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Whats your Gold Standard for onychomycosis?

Discussion in 'General Issues and Discussion Forum' started by MelbPod, Dec 22, 2008.

  1. MelbPod

    MelbPod Active Member

    Members do not see these Ads. Sign Up.
    It seems like such a basic topic, yet I cant seem to find a thread covering this issue in particular.

    My question is...What is your gold standard fungal nail treatment? and what are success rates like?

    It is understood, each patient is a different case depending on if there little Betty the 87 year old with poor kidney function or Bob the healthy 35 y.o.

    My experience of practice is minimal and over this time I fid myself questioning whether my management is up to norm of the larger podiatry population.

    My General treatment plan is of topical treatment with undecenoic acid and chloroxylenol in oil based tincture (brand withheld) as first line treatment,
    If this is unsuccessful, and depending on patients health I may request with GP a script for oral antifungal treatment.

    I have a number of patients who have been trying for 1,2,3 years and still have no success and I wonder what others are managing these apatients with.

  2. Admin2

    Admin2 Administrator Staff Member

  3. mimipod

    mimipod Member

    I sometimes think that the medicament chosen is not close to being as important as the agressiveness of the debridement.
  4. Admin2

    Admin2 Administrator Staff Member

  5. MelbPod

    MelbPod Active Member

    Thanks for your directions and tips
  6. MelbPod

    MelbPod Active Member

    One particular patient is a 11 y.o boy, who noticed change in nail at a school camp about 9 maonth ago.
    I saw him for the first time last week and his entire nail (except for a tiny distal fragment attached to the nail bed, has gone. This includes the matrix tissue, I can put a blacks file in the space it has left under the eponychium.

    The GP had previously recomended topical treatments, and oral medications are contraindicated in children.

    As no debridement is possible....where too? Maybe something else going on?
  7. Adrian Misseri

    Adrian Misseri Active Member


    I'm with mimipod, I think that heavy debridement of the infected nail is important as the acive spreading fungal elements will be at the junction between infected and uninfected nail tissue. Quite often I then recomment daily tea tree oil, and if that goes no where I'll refer to the phamacist for a topical preparation. In some cases I'll consult with the GP for scrapings and oral therapy, but not that often. In the case of your 11 year old boy, I'd be treating it topically to make sure there are no fungal elements left as the new nail grows back.
    Personally I like the tea tree oil because it's natural, and everyone seems to have some the bathroom cupboard. Did see some interesting results at a conference a couple of years ago regarding the antifungal properties of lavender oil, seems it works quite well not directly applied, but as an aromatic, i.e. put a couple of drops on a cotton wool ball and put it at the end of the shoe and the aroma will penetrate through the footwear and feet, and into the infected nail/skin, helping to kill the fungus.
    Treating onychomycosis is such a difficult task, and takes such a long time, makes it difficult with patients.
    Good luck!
  8. eddavisdpm

    eddavisdpm Active Member

    Onychomycosis is such a common condition that it deserves a closer look. I have changed treatment regimens several times throughout the years. Two treatments that I have adopted in the last couple of years are providing very decent results.

    1) Nail debridement plus application of Naftin 1% gel. The patient is asked to rub the gel into not only the nail but the posterior nail fold. A significant number of patients demonstrate clearing of the nail, that is, the new nail growth emanating from the matrix. It appears that the application of the Naftin gel to the posterior nail fold is what is effective, significantly more than the nail plate itself. Naftin cream does not work, only the gel form. I assume that the penetration characteristics differ.
    2) Oral meds. The persisting issues with the "official" onychomycosis medications remains high cost, the need for liver function tests, care to monitor drug reactions, battling with insurance carriers, etc. A relatively inexpensive broad spectrum and highly effective antifungal is Diflucan (fluconazole). It has the same potential issues with the other oral meds but the dose needed to cure onychomycosis is only one 150 mg. capsule once a week. At that low and infrequent dose, I have run into no problems. Additionally, the cure rate is high because of Diflucan being a broad spectrum antifungal. Patients in the US need be advised that this is an "off-label" indication by the FDA.


