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Total nail avulsion with phenolisation for onychomycosis

Discussion in 'General Issues and Discussion Forum' started by hill, Dec 25, 2014.

  1. hill

    hill Active Member


    Members do not see these Ads. Sign Up.
    greetings friends and merry christmas and happy new year for the christian readers
    I would like opinions on the following. Just had a pt who wanted me to perform a tna -total nail avulsion with phenolisation on the one hallux in order to prevent the entire nail from growing back due to chronic onychomycosis. he requested this of me and was sent to me by surgeons due to the fact that I am one of the very few around here who would be able to perform this procedure. He is in his mid forties and healthy and wants this done becausehe is worried that his small chidren could catch it from him and he was told that it could be dangerous for children.He does not suffer from any pain at all, and does not want to even think of oral treatment because he does not want to "poisen his body".he has done a bit of local treatment in the past but did not want to hear any of my suggestions about other options of local treatment.
    Liver function is normal, no chronic meds. I told him that I am not prepared to perform the procedure in this case. I feel that its too radical a procedure to do in this case. I think that its too radical a procedure to do so lightly and I don't think its called for in this case. needless to say he was not happy with this. Am I being too conservative? I just dont think that this procedure is something that should be done so quickly.
    Opinions please.
    Thanks
    Hill
     
  2. markjohconley

    markjohconley Well-Known Member

    Hill, i take it you mean should you perform a 'nail avulsion'? rather than should i perform a TOTAL nail avulsion, is that right?
     
  3. hill

    hill Active Member

    there is no reason to perform a pna- no o/cs. he wants me to perform a total with phenolisation of the whole matrix- he wants no toenail there at all. seems like overkill to me for this specific case.
     
  4. Lab Guy

    Lab Guy Well-Known Member

    Hill,

    I would first educate the patient that his children are not at risk of contacting the fungus from him and therefore that reason should not factor into electing to have his nail removed.

    If he still chooses to have it removed, then in my opinion, I would have no problem removing the chronic mycotic nail permanently. He would be left with a thick nail bed that would resemble a nail and would not be tender in shoes or with activity. As he got older, he would not have to be concerned with debriding a thick mycotic nail that can also grow inward and cause a secondary bacterial infection. Is there a purpose for the nail that warrants fighting to keep it other than aesthetic reasons?

    Steven
     
  5. Rob Kidd

    Rob Kidd Well-Known Member

    I would have no problem performing this very simple procedure. However a tna without phenolisation may be more appropriate. Then one may treat the nail bed with antifungals - a process that would have been "shovelling excrement up hill" while the nail was still there.

    To this day I am uncertain of why practitioners are so reticent of undertaking so-called nail surgery - its easy, quick and essentially risk free with no debilitations; what is the big deal?
     
    Last edited: Dec 26, 2014
  6. Lab Guy

    Lab Guy Well-Known Member

    I agree, Rob, I do not know what the big deal is either. Our finger nails serve a purpose but I do not know what purpose the toe nails serve other than keeping the economy going.

    I think it is better to play the lottery than thinking the nail will grow back normal after a total avulsion even with treatment of topical antifungal medications. Long term, the recurrence rate is 99.9% in my experience. Remove the nail permanently and you don't have to waste energy and money applying antifungals and having further treatment down the line.

    Steven
     
  7. Nina

    Nina Active Member

    Hi Hill,

    As long as you have informed consent, you have counselled him on the pros and cons of the procedure you should be able to go ahead. This guy obviously sees himself as a reservoir of infection and is prepared to go to extraordinary lengths to protect his family.

    We all know that even if the onychomycosis is eradicated it is likely to return again eventually whatever the treatment. I performed several total nail ablations prior to terbinafine being available, mostly for pain associated with the thickness of the nail.

    Phenolising the nail bed for 1 minute is an option but there is still the risk of recurrence.

    These chronically infected nails are difficult to avulse you'll need a sturdy Ficklings nail elevator.

    Hope this helps

    Nina
     
  8. Lab Guy

    Lab Guy Well-Known Member

    "These chronically infected nails are difficult to avulse you'll need a sturdy Ficklings nail elevator".

