. At the speed nails grow, I don't think there would ever be a visible difference for this lady

    PS. I have never treated someone so very old. What a privilege. But if they live into their 90's or more, they usually aren't on many meds, of maybe just a diuretic. Too healthy..
  4. I second Simon's common-sense approach. I'm sure your patient won't be around much longer so why would you do anything for her fungal toenails, treatment-wise, other than make her comfortable?

    You may want to spend your time with her, instead, asking about her recollections of her life in Britain during World War II, since she would have been 33 years old during the Battle of Britain. It is so unusual these days to have someone who was an adult during that time in your country's history that you should take this opportunity to learn from her. If you don't come away from your time with her realizing how easy and good you have it now, compared to those troubled times for your country, I would be very surprised.

    "In history, a great volume is unrolled for our instruction, drawing the materials of future wisdom from the past errors and infirmities of mankind."
    Edmund Burke
  5. louisa50

    louisa50 Active Member

    Turbinafine at her age with it's long list of side effects, no, no and no. Her fungal nails will not harm her at all but the treatment might. Leave well alone.
  6. linda.j

    linda.j Member

    Thanks for replies. Yes she's a lovely lady and the om nails dont bother her.Will look forward to our chat at the weekend!
  7. blinda

    blinda MVP

    Agree with all the above, love the moving post from Simon.

    Just a note though; despite the bad press (which is burned into the memories of some GPs), terbinafine is NOT the spawn of the devil.

    Taken from the patient information leaflet (which was approved by the U.S. Food and Drug Administration);
    So, as with ANY oral medication, if there is any risk of existing hepatic impairment, then a liver function test (in the form of a simple blood test) along with a review of any other underlying conditions will reveal whether a patient is suitable for terbinafine.

    The efficacy and safety of terbinafine has been rigorously and robustly tested and it is still reported as; "a superior treatment for dermatophyte infections because of its safety, fungicidal profile, once daily dosing, and its ability to penetrate the stratum corneum." - Recent updates in oral terbinafine: its use in onychomycosis and tinea capitis in the US.

    If it wasn`t safe, it certainly wouldn`t be recommended for children;

    The efficacy and safety of terbinafine in children.

    Efficacy, safety and tolerability of terbinafine for Tinea capitis in children

    Terbinafine hydrochloride oral granules versus oral griseofulvin suspension in children with tinea capitis: results of two randomized, investigator-blinded, multicenter, international, controlled trials

    etc, etc.

    The most common side effect is smell and taste disturbance, which usually resolves after the course is completed.

    Whilst it would not be appropriate to prescribe any form of oral anti-fungal for the elderly lady in the OP, there is no reason why terbinafine should not be considered in a younger `healthy` patient as it remains one of the safest, efficacious and cheapest fungicides available in the UK.....until the cost of lasers come down. Just maybe ;)

  8. David Smith

    David Smith Well-Known Member

    Cheers Bel

    I shall be copying and sending these papers to all the GP's in my area tout de suite and the tooter the sweeter :drinks

    Regards Dave
  9. linda.j

    linda.j Member

    Bel thanks for your detailed post. Appreciate the links to the papers- will be my evening reading!
  10. blinda

    blinda MVP

    Pleasure, Linda. I`m just tired of hearing how `dangerous` terbinafine is.

    If other established meds, such as asprin, had to go through the same trials, they would most certainly not pass NICE standards/guidance due to their `side effects`.

  11. louisa50

    louisa50 Active Member

    I often have to remind myself that just because we can treat something doesn't necessarily mean we have to. It very much depends on the circumstances.
    I request turbinafine for all kinds of people of all ages but if I don't think it will benefit somebody in the long run then I tell them that it probably isn't worth their while.
  12. linda.j

    linda.j Member

    Yes thats very true. I should have explained in the original post that I remember reading somewhere (Podiatry today?) a link between OM and cellulitis so was wondering if treatment would be indicated- my gut reaction though was the more 'social' treatment plan- have a good chat while just trying to make her feet comfortable.
  13. blinda

    blinda MVP

  14. phil

    phil Active Member

    I would doubt you would find a 106 year old in a nursing home WITOUT onychomycosis!
  15. Walking1

    Walking1 Member

    I fully concur with the previous writers forget the nails and concentrate on the knowledge she can give to you and others.
  16. björn

    björn Active Member

    And why not laser? ;) Painfree, no side effects......

    How do we know she isn't going to live until 120? 14 more years of ugly nails. Additionally, she might fancy herself with one of the blokes in Suite 42, and want everything that laser promises to deliver.

  17. Paul Bowles

    Paul Bowles Well-Known Member

    1064nm Laser is NOT painfree...you obviously have never used it.

    There are side effects, another sign you probably know very little about it or have never used it.

    The rest of your post is just trolling. Keep it on topic. I think the advice above is very clinically sound.
  18. björn

    björn Active Member

    Correct Paul, I haven't used it. As for no side effects, that's how laser is being promoted on radio here in Melbourne at the moment. Additionally at least one clinic's website promotes it as painless.

    As for trolling, surely you couldn't have taken my comments seriously (winking smily face)? If so I apologise.
  19. rosherville

    rosherville Active Member

    Can't compete with 106 but I do have a 102 year old, very with it, father with longstanding OM. All I advise is periodic reduction, would not consider any systemic treatment.
    * I recently discovered a cupboard full of unused prescribed pills & potions, 'I'm fed up being told I'm not following the right lifestyle by a young doctor a third of my age'.
    And when I asked why he still got up at 7am every morning, 'People die in bed you know' ! Can't argue with that.

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