    There are a paucity of good studies on this. The relatively low cost of Diflucan compared to other oral antifungals may fail to provide an impetus for more thorough studies in my opinion.
  9. eddavisdpm

    eddavisdpm Active Member

    The link is to an article that must first be purchased to be read. Please summarize the article or provide a version that does not require a fee.
    Ed Davis, DPM
  10. DrLCT2

    DrLCT2 Member

    I agree with several of the submitters that extensive (heavy) debridement is the key to any possible success. Over the years (41 or more) I tried just about everything (topically & systemically); and in the end, found that extensive debridement, vinegar solution soaking, scrubbing with a fairly stiff brush and an anti-microbial scrub/soap/solution, thorough drying, and finally applying vinegar (it doesn't seem to matter what kind - white or cider) directly with an eye dropper has produced the best results.
    Merry Christmas & a Happy New Year to All!
  11. Dr. DSW

    Dr. DSW Active Member

    I'm not convinced that any topical really has any SIGNIFICANT efficacy on a consistent basis, and I believe debridement is the only palliative treatment with any real success. As Dr. Davis pointed out, the oral antifungals such as terbinafine and Diflucan are oral agents with success when indicated, but as previously stated, I can't say I've had any real "luck" with any of the plethora of topicals available.
  12. mstern1

    mstern1 Welcome New Poster

    OK, OK this is my first response.
    Onychomycosis is very frustrating and hard to treat. I read all the responses and agree that aggressive debridement is essential. I think first in order to know what you are treating you need to do a nail fungal test. Many of these come back as onychodystrophy. Theses nails will not get better and treatment of these with oral medications not only lowers effectiveness rate published and is contraindicated. Many of the patients I see have this condition and have been treated by primary care with 2-3 rounds of oral medications with obviously no success.
    Oral lamisil, which is my treatment choice went generic about three months ago and so the cost of treatment has gone down to about $25.00/month.
    Over the years I have tried ALL the topical treatments....tinctures, vinegar, Penlac etc. to limited success rates. The newer topical medications are homeopathic and include camphor, menthylateum, etc. Vick's vaporub also includes many of these and I have started using this for topical care of onychomycosis. It is essential for aggressive debridement weekly. This works as good as the expensive topical treatments out there.
    Sorry for rambling. MJS
  13. Tuckersm

    Tuckersm Well-Known Member


    The Chocrane data base is free to those in countries whose governments subscribe (this includes at leaset Australia and the UK)

    abstract Below

  14. Nat

    Nat Active Member

    FYI, generic terbinafine is now available. Costco charges $22 for a 30-day supply. Bi-Mart, Fred Meyer, and Rite-Aid charge $4 for a 30-day supply. That's right, $4!

    The patient can pay out of pocket (i.e, no insurance hassles) for less than the typical insurance co-pay.

    Availability of generic changed the game completely.
  15. Gibby

    Gibby Active Member

    Debridement, topical Naftin gel or Penlac, KOH or outside fungal culture, oral Lamisil- 90 days.
  16. dyfoot

    dyfoot Active Member


    My 2 cents worth: aggressive debridement, pure Tea Tree Oil daily (avoiding the surrounding skin due to risk of sensitivity reaction) and metho. or surgical spirit sprayed liberally after ANY and ALL moisture exposure (multiple times daily eg: after showering/bathing and when removing socks), also treat any skin infection (eg: full-strength Whitfield's) whilst treating nails and disinfect socks (eg: Canesten Hygiene rinse).:craig:

    Biggest problem is patient compliance.:pigs:

    but the nails are theirs not mine!:bash:


  17. DaVinci

    DaVinci Well-Known Member

    Since when is Tea Tree oil a "gold standard", especially in the context of the lack of evidence and there was talk of the EU banning it over safety fears!
  18. blinda

    blinda MVP

    Can i ask a (stupid) question?:eek: When you talk of `heavy debridement` are we talking total nail avulsion here or reduction with bur/scalpel?

    I agree...

    I have copied what i posted on a VP thread....

    There is an interesting study in the Australasian Journal of Dermatology (Rutherford et al, 2007) which highlights the incidence of reactions to oxidized TTO as being relevant enough to warrant appropriate warnings (banning) on TTO products. It also states that the antimicrobial effect of TTO against bacteria, fungi and virus (herpes simplex only) has only been demonstrated in in vitro studies and that no clinical studies have revealed superiority of TTO over existing licensed pharmacological tx.

