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What works with Onychoposis(fungal nail)

Discussion in 'United Kingdom' started by Theresa Walker, Oct 2, 2017.

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    Hi Guys

    Advice needed if possible, I have a pt that I have now seen a couple of times who has Onychoposis on all nails. She presented to me 6/52 ago stating that had seen GP who had prescribed meds, she has also tried all varying gels/liquids etc on the market, states that clears slightly but always comes back. Has come to me now for a "quick fix". I reduced down the nails and got her started on some lamisil initially.
    Just wondering what treatments you guys are having success with on your pts to try and pacify this lady?

    Any advice would be appreciated

  2. Catfoot

    Catfoot Well-Known Member

    Hello Theresa, I'd like to help but I don't understand your post. Onychophosis is not a fungal condition. It is a a localized or diffuse hyperkeratotic tissue that develops on the lateral or proximal nailfolds, within the space between the nailfolds and the nail plate, and is a common finding in the elderly. I don't know why the GP has prescribed meds for this ?? And why have you suggested Lamisil? This is a problem that can be dealt with by physical means.

  3. Hi there Catfoot

    Im so sorry, I meant Onychomycosis, Im up to my ears with a failed steriliser etc here and incorrectly typed
  4. Catfoot

    Catfoot Well-Known Member

    Theresa, I'm afraid that your lady is out of luck if she wants a "quick fix" with this condition .

    There are various laser treatments for this and also a system called Clearanail but they are expensive. You'll need to refer on to a Podiatrist that has one of these systems in their surgery.
  5. davidh

    davidh Podiatry Arena Veteran

    I advise looking at the nail condition afresh. Are you sure she has a fungal nail? Did the GP do a nail scraping to identify the contaminating organism?

    Lamisil works but takes time. Clearanail? I don't know. If that's the laser treatment for fungal nails the effectiveness doesn't match the hype. I'd be very wary of referring a patient for that type of treatment. There is another treatment which involves boring minute holes into the nail plate, then treating with a topical medication.

    Check the diagnosis first, then refer on - talk to some pods before referring. If they are unhelpful or rude (not all of us are), move on.

  6. Thank you David
    Yes she has had a confirmation from the GP re biopsy taken a while back, so I trust this to be correct and the nail is definately O/P. Must admit we were advised Lamisil whilst training, but I have since heard about
    topical application of teatree oil/olive oil mixed placed onto nail left 10 mins taken off with old toothbrush and then vics applied and left this done 2 x daily?. Just wondering if anyone has heard of this method as I have another lady who had this recommended to her by another FHP and she has seen results?. just wondering if
    It is wise?
  7. davidh

    davidh Podiatry Arena Veteran


    In general, sticking to scientifically-proven treatment is the best way forward.

    If the contaminating organism is identified, and a topical preparation is applied which is specific to that organism, and you are happy that the topical prep will actually reach the organism, then you have a fair chance of shifting it.
    If you simply remove some of the nail and apply vic in the vague hope that it may work, having heard of it work on one other patient, not only is your treatment method unscientific, but you leave yourself open to professional criticism, and worse - possible malpractice action.
  8. Catfoot

    Catfoot Well-Known Member

    Clearanail is the treatment which involves drilling holes in the nail plate to allow the solution containing the active ingredient to reach the infected subungual area. It has been discussed on these pages.
    The Pinpointe Laser has also had extensive coverage here and both have been the subject of research papers.

    Heather, did the GP prescribe oral Lamisil, because that works but takes months.

    The only "quick-fix" for her condition in this situation is to do 10 total nail avulsions, which is a bit OTT :eek:
  9. davidh

    davidh Podiatry Arena Veteran

    Yes, I read about the drilling holes in the nails technique on here - also about the hefty price-tag for the kit. I was not particularly impressed. To my mind the main benefit was to the people selling the kit. The results may be good in some cases, but is that technique really the best our profession can come up with?

    The Laser treatment is high on hype (and price) and low on actual good and proven results. I know that ill-informed pods are getting their fingers burned because having purchased the kit they find it does not necessarily do what was promised.

    Thanks for responding.