    When thick mycotic nails are avulsed from proximal to distal, very little force is necessary and the nail comes off quickly. Still, you want to take your time to ensure your not creating any tears within the nail bed. Any remaining fungal debri attached to the nail bed is carefully debrided off.

    Steven
     
  9. Rob Kidd

    Rob Kidd Well-Known Member

    Lab Guy, your are entirely correct; finger nails are very important in adding adding to fine-tactile-movements such as doing up a shirt button. Toe nails - in human primates do nothing apart from be a pain in the toe when they go wrong. Their original function was all lost with the gaining of the bipedal habit. You may be right about the recurrence - I simply do not know; I was largely thinking aloud.
     
    Last edited: Dec 27, 2014
  10. hill

    hill Active Member

    the nail in this case is not really thick. no pain present and the only reason he wants it done is that he thinks that his kids will get it and that it can be dangerous for them.
     
  11. hill

    hill Active Member

    he also thinks that removing the nail with full phenolisation would heal him of the fungus. that there would be no residual fungus.
     
  12. Lab Guy

    Lab Guy Well-Known Member

    You have probably told him there is indeed a chance of recurrence. You probably told him the fungus is ubiquitious but that your children have a strong immune system to protect them from catching it and if they do, it is not dangerous. I have been to Israel, danger is driving on their roads!

    My gut intuition is telling me that the real reason why he wants his nail removed is because he has an underlying irrational fear of the fungus or anything that he considers is going to "poison" his body. I see that you reside in Israel, is he a strict orthodox Jew and the fungus would be considered non-kosher? I do not know but his need to have his asymptomatic fungus nail surgically removed is indeed indicative of an underlying phobia or irrational fear in light of your appropriate education regarding his nail fungus.

    Still, even if he remains resolute in his decision based on his personal belief system, I would accommodate him and permanently remove the nail as what harm would I be causing him? None. If he was asking for his big toe to be removed, than that would be a different story.

    The mycotic nail seems to be tearing him up emotionally and removing the nail will give him peace of mind. If you yourself are afraid or do not hold onto the belief that his nail should be removed, then perhaps refer him to someone that will. You are right in practicing the way you see fit.

    Steven
     
  13. hill

    hill Active Member

    thanks for the advice. in this case the pt is not even orthodox, there is no problem re kosher. onychomycosis here is very common. i also often perform tna's when i see a clinical need. the case here is that the nail is only slightly thick, discoloured and been shown by a lab test to be fungal. totally asymptomatic. the pt was prescribed a round of terbinafine in the past by a dermatologist but did not take it because he did not want to "poisen his body" with oral meds. he says that he has lived with it for years but now wants to get rid of the nail because he has this fear of it being dangerous for his kids. seems he was told in the past by a dermatologist that it could be dangerous for children?!!! i have advised him of the different options etc but he is adamant. he is so irrational about this that he said that if i dont perform the procedure then he will get hold of phenol himself and do it himself with the help of youtube. talk about irrational. does not want to "poisen his body" with oral meds but is prepared to do that.
    perhaps i will just get informed consent and just do the procedure.
    thanks
    hill
     
  14. W J Liggins

    W J Liggins Well-Known Member

    Hello Hill and happy Hanukkah (bit late but never mind - I'm late for Christmas too).

    Taking account of our duty to 'first do no harm', I really don't see a problem with this chap. For his own reasons he clearly is focused on clearing his mycosis. You have discussed the more conservative potential treatments which he has declined, and insisted on eradicating the problem. It could be strongly argued that by refusing to carry out an ablation you will be doing him more harm than good and he will eventually find a practitioner to carry out the procedure anyway. As you suggest above, having warned him of the potential adverse reactions and taken 'informed' consent you can go ahead. He's happy, the referring practitioner is happy, and you're happy.

    Happy New Year (My Jewish friends do celebrate it in the U.K., probably because they like a drink also!)

