It seems like such a basic topic, yet I cant seem to find a thread covering this issue in particular.
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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.
Thanks,
Sally
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Other threads tagged with onychomycosis -
I sometimes think that the medicament chosen is not close to being as important as the agressiveness of the debridement.
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Thanks for your directions and tips
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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? -
G'Day,
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! -
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.
http://emedicine.medscape.com/article/1105828-treatment
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. -
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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 -
Merry Christmas & a Happy New Year to All! -
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.
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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 -
The Chocrane data base is free to those in countries whose governments subscribe (this includes at leaset Australia and the UK)
abstract Below
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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. -
Debridement, topical Naftin gel or Penlac, KOH or outside fungal culture, oral Lamisil- 90 days.
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Hi,
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:
Cheers,
Brad:drinks -
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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...
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:
Cheers,
Bel
Ref:
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 -
BTW: I sent photo of t-shirts to the wife ... thanks ;) -
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:
Cheers,
Brad:drinksLast edited: Feb 15, 2009 -
Thanks for the link Craig, I noticed SotonPod (clever fella;)) made the pertinent point...
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.
Cheers,
Bel -
Just spotted this....
Cheers,
Bel -
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. -
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 -
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?
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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 morbiditiesLast edited: Feb 20, 2009 -
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.
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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:
Cheers,
BelLast edited: Feb 25, 2009 -
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? -
http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=19758
The EU has safety concerns about it; the well done RCT's are showing its no better than placebo. -
What's your "gold standard" topical therapy for onychomycosis?
Cheers,:drinks
Brad -
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I have to agree with DaVinci, wouldnt risk using teatree oil.
By the way DaVinci.....do you have a real name and identity? -
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DaVinci makes some wise comments...Its a shame the person behind them can't be recognised for this.
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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:
Cheers,:drinks
Brad -
Hi Craig,
You have to crack the code!;)
Cheers,:drinks
Brad -
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. -
Cheers
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