  10. Thanks very much David and Catfoot for your input on this situation, I have taken onboard your comments and will talk with my pt about various options available and find out who in my area does the clearanial and laser options and prices.

    Thanks again
  11. Catfoot

    Catfoot Well-Known Member

    More info on nail fungus here ;


    There are 2 conditions that cause a Podatrist's heart to sink and they are verrucae and nail fungus.

    The problem with treating these conditions, as I understand it, is based on the fact that the infective agent is intrinsic to the host's skin cell structure. The challenge is to load the area (by whatever means) to a sufficient concentration to destroy the virus/fungus.

    Most treatments for onychomycosis are fungistatic ie. they stop the growth of the fungus temporarily, the theory being that the nail can grow out in the meantime. Both itraconazole and terbinafine inhibit growth of dermatophytes.

    I don't believe that there is any treatment that is fungicidal ; ie actually destroys the nail fungus in situ without causing serious damage to the toe..

    ^^^^ As I said intially this is my understanding on the subject and I am open to being further informed.
  12. Dieter Fellner

    Dieter Fellner Well-Known Member

    I wouldn't be too strong in the condemnation of nail trephination for nail fungus. The technique makes a lot of good sense and has the backing of research papers. It is correct the equipment requires a capital outlay and it is what it is. I have the equipment, rarely use it.

    Now, Lamisil is often the 'go-to- option in the US. Takes a long time? Well, yes. Three months of daily pill popping. But has the advantage of also treating concurrent tinea pedis. As others have said, 'no quick fix'.

    Re-infection is a ubiquitous concern. Patient must be counselled about pro-active preventative steps.
  13. Pauline burrell-saward

    Pauline burrell-saward Active Member

    It was suggested at a conference a few years ago , to remove as much of the affected nail as poss. via drill and then apply the loceryl drops weekly .

    I have carried this out since and have been pleasantly surprised at the good results.

    makes since, if you think of it , you are not treating the fungus part of the nail but the new growth and surrounding area
  14. Dieter Fellner

    Dieter Fellner Well-Known Member

    There are many, very effective topicals for fungal nail. Regular debridement reduces the fungal load on the nail and enhances the requirement for the treatment to reach the nail bed where the fungus resides. That's the rationale behind nail trephination. Topicals have a hard time penetrating the nail plate.

    As with any other treatment, works for some, not for others.
  15. SingaPod

    SingaPod Member

    Based on what I've read and personal clinical experience Amorolfine nail lacquer (such as Loceryl but you can sometimes get it as a generic lacquer for a lower cost) can be reasonably effective if the patient is really religious about applying it. They need to rough up the top of the nail with the file and apply it at least once per week. My understanding of it is that Amorolfine is a fungostatic not a fungicide in the quantities found in nail lacquers, this means that it will stop fungal spread but not remove the fungus itself, this means that it has to be applied until the nail is completely replaced, this could take 1-2 years.

    If there has been limited improvement (after 6-12 months) then it may be necessary to work with their GP to get oral anti-fungal medications as a combination treatment as this will get at the fungal infection in the germinal matrix which the lacquer cannot get to.

    If you go for nail avulsion I would recommend getting an oral anti-fungal at the same time as (assuming the nail isn't phenolized) you can get re-infection when it re-grows and this reduces this risk.
  16. Dieter Fellner

    Dieter Fellner Well-Known Member

    Agree with the fungus, to an extent (can work well enough if there is good patient compliance with active treatment and preventative measures to reduce risk of re-infection) - I push most of my patient to oral Lamisil. The majority of patients have tinea pedis also and the fungus then creeps onto the nails. The tinea may be low grade (few clinical signs) or florid, or anything in between. Always treat skin and nails and footwear ( patient can spray shoes with Lysol regularly)

    An older method is to manage the nail with Urea 40% under occlusion for a few days - this softens the nail plate very nicely and this can be trimmed / burred . Most of the diseased nail can be removed in this way.