    Cheers

    Bill
     
    Last edited: Dec 28, 2014
  15. hill

    hill Active Member

    thanks
     
  16. mycoses33

    mycoses33 Member

    Try and convince the pt. that you may be able to eradicate the fungus by simple nail avulsion, debridement of subungual mycosis and application of antifungal liquid daily to the new nail as it regrows. IF this is unsuccessful then the next step is permanent phenol removal. I try and perform simple avulsion and debridement at least once before phenol. I have some success with this procedure for people who cannot take po meds. Of course fungal skin infection must also be controlled w/ antifungal creams to prevent recurrence of nail fungus from adjacent chronic skin infection. I still remember the days before po meds when I had patients soak feet in 1% potassium permanganate solution to eradicate severe skin infections covering both feet.
     
  17. Lab Guy

    Lab Guy Well-Known Member

    What is the purpose of spending all this time and energy to save the nail? What are your compelling reasons to save the nail plate?

    Steven
     
  18. W J Liggins

    W J Liggins Well-Known Member

    Is it not the case that we should carry out the minimum treatment to achieve the maximum outcome? Surely, in this instance to carry out two episodes of surgery is counter productive, especially since the patient has expressed himself more than happy to have permanent eradication of the problem?

    Bill Liggins
     
  19. mycoses33

    mycoses33 Member

    I once had a young female patient ask to have hammertoe surgeries on all her asymptomatic toes so that the toes could be shortened giving her smaller feet so she could wear smaller shoes. and she was serious. I declined . I try not to let patient demands influence what I feel is the best clinical choice medically. The patient demand and best clinical choice are not always the same. A clear normal non infected nail is always preferable to no nail at all for cosmetic appearance. Picture yourself explaining to a lawyer why you did not try and save the nail when the patient changes his attitude and decides he is unhappy with the appearance of the toe with no more toenail and accuses you of not advising him you might be able to save the nail. I have been there and it is very uncomfortable.
     
  20. Lab Guy

    Lab Guy Well-Known Member

    "Picture yourself explaining to a lawyer why you did not try and save the nail when the patient changes his attitude and decides he is unhappy with the appearance of the toe with no more toenail and accuses you of not advising him you might be able to save the nail."

    Picture yourself seeing this patient (who has been irrationally obsessed about his desire to have his mycotic nail removed) return to your office extremely upset and disappointed. He paid for your avulsion procedure and religiously applied the topical medication and his nail still became reinfected. He now has to go through a second procedure and still worry about recurrence.

    Do you truly think this patient is concerned about cosmetic appearance?? Not only that, but if the procedure is done well, it looks pretty good. Maybe if you picture yourself having appropriate medical records and a signed consent form, you can spend time serving your patients' needs rather than worrying about yourself being sued.

    Steven
     
  21. Medvice

    Medvice Member

    Hi Hill,

    I have always considered total nail avulsion a very extreme treatment for Onychomycosis.

    Personally I think that refusing to perform the operation was ethical and wise. If the patient had the operation, and then later discovered that there was preferable treatment, they may blame you.

    We have developed a far less invasive treatment that leverages the effectiveness of anti-fungal agents like Lamisil by giving them access to the nail bed through minute holes in the nail plate.

    The Podiatrist uses the device to make tiny holes less than 0.5 mm in diameter in the patients nail. The patient usually will not feel anything, although sometimes a small prick is felt, because the device controls the depth of the hole, to ensure that the nail bed is not harmed.

    The patient then applies a topical treatment (we have found tat Lamisil spray is extremely effective) until the infection is killed. Typically we are seeing infections killed within one month and a very clear improvement in just two weeks (which is much faster than anything else that I am aware of).

    The device is called Clearanail and has jus been released in the UK. I would be very happy to meet with anyone that is interested at the Arab Health meeting in Dubai this Jan 2015.

    Here is our website

    http://clearanail.com/page4.htm


    Here is a paper we are writing about the treatment

    http://www.clearanail.com/CLEARANAIL_RTTD_LO-RES.pdf


    This is the device on sale in the UK

    http://www.algeos.com/clearanail_kit.html


    This is a video of the device used

    https://m.youtube.com/watch?v=jt3R4f9Mmy0

    I would be happy to answer any questions you may have.

    Good luck!
     
  22. Lab Guy

    Lab Guy Well-Known Member

    Clearanail is useful to separate patients from their money. Hope nobody in their right mind will use Clearanail.

    Steven
     
  23. Medvice

    Medvice Member

    Hi Steven,

    Here is a paper with some case studies.

