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Nail and foot fungal infections

Discussion in 'General Issues and Discussion Forum' started by rachel.liminton, Oct 9, 2011.

  1. rachel.liminton

    rachel.liminton Active Member

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    Hi pods, just wondering what the latest update is on fungal infections of the nail and skin......i see many frustrated clients and can not give them a definitive answer.....so what is the best method to eradicate fungus:pigs::pigs::morning::morning:
  2. blinda

    blinda MVP

    Re: Nail and foot fungus

    The definitive answer is; Fungicide.

    Then again, it depends. As with all things pathological, each case has to evaluated and treatment plans formulated according to the patients individual needs and medical history. Expected recurrance of infection has to be addressed. Personally, I encourage pts to maintain control of chronic tinea, you`ll never completely eradicate it.
  3. rachel.liminton

    rachel.liminton Active Member

    Re: Nail and foot fungus

    clients have become a bit warey re the oral anti fungal agents, just wondering what the milage is in Tea Tree oil and laser therapy??
  4. blinda

    blinda MVP

  5. W J Liggins

    W J Liggins Well-Known Member

    Hello Rachel

    Why have patients become a bit wary re: oral anti-fungal agents? I have not experienced this.

    All the best

    Bill Liggins
  6. dgroberts

    dgroberts Active Member

    Because GP's seem to be very keen in explaining that they will cause liver failure.

    It may be quicker to do that than arrange microscopy, follow up and prescription.

    For reference, pathways (that I know of) for oral terbinafine require positive microscopy before prescription. I've seen quite a few blatantly obvious OM nails that have come back negative (nail samples not taken by us though??) and nothing prescribed.

    To be fair though, it's not a life threatening condition is it. Should the NHS be funding what could be described as, in most cases, a cosmetic problem.
  7. stevewells

    stevewells Active Member

    With respect I dont think its ever just a cosmetic problem.
  8. DTT

    DTT Well-Known Member

    Hi Steve

    I saw an interview with a PCT manager about a year ago who was complaining that between the two trusts in his area they had spent one and a half MILLION pounds on diagnosing and Txing mycotic nails and the consensus of the medical staff was the monies could be better spent on heart surgery " rather than a cosmetic problem".

    I do know of several GP's in my area that refuse to send patients clippings for analysis . They usually send them for otc preperations or Rx Loceryl.

    Oral terbinafine has been identified to cause liver damage in some cases so I try and strike a balance between the risks and the severity of the condition in deciding a course of action.

    Cheers Fella
  9. blinda

    blinda MVP

    I`d like to see the `evidence` that oral terbinafine causes liver damage. This is postulated by some, not all, GP`s. I contest that any medicament, particulary when administered orally or IV, has `an effect` on the liver as all medication has to be metabolised by the liver!

    The RCT which GP`s like to refer to is the one where a 48 year old woman developed hepatoxicity (and subsequently required a liver transplantation as she already had severe cirrhosis) after taking terbinafine. However, they often fail to mention that she was also taking dosulepin and propranolol, anti-depressants which oddly enough have `an effect` on the liver:rolleyes:

    See here;http://bestpractice.bmj.com/best-practice/evidence/intervention/1715/0/sr-1715-i3.html

    A quote from the above;

    RCTs involving terbinafine frequently measured levels of liver enzymes and found that increases were asymptomatic, and reversed once the drug was stopped. Adverse events unique to terbinafine include sensory loss such as taste, smell, or hearing disturbance ( see option on oral griseofulvin and option on oral itraconazole).

    Oral terbinafine has been declared safe after many trials, such as these;


    I agree with Wellsieboy, it is not merely a cosmetic problem, it is an infection which poses a substantial risk to undermine the integrity of the epidermis and subsequent bacterial infection. There have been a number of studies which identify a correlation between cellulitis and tinea infection.


  10. DTT

    DTT Well-Known Member


    Taken from the official FDA information site

    That was my understanding of the side effects , hence my comment to make a balance made on hard medical evidence before suggesting systemic Tx.

    Are we as podiatrists qualified or have the knowledge to assess which of our patients have / have not got liver disease at whatever stage ???
    Last edited: Oct 11, 2011
  11. blinda

    blinda MVP

    Exactly. I`m not disagreeing with you, Del. Of course balance, or evaluation, should always be taken before recommending any treatment.

    Hence, if the pt has any chance of liver dysfunction/impairment the same site (which contains information approved by the FDA ;)) which you quoted from advises;

    Your doctor should do a blood test to check you for liver problems before you take Terbinafine HCl.

    Maybe tinea in itself is not `life-threatening`, but it does increase risk of further complications with co-morbidities. I can also understand the reluctance of GPs to spend NHS money on obtaining and culturing nail and skin samples. That is why I offer to take the samples myself and send them directly to the path lab for a microbiology and culture report. It does cost the pt £35, but many are willing to pay this if it provides a definitive diagnosis, which a GP requires, to be prescribed the appropriate medication.

    I never said we were. That`s the doc`s job.

    Remember, terbinafine is not the only anti-fungal, griseofulvin (the only oral anti-fungal approved for children) and any of `azole` family are also effective.

