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How important is debridement in onychomycosis?

Discussion in 'General Issues and Discussion Forum' started by NewsBot, Jan 22, 2006.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

    Members do not see these Ads. Sign Up.
    This is 'in press' at The Foot:
    Study to determine the efficacy of Clotrimazole 1% cream for the treatment of onychomycosis in association with the mechanical reduction of the nail plate
    Published online 20 January 2006.
     
  2. R.E.G

    R.E.G Active Member

    These are remarkable results, far better than anything else published.

    I do not have access to the complete article but would be interested in the 'inclusion' criteria for nails, particularly matrix involvement.

    I know this is not very 'scientific', but I did try nail debridement almost to bleeding point, on two patients with matrix involvement, every six weeks for at least 12 months, together with Loceryl nail lacquer applied once per week. There was no improvement.

    Bob
     
  3. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Maybe the key is the agrressive debridement, which was done every 2 weeks (which is unusally frequent). In previous studies it was not clear just how aggressive the debridement was. Maybe we need to revisit the frequency at which the debridement occurs and how aggressive it is (I am aggressive).
     
  4. R.E.G

    R.E.G Active Member

    Craig
    how aggressive do you want to be, I said almost to bleeding point, perhaps I should have said 'with a few hems'.

    What about inclusion criteria?

    Bob
     
  5. Felicity Prentice

    Felicity Prentice Active Member

    From a quick reading of the abstract it would appear the frequency of the debridement (as you say Craig - every 2 weeks is luxuriously frequent), along with (presumably compliant) twice daily application of the medicament which seems to have done the trick. It is interesting that they chose to use a cream, rather than a lacquer or tincture; presumably the regular disruption to the nail plate surface facilitated the absorption of the cream.

    I agree, I would love to see the inclusion criteria. In my experience o/myc of the matrix is a beast to treat with topical mediaments - if the vascular supply is up to it, I would go oral meds.

    Damn nice to see some serious research on this topic, given the frequency of presentation in practice - it gives us the chance to implement some EBM at last!

    cheers,

    Felicity
     
  6. Sean Millar

    Sean Millar Active Member

    I have tried something similar in my practice. I normally debride the affected nail with slow bur and scapel until all visiable signs of effected nail is gone. This normally exposes the nail bed (reduction is stopped when discomfort of the bed occurs). The client is then advised to use Lamisil spary on the affected nail twice daily. The client then returns in 6/52 for further debridement. I find that the nail is normally clear within the length of time if takes for the affected nail to grow out. I have had some success with this treatment. I find it a useful option for clients who don't want or wouldn't be suitable for oral meds. The treatment is relatively inexpensive, and has good compliance due to ease of application. Further research would be interesting.
     
  7. Soton Pod

    Soton Pod Member

    An interesting piece of work. As well as the inclusion criteria it would be necessary to see what the criteria for "cure" actually was - clinical, mycological or global. Of course the other important factor is follow up. The main problem in onychomycosis is not cure, drugs will do this, but its relapse and reinfection.
     
  8. Tim VS

    Tim VS Active Member

    How do you deal with the exposed nail bed post reduction? Would you apply a sealant such as Acrytensil, or just leave it 'til the new nail grows over?

    Very interested in this.


    Regards,

    Tim VS
     
  9. John Spina

    John Spina Active Member

    While the more debridement the better is a good rule of thumb,here in the USA there is a problem:Medicare only pays for this every 8 weeks.So how does anyone deal with this?Any input is appreciated.
     
  10. R.E.G

    R.E.G Active Member

    Tim,

    In my experience you will not get to 'expose' the nail bed.

    I use tungsten bits and a dry drill. Debride the nail plate to just before bleeding point.

    As the reason for debridement is to allow the topical treatment more intimate contact with the infection, sealing it afterwards would defeat the exercise.

    News Bot

    Any chance of the full article or more detail on inclusion criteria. This also applies to posters who are achieving success with this method.

    Regards Bob
     
  11. admin

    admin Administrator Staff Member

    Its not yet available.
     