    The treatment is proving to be extremely effective..

    Novartis (the producers of Lamisil) are trying to produce a laser for the same reason making holes in the nail plate.

    http://www.clearanail.com/CLEARANAIL_RTTD_LO-RES.pdf

    In my experience lasers are; very expensive, ineffective and require multiple treatments, whereas our treatment is very effective and only requires a single treatment.

    Rolf
     
  24. Medvice

    Medvice Member

    We are working with one of the top Dermatologists in the UK to develop the Clearanail system.

    We have found that the tiny holes allow the medication to kill the fungus in the germinal matrix, where normally only oral treatment can reach it. Thus it is a far safer and more effective treatment.

    I believe it is better to save a toenail if possible. I think that the toenail also plays a role in stabilising hallux during walking, and so removal has more than just an aesthetic impact.
     
  25. W J Liggins

    W J Liggins Well-Known Member

    Fair enough. You have now made it quite clear that your intent here is to sell your system.
    However, sadly, this does not square with your previous statement that refusing to perform the ablation is 'ethical and wise'. Furthermore, you are either extremely ingenuous or extremely cynical in comparing this case, which involves pathology, with cosmetic surgery.

    The O.P. has asked for advice. My advice would be to avoid your system like the plague, and any others which use similar grounds - and by the way, nail ablation in suitable cases is appropriate, not 'extreme' treatment.

    Bill Liggins
     
  26. Medvice

    Medvice Member

    Hi Bill,

    I'm simply trying to highlight that there may be an option other than oral treatment that heals the nail.

    I think that TNA is extreme, in this case (which is why the author started the thread).

    If I was a patient I would welcome the opportunity to heal the nail as opposed to remove it permanently.

    Consequently the only basis that I can see for avoiding the Clearanail system (which is a safe and effective treatment) would be based on cynical motives.

    Furthermore I suspect that you charge for the services of permanently removing the Patients toenail, which arguable (hence this thread) is not in the best interest of the patient.

    Just because I'm making people aware of an option that is preferable to TNA, I do not believe this should make me a target.

    I can to some degree, understand the cynicism on the forum, as there are a number of laser systems, that are marketed for treating Onychomycosis, and my understanding is that none of them are effective (as heating the fungus has been shown to be ineffective.

    The Dermatologist Dr Ivan Bristow, that wrote the paper refuses to have anything to do with lasers for that reason.

    He is however getting very good results using our device, and I would have thought that any clinician with their patients best interest at heart would look at the evidence before dismissing treatment options.

    :bang:

    Rolf
     
  27. W J Liggins

    W J Liggins Well-Known Member

    i) the OP did not ask about oral treatment
    ii) phenol nail ablation is a safe, satisfactory and appropriate t/t (in this case)
    iii) you are not the patient in question. The patient has clearly stated that their chosen t/t is ablation
    iv) I imagine that you charge for the Clearanail system, which adds hypocrisy to the charge of cynicism
    v) you have (as yet) produced no RCTs to prove your claim that your system is "safe and effective treatment"
    vi) Dr Bristow is not a dermatologist let alone "one of the top dermatologists in the UK" and I am sure that he would not claim to be. He is a podiatrist with a special interest in dermatological presentations in the foot. I think that you demean him by claiming otherwise

    If you cannot even be accurate on such a simple matter as to who is testing your system, you cannot be surprised that you will not be taken seriously on clinical matters.

    I will not assist traders with the opportunity to market their wares on a clinical site and will therefore not answer any further posting from you.

    W J Liggins
     
    Last edited: Jan 5, 2015
  28. Medvice

    Medvice Member

    I will not assist traders with the opportunity to market their wares on a clinical site and will therefore not answer any further posting from you.

    W J Liggins[/QUOTE]

    Thank God for that!
     
  29. Lab Guy

    Lab Guy Well-Known Member


    Rolf, I pasted this from your PDF paper:

    Many experimental chemical
    agents have been trialled to assess their ability to render the human nail more permeable and work in the 1980’s
    experimented using the CO2 laser to create holes in the nail plate to permit easier passage of medicaments to the
    nail bed [19]. The concept of drilling small holes in the nail – termed “nail trephination” was first developed in the USA
    and has been used to treat sub-ungual haematoma [20]. The mechanical technique described here has a number of
    advantages over chemical and laser technologies. Firstly, the cost of the device; retailing at £2000 the device is
    significantly cheaper than laser
    technologies and therefore potentially more accessible to clinical practitioners. Secondly, the device has
    demonstrated to be safe for the patient and practitioner alike.