    Another good read is Aberer, 2007. `Contact allergy and medicinal herbs`. This addresses the misconception that unlicensed herbal remedies are `harmless` or `gentle` drugs, as many contain active ingredients and/or toxic substances, which are not only capable of producing reactions such as contact dermatitis, anaphylaxis and photosensitivity, but can also adversely interact with other prescribed medication. It also discusses reaction to marigold therapy:dizzy:


    Rutherford T, Nixon R, Tam M and Tate B. Allergy to tea tree oil: retrospective review of 41 cases with positive patch tests over 4.5 years. Australasian Journal of Dermatology (2007) 48; 83-87

    Aberer W. Contact allergy and medicinal herbs. Journal of the German Society of Dermatology (2008) 6; 15 -24
  19. Craig Payne

    Craig Payne Moderator

    Reduction with bur/scalpel down to almost bleeding (see: How important is debridement in onychomycosis?). I am forever telling the students to take more off....:bang:

    BTW: I sent photo of t-shirts to the wife ... thanks ;)
  20. dyfoot

    dyfoot Active Member


    I use Tea Tree Oil because it is readily available, inexpensive, is accepted by the Australian public, is easy to use and I have only seen reactions to it when patients apply too much on the skin ( that's why I emphasise to apply it to the nail/nailbed only). I know there is little evidence regarding its efficacy, but what topical agents have good evidence for "gold standard" treatment of onychomycosis?:sinking:


    Last edited: Feb 15, 2009
  21. blinda

    blinda MVP

    Thanks for the link Craig, I noticed SotonPod (clever fella;)) made the pertinent point...

    Whilst i cannot point to any recent evidence of a Gold Standard for topical therapy alone in OM, I advise pts to apply Amorolfine 5% (Loceryl or Curanail) twice weekly after I have reduced the nail, because in addition to its antimycotic activity, the lacquer provides a physical barrier thus preventing reinfection.

    Obviously, combination therapy with an oral fungicidal (such as terbinafine) will produce better results, but as a derivative of morpholine, Amorolfine is a member of a class of compounds that also have application as a fungicidal (in addtion to fungistatic activity) against dermatophytes.

  22. blinda

    blinda MVP

    Just spotted this....

    Not sure if it applies in Australia, but Griseofulvin is the only approved oral anti-fungal therapy in the UK....nasty side effect of flactulence though :eek:

  23. beekez

    beekez Active Member

    At the risk of being shot down.

    On the topic of debridement I notice the majority in this thread are pro drilling onychomycosis (as am I) and some are using tungsten drill bits others are using diamond burrs.

    In my experience when I was studying, onychomycosis was a no go zone with a drill in your hand, it was banned :hammer: .
    Did others have similar experiences? Do you have procedures in place for using the drill with onychomycosis to reduce the risks? Such as planned ventilation, debridement of the majority with clippers and blade (as much as possible) drill bit type etc.

    Like most of you I appreciate the need to debride the nail in order to apply topical treatments to improve effectiveness, I am just interested about how people go about this.
  24. gush_horn

    gush_horn Member

    Guess i can weigh in a little on this topic. In my final year of study i did a research proposal on the exposure to particle matter from the mechanical drilling of nails. The facts are that the majority of nail dust that is produced from the drilling of nails are in the smaller classification (PM 2.5) and are of course more dangerous (ability to track to alveoli). Based on the research on the efficiencies of drill dust extractors (published largely by the producer of the drill) the rates of dust removal is between 20-90%, with water units giving about 90% effective aerosol reduction. If you have a look at the total dust produced from an average drilling (10 nails) and compare the daily exposures to the WHO guidelines there appears to be a significant over exposure to particle matter, even when reducing it by the 90% that dust extraction claims to.
    I think its important to maintain airflow within the clinic (open windows, air purifiers etc), maintain the drills (replacing dust bags regularly & servicing) and the use of adequate personal protective equipment (goggles, dust mask (not queen charlot)).

    hope this helps a little
  25. beekez

    beekez Active Member

    Thanks for the information it appears it may not be such a good idea, although either is riding a motorbike if you look at it that way!
    Was your study just using nails with no clinical evidence of onychomycosis?