  12. I work predominantly with patients who cannot tolerate oral antifungal treatment - due to use of other systemic medications. There is high rate of onychomycosis amongst them. Without wishing to appear to be an 'alternative' practitioner, I started to encourage my patients to try pure Tea tree oil, dropped once or twice daily onto affected nails, after routine debridement at intervals of 2 months.
    The results after 2 - 4 months have been very encouraging. Whilst only anecdotal at this stage, the patients motivated to regularly use the oil, showed a distinct 'line' where the nail began to grow from the matirix, without active mycotic infection.
    Many have achieved complete clearance of infection, though long term freedom from infection has not been assessed.
    The oil seems to achieve excellent penetration of the nail tissues, and is a known anti-fungal.
     
  13. Sean Millar

    Sean Millar Active Member

    nail bed clearence.

    I normally find the nail bed has seperated from the nail plate. I drill down using a diamond burr slow speed. At the point when you are just about through the nail is when I usually stop. The scapel blade is then used to debride any remaining affected nail. The exposed nail bed has not normally lost it integrity, but is normally sensitive to the touch. The bed needs to stay exposed for the period of treatment. Consequently, you have freed the nail of most of the affected nail and the antifungal spray treats the nail bed any remaining nail.
     
  14. mahtay2000

    mahtay2000 Banya Bagus Makan Man

    In non-matrix involved O/M, I debride aggressively, Use hydrogen peroxide to flush out the crevices and then advise pts to use a drop of povidone iodine dialy. The results are similar to the above test, maybe a little less.
    I find this treatment especially effective in long standing sub ungual O/M.
     
  15. John Spina

    John Spina Active Member

    Regarding Barbara's post:Tea tree oil is very effective and I had at least 2 or 3 people who insisted on it and swore by it.
    Most topicals in and of themselves do not really work.I have a patient who has had mycosis for 50+ years and every topical known to man had been tried.I am getting some results with ciclopirox topical.He still has mycosis.
     
  16. I now have a couple of good photos of my patient's nails after 3 months of Tea tree treatment. They show excellent clearance of mycotic infection - a distinct "tide-mark"
    Of old infected nail growing out and new clean nail coming in. Anyone keen to see these can email me, and I will post them back.
    Cheers, barbonice@yahoo.co.nz
     
  17. Hylton Menz

    Hylton Menz Guest

    The most recently updated systematic review of randomised controlled trials for onychomycosis is:

    Crawford F, Ferrari J. Fungal toenail infections. Clinical Evidence 2006;15:1-2. (link)

    The search date was June 2005.

    Findings:

    Oral itraconazole: more effective than placebo, less effective than terbinafine
    Oral terbinafine: more effective than placebo, griseofulvin and itraconazole
    Oral fluconazole: more effective than placebo, although benefits only modest
    Oral griseofulvin: less effective than terbinafine, no different to intraconazole, or ketoconazole

    Topical ciclipirox: more effective than placebo, but benefits only modest (34% cure rate versus 10% for placebo)

    No RCTs were found for topical amorolfine, butenafine, fluconazole, terbinafine, ketoconazole or tioconazole

    Conclusions:

    Beneficial: oral terbinafine and oral itraconazole
    Likely to be beneficial: oral fluconazole, topical ciclopirox
    Unknown effectiveness: oral griseofulvin and ketoconazole, topical amorolfine, butenafine, fluconazole, ketoconazole, terbinafine, tioconazole

    The authors state the next update will also assess the role of mechanical debridement.
     
  18. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The impact of aggressive debridement used as an adjunct therapy with terbinafine on perceptions of patients undergoing treatment for toenail onychomycosis.
    J Dermatolog Treat. 2007;18(1):46-52.
     
  19. phil

    phil Active Member

    Has anyone tried chemical debridment of mycotic nails? I read (somewhere, sometime) about using a urea paste to basically melt the nail off. Then, presumably, you could begin topical application of whatever.

    Anyone ever tried this, or even heard of it?
     
  20. Ian Linane

    Ian Linane Well-Known Member

    Hi Phil

    Have used this quite a number of times. 40% Urea in a parafin base. Generally I burr the nail quite a way down then apply the urea in a welled pad onto the nail. and bandage securely. Leave it for 4 days and have the pt back. Gentle scapping then allows you to take the nail way back to the nail bed without any discomfort. I then get the pt to apply a topical solution apply a topical ointment as the nail grows back.

    Also a very good technique for all manner of thickened nails and deeply fractured nails. Take them back with the burr apply the Urea, scrape away and monitor the regrowth. Simple, effective. My experience is that most nails grow back well and that infected nails improve. You can just burr away the fungal aspect a little aplly the uera and just scrape out the infected bit instead.

