A Deeper Dive Into Specialized Aspects of Onychomycosis Treatment

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In a continuation of an interview with Tracey C. Vlahovic, DPM, FFPM, RCPS (Glasg), we learn more about specialized aspects of treating onychomycosis, including pediatric treatment, ancillary treatments, and where clinicians might be able to improve to impact overall results.

Q: Can you share information with us regarding the use of efinaconazole 10% topical for pediatric use?

A:

For more information, please see a previous blog from Dr. Vlahovic here. 

For pediatric patients, ages six years old and above, Dr. Vlahovic shares that efinaconazole 10% topical is now approved for that population.

“I was the phase four principal investigator for that clinical trial,” she says. “So, I had my own patients that were in that trial. It was really interesting to see how patients progressed throughout that year-long trial.”

She goes on to say that having a topical option available for these children and adolescents, is encouraging, because a lot of parents come in and don't want their child to be on a systemic medication and prefer a topical agent.

“So, it's wonderful that we have a safe and efficacious option for our children and our adolescents ages six and above who have onychomycosis, to have a topical therapy available for them,” she says.

Q: What other factors should clinicians consider when devising a comprehensive treatment

plan for onychomycosis?

A:

When giving a patient a prescription for a topical antifungal, Dr. Vlahovic says she always discusses that it's not just the pharmaceutical agent, but one also has to think about the environment.

“So, we have to think about their shoe gear, their socks, their bathtubs, all of those different things, and make sure that that environment is as reduced for fungus as possible,” she adds.

Based on an article that came out years ago regarding the ultraviolet (UV) light device for shoes,¹ Dr. Vlahovic recommends patients with athlete’s foot and onychomycosis purchase the UV light to sanitize their shoes, because she wants to reduce the fungal bioburden as much as possible in this patient population to reduce recurrence.

“That's a really big issue with onychomycosis; recurrence and reinfection,” she stresses. “So, to try to be mindful of that, I want to make sure that my patients are taking care of that part of their environment.”

Dr. Vlahovic says she also discusses sock wear.

“I encourage patients who, again, have onychomycosis and tinea pedis, to utilize copper fiber-based socks or silver fiber-based socks,” she explains. “To again reduce some of that microbial load that is present naturally on their feet and in their shoes, and reduce the amount of reinfection and recurrence that can occur. Of course, good foot hygiene is always a part of it and utilizing different disinfectants in the bathtub and bathroom where there's a shared space where someone else may have onychomycosis, or that you are fearful of giving it to someone else in your household, that's something that's important as well.”

Q: Where do you feel clinicians can improve as far as diagnosing and treating onychomycosis?

A:

Dr. Vlahovic says that one important point for clinicians to realize is that 50 percent or even more sometimes of the nail disease podiatrists see is onychomycosis. So, that means that 50 percent of the nails that clinicians see are not onychomycosis. Accordingly, she stresses the importance of considering the entire differential diagnosis, including performing a thorough medical history and examination.

“Keep in mind that your skin and your nails have finite ways of expressing themselves as far as inflammation and an infection are concerned,” she says. “So a nail that has onychomycosis will have subungual debris, onycholysis and discoloration. A nail that has psoriasis involved in it will also have subungual debris, onycholysis and possible discoloration. It's very difficult to tell the two apart. So, it's our job to be the detective. It's our job to make that determination. And visually, sometimes it is really difficult, if not impossible, to do.”

Dr. Vlahovic shares that this is where clinical lab testing comes in. Whether a clinicians is doing a PAS stain, or a KOH and culture, or a PCR, if you're not sure, or if you feel that the patient might have multiple things going on, it's important that clinicians utilize this testing to really make sure the patient actually has onychomycosis.

“The last thing we want to do is give a patient who doesn't have onychomycosis a topical or oral antifungal,” she says. “That just doesn't make sense. So, we want to make sure that we are getting the diagnosis correct and we're ruling out the differential diagnoses that it could possibly be. We look at things visually we can do lab testing, but of course it all starts with a good patient interview and clinical exam.”

Dr. Vlahovic discloses that she is a consultant for Ortho Dermatologics.

Reference

1.     Ghannoum MA, Isham NI, Long L. Optimization of an infected shoe model for the evaluation of an ultraviolet shoe sanitizer device. J Am Podiatric Med Assoc. 2012;102(4):309-313.