  12. DTT

    DTT Well-Known Member

    Makes a change :rolleyes:

    I have reservations on the Rx of Griseofulvin as well ( mainly coz it dont work in adults after a 12 month course in many cases) but as always, what do I know


  13. shrub

    shrub Member

    For interest purposes: When in the UK I was told that Wicks Vapour Rub works very well on fungal nails - tried and proved to be successful although fairly slow. Now in Oz have suggested this to several patients and proving to be very successful, especially if the toenail is chauxic and painful. - also something cheap and which most households readily have available. Having checked with a specialist first he was happy that I give this advice, although some GPs suggest that it should not be used if client is on Warfarin (so I advise those clients on the standard topical treatments) - specialist unaware of any reason why the GPs believe this. I have suggested this over the two years here and have some very happy customers. :D
  14. DTT

    DTT Well-Known Member

    Loads more here

    Last edited: Oct 14, 2011
  15. shrub

    shrub Member

    Thanks for that.
  16. Kaleidoscope

    Kaleidoscope Active Member

    I am VERY grateful to Bel for her post of 11th October and in particular a paper she highlighted:

    Dermatology for the practicing allergist: Tinea pedis and its complications (Hasan, Fitzgerald, Saoudian and Krishnaswamy)

    Also her comment:

    QUOTE: I agree with Wellsieboy, it is not merely a cosmetic problem, it is an infection which poses a substantial risk to undermine the integrity of the epidermis and subsequent bacterial infection. There have been a number of studies which identify a correlation between cellulitis and tinea infection.

    As this paper cleared up a conundrum I was struggling with.... that of GPs (repeated) non-detection of fungal infiltration (of typical presentation of interdigital 4th/5th Tinea Pedis) in a patient who (because of a missed diagnosis) went on to have protracted ill-health rising from cellulitis then osteomyelitis and eventually, Atrial Fib (in a clinically ‘well’ pt.!) (Interestingly this was my 1st patient in PP after graduating, and its resolution, gave a real boost to my confidence!)

    Basically: Pt. presented with 12 mths ‘rash’ treated with topical antibiotics, steroid cream (pt. self-prescribing!) oral antiBs x 4 and eventually a stay in hospital with intravenous antiBs!

    To my (unpractised) eye it was Tinea Pedis... no mistake! (although it had progressed to dorsum/plantar) I asked whether she had had a test for fungal infection to which she replied .... 3 times ALL NEGATIVE!!

    I said despite negative results I felt it always prudent to treat the simplest cause first.... so she was started on Lamisil x 2 daily and I saw her again in 2 weeks. (I told her to avoid using the steroid and other creams)

    [What MUST be mentioned here was her shoes..... plastic court shoes with such a growth of fungus in it was impossible to miss!!!! I urged her to throw them away!!! ... and use Daktarin in any future shoes BEFORE wear.

    Next visit. All itching had stopped ‘rash’ was drying out – practically gone. Patient was angry!!! Actually not at me! She could NOT believe GP hadn’t spotted this and treated her!!!! She was STILL wearing fungus-shoes!!!

    Next visit: 2 weeks. ALL GONE! (including shoes!!!) Told pt. to use Lamisil as and when any signs of itching as TP very likely to recur, also continue spraying shoes... (she HAD been tested for DM incidentally)

    The vital message here is in the paper above that Bel highlighted (above)....and I quote below its take-home message:-

    “In some patients gram-negative infection may complicate tinea pedis. Gram-positive bacteria usually dominate the interdigital spaces of the feet and upon infection with dermatophytes, bacterial products similar to penicillin may inhibit their growth. This may result in a predominant growth of gram-negative bacteria like pseudomonas, proteus and klebsiella, leading to gram-negative cellulitis. In such situations, demonstration of fungal elements may become difficult as excessive gram-negative bacterial presence may inhibit fungal growth and make it harder to detect fungal hyphae on KOH preparations. Antifungal agents released from the gram-negative bacteria may also contribute to decreased presence of fungus. Hence, cultures of skin scraping may demonstrate gram-negative bacteria but no fungal pathogens(!!!) Aggressive treatment of the underlying fungal as well as the gram-negative bacterial infection can, however, lead to amelioration of cellulitis in these patients.”

    Brilliant learning example (for me) and one of the main reasons I frequent PA (rather TOO much LOL!) and the answer to WHY Tinea Pedis wasn’t treated at the start and the unfortunate sequelae (above) avoided!! Thanks Bel you ARE the Dermatology Queen!!
  17. MCA

    MCA Member


    Here in Canada I am using Formula 3 for nail fungus - a topical with much better results and compliance than Penlac. Not sure if it is available elsewhere.
  18. blinda

    blinda MVP

    Formula 3, eh? Cool name. Quick search on this engine; nudge, nudge....


    ......reveals the actve ingredient for F3 is Tolnaftate; a fungistatic (prevents spore reproduction). Penlac is also a fungistatic anti-fungal, with Ciclopirox being the active ingredient.

    Not sure if Amorolfine 5% is licensed for podiatric use where you are, but it`s prescribed here as a`new chemical class`, reportedly fungicidal in action, albeit in vitro studies only;


    Hope that helps!
  19. daisyboi

    daisyboi Active Member

    Hi BLinda

    Lots of interesting and informative reading there, thanks very much. Can you please tell me what lab you send your nail clippings to for analysis.
  20. blinda

    blinda MVP

    Hi daisyboi,

    I send tissue samples to the path lab of my local hospital;


    I have a good professional relationship with the path lab as I made contact with them and asked if I could spend an observational day with them (watching the microscopy and culture of samples) with a view to sending them samples, shortly after I graduated. I would thoroughly recommend it.

    Chin, chin

    BTW, I don`t EVER send `nail clippings`, you need to harvest subungual tissue (and plenty of it) from the active (most proximal) part of the infection for an accurate dx.

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