    Ian
     
  21. martinharvey

    martinharvey Active Member

    Hi Phil and Ian,

    there is a fair amount of literature on chemical debridement of nails. Various ointments used under occlusion have been tried. Farber and South (1978) suggested an ointment containing: Urea 40%, white beeswax or paraffin 5%, anhydrous lanolin 20%, white petrolatum 25%, silica gel 10%. Buselmieir (1980) suggested 20% urea combined with 10% salicylic acid. Hay et al (1988) and Bonifaz et al (1995) discussed using 40% urea combined with 1% bifonazole to soften the nail plate and after removal using 1% bifonazole cream daily for 2 months. Many Authors discussing urea refer to its unpleasant odour after a week which may affect patient compliance. The use of an oral therapy (Terbinafine or Itraconazole) together with chemical debridement may possibly be appropriate. Personally I get them on oral therapy, subject to suitability, and concomitantly aggressively debride the nails. To help damp down the mycotic population in the local area I suggest they apply a few spots of pure lemon oil daily. The pure essential oil smells a whole lot better than urea and seems to work as well as anything else when used with debridement and oral therapy (please don't ask me to explain how - I dont know, I'm just a Pod - ask an aromatherapist, they claim it's anti fungal)
    Regards, Martin.
    References:
    Farber, E & South, D.A. (1978) Urea ointment in the non surgical avulsion of nail dystrophies. Cutis 22, 689.
    Buselmieir, F.J. (1980) Combination urea and salicylic acid ointment nail avulsion in non dystrophic nails: follow up observation Cutis 25, 393-405.
    Hay, R.J., Roberts, D., Doherty, V.R. et al (1988) : The topical treatment of onychomycosis using a new combined urea/imidazole preparation. Clinical and experimental Dermatology 17, 164 - 167.
    Bonifaz, A,. Guzman, A., Garcia, C. et al (1995) Efficacy and safety of Bifonazole urea in the two phase treatment of onychomycosis. International Journal of Dermatology 34, 500-503.
     
  22. Ian Linane

    Ian Linane Well-Known Member

    Hi Martin

    Thanks for the info.

    Ian
     
  23. martinharvey

    martinharvey Active Member

    Hi Ian, you are most welcome. Looking for some history on it's use I did check the subject in one of Granny's old books: A Pharmacoepia for Chiropodists (1937) Le Rossignol, J.N., Holliday, C.B., Faber and Faber. p35. This refers to using a 10 -15% Salicylic Acid Ointment (Unguentum Acidi Salicylici) on Onychomycosis. It doesn't stipulaate a modus operandi however.
    Kind Regards,
    Martin
     
  24. Graeme Franklin

    Graeme Franklin Active Member

    Hi Ian,

    Which supplier do you get the 40% urea in paraffin from? Or is it from a chemist?

    Cheers,
    Graeme
     
  25. Ian Linane

    Ian Linane Well-Known Member

    Hi Graeme

    Had a friedly chemist at the time. I think some suppliers might do it but could not tell you which ones.

    Ian
     
  26. Graeme Franklin

    Graeme Franklin Active Member

    The chemist it is then!

    Cheers,

    Graeme
     
  27. Dr Toe

    Dr Toe Member

    WHEW! What a load of information! Personally I use a product from Gehwol supplied by Canonbury that, because my Dad who lives in America, cannot come to me for treatment (he's been here once), I have sent him a Burr and some Gehwol nail treatment oil. A few months on I asked how he was getting on with the nail reduction (the burr) and he said he didn't have to use it as the Gehwol worked brilliantly. He is a 70yrs old and is on warfarin so the oral meds that were prescribed, and the acid treatment were contraindicated. All other treatments have been unsuccessful, and he now is a happy man with a normal nail (it was only the left hallux)

    Glad to hear there is so much interest in this, but as there is, why is it such a mystery for podiatrists to find a be-all end-all cure for this?
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial.
    Malay DS, Yi S, Borowsky P, Downey MS, Mlodzienski AJ.
    J Foot Ankle Surg. 2009 May-Jun;48(3):294-308.
     
  29. Johnpod

    Johnpod Active Member

    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.
     
  30. blinda

    blinda MVP

    Perhaps you mean fungi, Johnpod? :drinks not that I bear a grudge or anything like that...;)
    Seriously though that was a :good: and agree that there is no point in applying medication to the nail plate, which is designed to protect the vulnerable subungal tissue, we have to target both the proximal and germinal matrices. Thus, debridement is essential for effective tx.