    After gaining these results do you still use the drill regularly in everyday practice and with onychomycosis.
  26. gush_horn

    gush_horn Member

    I mainly focused on particles in terms of size. However, if you do look at the issue of mycosis then the drilling of infected nails can lead to an aerosol of 'active' particles that have more of an effect when they penetrate the lungs. Cant remember the exact figures but there are a high number of podiatrist that have active antibodies to these types of particles.
    I know that some public health services in Australia do not allow drills to be utalised. Hard to say the exact risk but high exposure to fine particles has been solidly linked to a number of serious morbidities
    Last edited: Feb 20, 2009
  27. Axeman

    Axeman Member

    Aggressive debridement/reduction of the infected nail is a must in my opinion. Also, twice weekly appl of Amorolfine....but the cost of this can be prohibitve....daily Tea Tree Oil to the nail is my alternative to Amorolfine....but I find this tends to contain the infection rather than treat it. I don't recommend TTO for elderly patients because I don't want them to get it on to the surrounding skin. ie mobility and vision obstacles.
  28. blinda

    blinda MVP

    Had a pt in yesterday with OM affecting entire plate and matrix. She had been advised to apply TTO by a practice nurse. After 6 months of application and recurring discomfort and erythema (Read; Contact dermatitis) to the PNF the GP prescribed AB (which she hasn`t taken) to "deal with the redness":confused:. There was no infection present, other than the OM:bang:

    Last edited: Feb 25, 2009
  29. joyfulmia

    joyfulmia Member

    As far as tea tree oil goes I usually recommend this to patients who are not candidates for oral antifunguals (ie risks/ drug inteactions/side effects)
    I only recommend a 30% concentration as 100% can burn the skin and surround (which is definitely no good in your diabetic patients). I also suggest monitoring closely and using it every day or every 2nd day. When pts tell me they have some tea tree at home it sends the alarm bells ringing( as this is usually 100% conc. and used in industrial cleaners also)- you often notice if the pt is using it too strong as it starts to eat at the nail so it all crumbles off completely...
    I had a colleague who instructed a pt to use it on his nails and he somehow ended up getting the wrong end of the stick and applied it DAILY between his toes- which created nasty skin breaks!!
    what concentrations are other people using?
  30. DaVinci

    DaVinci Well-Known Member

    I am surprised that anyone continues to use it:

    The EU has safety concerns about it; the well done RCT's are showing its no better than placebo.
  31. dyfoot

    dyfoot Active Member

    Hi DaVinci,

    What's your "gold standard" topical therapy for onychomycosis?


  32. DaVinci

    DaVinci Well-Known Member

    Aggressive debridement and loceryl (amorolfine) as thats what the evidence supports as being better than a placebo (see cochrane reveiw earlier in this thread)
  33. MelbPod

    MelbPod Active Member

    I have to agree with DaVinci, wouldnt risk using teatree oil.

    By the way DaVinci.....do you have a real name and identity?
  34. Craig Payne

    Craig Payne Moderator

    I been working that one for a while. They from Melbourne; they have been to one of the Boot Camps; they once called me a nickname in a post that only a few people have used; there is also some mannerisms in their posts that point to it being one particular person ... but when I asked them if it was them, they convincingly denied it .... so he/she is very secretive ...
  35. MelbPod

    MelbPod Active Member

    DaVinci makes some wise comments...Its a shame the person behind them can't be recognised for this.
  36. dyfoot

    dyfoot Active Member


    The only problems with Loceryl are the cost and it's tricky to use. From my research Penlac (ciclopirox) seems to have the best evidence of the topical treatments, but it's not available in Australia.:dizzy:


  37. dyfoot

    dyfoot Active Member

    Hi Craig,

    You have to crack the code!;)


  38. Bug

    Bug Well-Known Member

    Not all are and it does depend on the weight of the child. I have a couple of kids in that are using either oral or topical antifungals. All of which we have a regime worked out with the local dermatologist. We all have access to Paediatric Pharmacopoeia from the RCH which is a fab resource when working with kids, not sure to access it privately in Australia however the RCH pharm's are fantastic when called with perscription/medication questions.

    I also think we need to consider what is happening systemically. Is is this the child or adult that has recurrent thrush elsewhere? Often the dermatologist near us advises a dietitian consult with a 3 month trial of elimination of yeast and sugars. While initially skeptical, the results have been marvelous for those kids and parents that have been committed enough to to the cause.
  39. joyfulmia

    joyfulmia Member

    I hadn't heard that there was safety concerns about it?! My colleagues and I regularly suggest it to those who want to try treat OM if they havent had any sucess with other topical treatments. I believe our new graduates (within our company) were still taught this was a good option- I will have to investigate. I knew the research didn't put it as being much better than placebo, but I have a few who it has worked really well for.


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