    Warts I find less problematic and now take a three (four?) tier approach:
    1. Initial home treatment with an OTC topical for 2 weeks
    2. If not improved Cantharadin applied once or twice almost always resolves the lesion
    3. If this fails, I use Folkner's Needling - not seen too many non-responsive patients at this stage.
    4. As a last option I surgically excise the lesion.

    As an aside, a surprising number of plantar forefoot lesions will similarly respond - IPK's, tyloma's etc ... Kilmartin et al published a great paper to show many of these lesions ( I think 56% from memory) have a 'wart' component.
  17. Dave Cartwright

    Dave Cartwright Welcome New Poster

    On the fungal nail debacle, has can anyone offer up their experience with the Pinpointe Footlaser now it's been around a while?
  18. Catfoot

    Catfoot Well-Known Member

    The person you need to contact about this is Hamish Dow who practises in Newcastle. he was a big advocate of this particular gismo.
    I'm sure you'll be able to look him up on the internet.

  19. Dave Cartwright

    Dave Cartwright Welcome New Poster

    Thanks Catfoot, I was hoping for comments from others, I know of Hamish, i was thinking of Pods over the pond that may have also used it. To get a broader opinion.
    But no the less, thanks for your comments.
  20. davidh

    davidh Podiatry Arena Veteran


    Try using the search facility on here. There's some info about laser for onychomycosis, not too much, but it may lead somewhere.
  21. Dieter Fellner

    Dieter Fellner Well-Known Member


    Personally I would not invest in laser therapy for fungus. Like all other treatments, a patient remains susceptible to reinfection. Laser, or any other treatment, is not a 'cure'. Fungal nails are managed, not cured.

    The estimate for success after laser is circa 65%. The patients I dealt with, who have had laser elsewhere, seem underwhelmed. This is not an insurance covered item in the US and is an out-of-pocket expense, and not cheap either. Nor is the equipment cheap to purchase.

    I think Clearanail trephination is a great option. Alas, this has not caught on (also an out-of-pocket expense)

    So, back to Lamisil etc. as detailed above.
  22. Meg Teasdale

    Meg Teasdale Welcome New Poster

    Good reading! I haven't heard of Cantharadin.. is this similar in terms of effect as Salicylic acid or Monochloroacetic acid? How frequently would you apply the Cantharadin and also how? Any additional info would be greatly appreciated!
  23. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hi Meg:

    I'm sure you will have googled Cantharadin - basically it's blister beetle derived toxin, packs a bunch of enzymes that breaks down tissue. In the formulation I use, as Compounded Medication, there is an additional agent that claims to be anti-viral. Dermatology will often use the agent.

    Clinical use is very simple. Debride as much as possible, apply duct tape to mask surrounding skin, paint on the Cantharadin, cover with more duct tape. Patient is instructed to remove tape after 4 hours and wash foot with soap and water. May or may not see a blister, sometimes with some 'pain'. Some do, some don't. I get them back after a week, re-apply if required. I rarely need more than two applications. After second application I take another look 4-6 weeks later. If it's gone it's 'yaiii' (really quite effective overall) - if not I progress to Folkner's Needling.

    Hope that helps!
  24. Jill Breivik

    Jill Breivik Welcome New Poster

    Just reading through this correspondence so perhaps you people might suggest something for my patient who has a fungal nail but is also breast feeding so won't use any medication. I was wondering about tea tree oil but I'm not sure if it is safe for her baby. Does anyone know?
  25. Amanda8044

    Amanda8044 Welcome New Poster

    Tea tree and Vick's both contain natural ingredients which produce peroxide as a byproduct of breaking down (ie, when applied). Over a short period of time of regular application, about 2 weeks, the nail is bleached, giving an improved appearance but having zero effect as a fungicide. Two weeks application of vicks can be about the equivalent of one application of undiluted household bleach. Check out NICE guidelines and Vicks company's own warnings against this practice.
  26. I have had good results with tea Tree oil diluted 50/50 with olive oil, applied daily with a cotton bud, together with monthly debridement by my nail drill. [​IMG] [​IMG]
  27. I have 2 brilliant pictures, before & after, 1 year apart but I can't seem to upload them, so bear with me.
  28. [​IMG] IMG_20200

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