    Cheers,
    Bel



    -
     
  31. Johnpod

    Johnpod Active Member

    The germinal matrix IS the proximal matrix, Bel. Perhaps you mean both sterile and proximal matrices?

    I suppose we have to accept that you are technically hemi-correct!:wacko:
     
  32. blinda

    blinda MVP

    :D:DTouché !


    Cheers,
    Bel




    -
     
  33. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    This clinical trial has just been registered:

    Effectiveness of Podiatry Care on Onychomycosis (EPOCAON)
    Sponsored by: University of Malaga

    Link to trial
     
  34. Mr C.W.Kerans

    Mr C.W.Kerans Active Member

    Going back to the original post, was it single (? 1st.) nailplate involvement, or were multiple contaminated nailplates on one or both feet involved? Also, was the fungal contamination confined to the distal nailplate or was there proximal/ sub-eponychial involvement. Without a full clinical trial with hard clinical evidence resulting, the outcome of the original treatment regime ( radical debridement+ topical antifungal), while very interesting, is subjective and anecdotal. With regard to chemical debridement of the nailplate, I have heard of the use of Salacylic Acid and Urea at variable strength each but I've never used either myself. For such a widespread and common problem in everyday practice, this deserves further investigation.
     
  35. toughspiders

    toughspiders Active Member

    Hi

    Are we talking normal nails here by normal i mean not o/x??? I have had limited success in nails where the nail bed had been damaged,,,surely an abnormal nail allows the entry of fungal elements easier? Thus meaning reinfection more likely
     
  36. jabr

    jabr Active Member

    This is exactly what i've been doing as well, though my topical of choice is Canesten cream, good for yeast infections if it happened to be that. It just seemed more logical to get to where the fungal matter is rather than expecting it to work it's way through the nail plate, why on earth not remove the nail?

    I also like the fact that the patients feel as though a vigorous treatment has commenced, they seem keen to carry it on once most of it has been cleared away.

    I only do it on cases where the infection hasn't reached the matrix though, I think the urea cream removal sounds like a good plan for those ones.
     
  37. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All
    I was interested to see the use of Tea Tree oil in the treatment of onychomycosis. Looking through databases there seems to be an increasing body of evidence supporting the use of TT oil although more it has been suggested that more research needs to be done on the effect of TT oil on soft tissue. Aromatherapists etc. I have spoken to suggest that, if used it should be diluted in a carrier oil but what strength I don't know.
    I don't recommend its use to my patients at the moment but if the research continues to be positive with no risk of tissue damage etc. then I might start using TT oil as this condition is difficult to treat.
    Regards
    Deborah
     
  38. DaVinci

    DaVinci Well-Known Member

    I assume you missed this discussion on how useless it is: Is there a place for tea tree oil in foot care? . It does intrigue me as to why so many podiatrists are so willing to use it :confused:
     
  39. Fungus

    Fungus Welcome New Poster

    I have myself had onychomycosis with matrix involvement for years and have been completely unsucessful with all treatments, including a 6-month period on oral tebinafine tablets while treating the nails with tea tree oil and vinegar among other things. I would file the nails down, but probably not enough.

    Recently I used a mechanical drill to remove the fingernails altogether, leaving the nailbed completely bare. This is a time-consuming and uncomfortable process but it is possible if you proceed with care and caution. Since then I have twice daily applied lamisil single-dose gel, which is supposed to treat athlete's foot, but I chose to use it as a nail laquer, and I apply it both on the nail and on the surrounding area without cleaning off what accumulates, I let it stay and become a film that thickens after a while. Every 2 weeks I scrape it off and start over again.

    My fingernails are now 95 % grown out healthy. But during the process I have had to repeat the debridement process 3 times to remove re-infected nail at the tips, but only the nail that is obviously re-infected.


    To me it is obvious that even a thin nail is tough barrier to penetrate and for topical treatment to be effective you should remove as much nail as possible, preferably the entire nail.
     
  40. Lab Guy

    Lab Guy Well-Known Member

    I would guess that the most common reason for people developing onychomycosis is a weakened immune system due to age, genetics or systemic disease. I think we have to target the immune system if we are going to win the war with mycosis.

    Steven
     
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