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Salacylic acid for Fungal Nails?

Discussion in 'General Issues and Discussion Forum' started by dsfeet, May 28, 2014.

  1. dsfeet

    dsfeet Active Member

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    Recently a few have my patients have been turning up with salacylic acid 25% prescibed for fungal nails by one of our elderly local GPS. This horrifies me as all I am seeing is burnt skin. One gentleman was 80 and using it on his fingernails. To me this asking for trouble. I realise that sal acid is used to peel back keratin layers and we know its used for warts but does anyone know if there is any evidence regarding this use. How would you deal with the GP or would you talk to the GP regarding its use. I have done a quick search of the literature and I have found no evidence to support its use.

    Your thoughts please.
  2. kayron

    kayron Member

    There uses to be a product on the market for Onychomycosis, until quite recently called Phytex. This product used to contain Salicylic acid albeit in smaller quantities.
  3. Rob Kidd

    Rob Kidd Well-Known Member

    We were taught this in the early 70's, though the deliverer - Mike Whiting - had serious issues with it. we have moved on a huge distance since then. The serious question is; why are you treating at all? Essentially, topicals don't work and systemics are liver toxic - don't go there. IMHO - leave it alone.
  4. blinda

    blinda MVP

    Sal A is a keratolytic, in that it `breaks down` keratinous layers of skin. In higher doses it is believed to have fungistatic properties, in lesser quantities it is a penetration enhancer for more potent fungicidals. As with all acids, it should be prescribed with caution, particularly for patients regarded as high risk for delayed healing.

    There is a school of thought that we shouldn’t treat OM, as it is often regarded as a purely cosmetic problem and that a FEW oral anti-fungals (eg ketacanazole) have been identified with hepatoxicity and subsequently withdrawn from the European market. However, the majority of anti-fungals, including terbinafine, do not have a clinically relevant impact on rise in liver enzyme production, any more than paracetamol or indeed alcohol, and have undergone numerous rigorous clinical trials in safety and efficacy.

    I would agree that a large portion of our elderly patients are not ideal candidates for OM tx due to drug interaction, but there is a growing population of younger, immune-compromised patients (due to DM2) who are at risk of the development of lower limb cellulitis, secondary to tinea pedis/onychomicosis. IMO, these may well warrant tx, thereby reducing potential complications.

  5. SingaPod

    SingaPod Member

    I have seen a lot of anti-fungal nail treatments in use which have salacylic acid as a method of getting past the outer layer of the nail as an easier alternative to things like loceryl nail lacquer which require fileing the dorsum of the nail. However its generally a much lower percentage then 25%.

    I have found with fungal nails a lot of (typically older) doctors seem to use a lot of old treatments which are now regareded as ineffective or dangerous treatments. Castellani's paint and potassium permanganate seem popular but iodine and anti-fungal creams are also used with abundance (the later often gunking up the sulci and macerating the skin), I haven't seen just salacylic acid used but it wouldn't supprise me at this point. I assume it is that they are using what was current when they trained and haven't updated, most seem happy to take advice from pods if worded well....

    While it has limited success in resolving anything but the most superficial fungal nail conditions I have found that patients using locerly nail lacquer seem to have lower rates of complications and cross infection to the skin/other nails. I presume similar products would have similar results. I assume that this is due to the fungistatic effect combined with the barrier of the dried lacquer on the surface of the nail.
  6. Kara47

    Kara47 Active Member

    Topicals don't work?
    I love hearing the number of pods who quote this line. Explain why, if in combination with reducing of the nail I find in over 90% of my clients, there is a visible improvement and eventually total clearance of the affected nail?

    I agree that oral medications are too toxic.

    As to the reasoning why treat it:

    Untreated nails can splinter & cause infection. Most of the elderly clientele I see with onychomycosis are already immunocompromised, have vascular insufficiency or diabetes. Why allow a problem to develop that can be prevented? I have already had to perform one PNA on an individual whose care staff refused to treat his onychomycosis, leading to a painfully infected toe.

    How infectious is it? Very common in aged care facilities, along with tinea. Should we just not treat either because "it's only cosmetic" and allow them all to spread it freely?
    It's great when you are trying to get a treatment programme going & the GP dismisses it out of hand because "topicals don't work ", so that is what the facility runs with ( because as we know, GPs are GOD & see onychomycosis every day!!):bang:

    Clinical trials may tell you topicals aren't effective, but please don't disregard clinical experience.

    I'll get off my soapbox now:morning:
  7. Paul Bowles

    Paul Bowles Well-Known Member

    I hate to point out the bleeding obvious but there is improvement because you are regularly debriding the infected nail. Topicals as quoted above have a very poor results profile.

    The research doesnt agree with your opinion - but you are entitled to it. Benefit versus risk oral terbinafine has a very low risk of side effects against a very high success rate.

    Problem is clinical experience is not good evidence.....hence you can see why we practice evidenced based medicine. Everyone however is entitled to their opinion.

  8. Jaimee Brent

    Jaimee Brent Active Member

    I find it really refreshing to hear someone else say this.
    I have known soooo many podiatrists who push oral antifungals to patients without warnings...or sell poor efficacy topicals in there clinics, pushing them on patients for years to try and heal it.
    I have a vast amount of patients with this problem who are over 80...most of them have polypharmacy issues already and cant reach their feet to effectively cut there nails let alone apply topical solutions.
    So, often, (although in gentler terms) "deal with it" and "at the very worst your toenail may fall off without trauma" is often my advice to patients.

    Very nice to hear someone else say that as well

    Thank you!

  9. Jaimee Brent

    Jaimee Brent Active Member

    I'll add...
    I do have a high rate in summer of the teen-50s age group getting OM.
    Living in Australia, that time of year is ripe with transference within public change rooms etc which dont have the best hygiene and constantly have moist floors.
    In these cases, if the OM is not beneath the hyponicium I do advise Loceryl and have had very good success with this (though more so in the teen-40 age group) or I suggest Terbinafine as best treatment option. I suggest possible risks but that with a healthy individual they are low and then suggest that the patient consult with their dr for said care.

  10. blinda

    blinda MVP

  11. Rob Kidd

    Rob Kidd Well-Known Member

    Mike Whiting was my tutor in the early 70's. I am sure that I hold good for what he said then; I cannot comment about now. It is probably fair to say that the world has moved on a huge distance since then (vis: Blinda!). Mike is now an old man - we should not hold as gospel what he taught in the early 70's. Mind you, I am an old man too! But I think it is fair to say that there is more thinking now.
  12. blinda

    blinda MVP


    Sounds like a top bloke and I think he was absolutley right to encourage clinical reasoning on whether pharma intervention should be considered. As I have said previously, conservative care is sometimes the best option with OM.

    So when you going to buy me that pint, then?


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