    I (and many other Podiatrists) was using my in-office Xanar CO2 laser back in 1986 to create tiny holes (I did not charge extra for this) in the proximal nail plate after debriding the nail plate as thin as I could. I had the patient apply topical anti-fungal medication and sometimes I even prescribed oral anti-fungal medication as well to those patients that wanted to exhaust every treatment modality to cure their fungus. Long term, fenestrating the nail plate with the laser with application of anti-fungal medication did not work. Short term the nails looked better, but if the nails were not constantly being treated, the nail would become reinfected.

    This option you are providing is not new nor it effective long term. I also do not understand why a paper would be published without a large cohort of cases with LONG TERM and not short term follow up. The paper offers no validation in my mind.

    Rolf, you are the CEO of this company and I do not understand why you would not do your due diligence to ascertain that this is an academic forum for Podiatrists. You are not a Podiatrist and therefore have no experience treating patients with onychomycosis. What gives you the right to give advice (and absurd advice) to Dr. Hill?

    Rolf, Onychomycosis continues to be the golden grail and if someone discovers a cure, they will own the world. To discover the cure is to understand the most common reasons why nails become infected to begin with and why recurrence is so high after treatment. Do you know those answers? I believe you do not and patients will have spent their hard earned money on a treatment that in their mind, expected it to cure their fungus.

    Until a cure is found, I would rather have the thick mycotic nail permanently removed so that the patient never has to struggle to trim it and suffer with the complications of the thick nail when they become elderly and further immunocompromised.

    Rolf, as CEO, was it a good idea to plug your company on Podiatry-Arena.com? It could have been a good opportunity by being completely transparent, no hype, and NOT giving absurd advice to a Podiatrist when its not your place to. The Podiatrists here care about providing the best available and affordable treatment for their patients. Making a living is important but making money is not their motive. Buying your product so they can charge 150 pounds per foot (according to your website) on a treatment that has no evidence of long term success is not what they want IMO. Know what you do not know so you may ask the right questions before plugging your company on a public forum.

    "I believe it is better to save a toenail if possible. I think that the toenail also plays a role in stabilising hallux during walking, and so removal has more than just an aesthetic impact." Do you just make this stuff up?

    Wait...maybe you are right. The toe box of the shoe is creating a plantarflexory moment against the hallux nail plate during the propulsive phase of gait. In turn, the plantarflexory moment exerted on the dorsal nail plate is transmitted to the nail bed, distal phalanx and plantar aspect of the hallux simultaneously providing increased distal hallux purchase as the first MPJ dorsiflexes with activation of the windlass. Yeah...thats probably what you were thinking.

    Steven
     
  30. Ros Kidd

    Ros Kidd Active Member

    I agree with Bill and his rational. TNA with phenolisation easy peasy. Problem solved. I am assuming that the OP does TNA's with no incision. Minimal tissue trauma always the by- word for surgery. I have had some female patients who have had acrylic nail adhered to nail bed, looked really good. Certainly never had a patient have a change in foot function post TNA, it was the otherway round, changed foot function gave rise to the problem eg: Charcot neuro arthropathy.
    My 2c worth.
    HNY
    Ros
     
  31. Mr C.W.Kerans

    Mr C.W.Kerans Active Member

    I think this is a case where there is no absolute indication or contraindication to proceed with the patient's expressed preference (total nail avulsion with phenolisation of the matrix). It therefore becomes a matter of individual practitioner judgement whether to proceed or not.
     
  32. W J Liggins

    W J Liggins Well-Known Member

    Precisely! Certainly not the judgement of an unqualified trader peddling his goods.

    All the best

    Bill Liggins
     
  33. Lab Guy

    Lab Guy Well-Known Member

    Bill, I think that's the last we will see of that unqualified trader peddling his goods :D

    Steven
     
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