Educating Patients About Onychomycosis

This podcast is supported by Ortho Dermatologics. 

Welcome back to Podiatry Today Podcasts. And in this episode, we continue to bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, Podiatry Today's Assistant Editorial Director. And joining us again is Dr. Ebonie Vincent, continuing our conversation on onychomycosis. This time we're diving into some key components of communicating with patients about the condition. Welcome again, Dr. Vincent. We're so glad you're here. So for this episode, we're talking a little bit more about patient education. I think many clinicians will agree that making sure that patients get information in a way that is accurate and understandable for them is sometimes half the battle in having an optimized outcome. So when it comes to onychomycosis, you touched on this a little bit in our last episode, but how do you approach educating patients about the condition of onychomycosis?

Ebonie Vincent, DPM:

So my first question to them is, what do you know about it? How have you been going about treating it in the past? Just so I can see baseline where people are in their journey towards it. Sometimes I'll ask about their surroundings. I'll ask if you're the only person in the household that has it, or if this is something that everybody has in your household, because that's also a good factor to note too. If they're like, "I'm the only one in my family in my house that has this and my wife or my kids are afraid that they're going to pick it up, is this contagious?" So I definitely want to ask the question of where they are in their education about onychomycosis and what they've tried, because that's a big starting point. Because they may be doing things that are counterintuitive to what the treatment process is, like I mentioned before, the man who was just lathering his feet with lotion thinking his feet was dry, but they're actually fungal.

And then I think that most people, when they have a problem, their initial appointment is with their family medicine doctor, and so their family medicine doctor may prescribe to them all of the oral medication, oral antifungal. They may prescribe a topical, they may even prescribe a cream for their feet, but the root issue is there's no debridement that's happening. I have never seen someone coming in saying, "Oh yeah, my family medicine doctor can just trimmed that toenail." I don't think that that happens. So the first thing is, are you adequately treating the root cause of it? Is the medication that you're lathering on, they're actually penetrating the nail bed in order to have an effect? Most likely not if you haven't had a debridement. And also, is your family medicine doctor driving home the point that this needs to be a consistent daily situation that needs to happen for months, not just two to four weeks?

I don't know if they're getting that type of education. They're getting this medication and thinking it's supposed to work in a quick amount of time. Oftentimes too, advertising for laser onychomycotic therapy, people think that lasers can fix anything these days, and I have to come sometimes walk people back from that laser ledge initially, because it's like they really do think that the one time that you zap something it's going to just miraculously go away. Educating people on, let's say, blood flow. Like if you're diabetic, patients come in and they have vascular issues and neuropathy issues and blood sugar issues. Like I said, we need to address that first because your new nail is not going to grow in the face of lack of blood flow. It's just not going to grow. So the patient education bit is really important to discuss the history of how you got it, how long, all that good stuff. And so when talking to patients about the extra parameters that are involved with healing your fungal nails, all of those things are important.

Jennifer Spector, DPM:

So in addition to giving them information and assessing their knowledge base, do you feel like patients benefit from really explicit education on exactly how to perform their treatments? And not just here's the prescription and go home, but do you think it's worth that conversation about what it'll look like on a day-to-day basis?

Ebonie Vincent, DPM:

Oh, absolutely. I actually email my patients. I tend to overtalk to them about things in the office because they have so many questions about just this terrible onychomycotic thing. But I tend to give them a list of things, like I have a list of home remedies that they can use as an adjunct therapy to the prescribed therapy that I do send. I usually give them this smorgasbord of options too, based off of what they come in with and how they've been treated in the past. I always tell them to start off with a topical, like anybody who's eligible for a topical, I will give them a topical. However, I do put on the list a whole bunch of over the counter treatments that they could use as a benefit. For instance, apple cider vinegar soaks, or they can use eucalyptus oil or tea tree oil on the nail specifically.

They can buy an over the counter antifungal cream or a Lotrimin powder to put in their socks and shoes to kind of all help prevent. I'll direct them towards Amazon to be like, "Hey, if you have an issue with drying out your shoes and you don't want to put them outside, here's a laser. You can just zap your shoes." All these things. Sometimes people have issues with just overproductive sweat glands and their feet just sweat all the time and they have no idea how to prevent the moisture from coming in their feet. So I'll direct them towards things like iontophoresis therapy. I don't particularly do that, but I will direct them towards the therapy that does. It's worth a try. They can do botox injections if it's like a hyperactive sweat gland situation. So those type of patients come in all the time just seeking alternative methods to just stop the moisture, which is causing their fungus. So yeah, we have to address the other parameters of the why you got this as opposed to just treating it, because it will return if you don't address all of those things.

Jennifer Spector, DPM:

And being that you said that, how do you go about communicating with patients about setting expectations for long-term prevention even after successful treatment and what those expectations are for the future? Because it isn't like getting chicken pox and then you're never going to get it again in your life.

Ebonie Vincent, DPM:

Exactly. You're not immune after this.

Jennifer Spector, DPM:

No. How have you managed that?

Ebonie Vincent, DPM:

I just tell them flat out like, "Hey, this is hard to treat." The skin is easier to treat than the nails. I'll say that. I'll start off with, "Hey, the skin is way easier to treat. The nails is going to take probably a year or more, and you have to be consistent." And I tell people like, "Hey, if you forget to do your treatment every day, the fungus wins. So don't come back here after three months talking about what I did didn't work, but I wasn't as consistent." I'm saying if you sweat 24 hours a day or if you put your feet in socks every single day and you think that just taking the pill is going to work, it's not going to work. Also, you can't be on the pill forever either. I'm taking blood tests or a liver panel to be sure that I can even prescribe the oral medication to you, because if your liver labs are off the charts, we're not doing the oral medication.

And then even if you do have normal liver panels, I'm doing six weeks and then we're going to do another lab and then we can do another six weeks. So total of 12 weeks, but then after 12 weeks, I'm stopping it for at least 12 weeks, because I won't be the cause of your liver damage. And most people, if they just rely on the oral medication, they're super excited when it goes away, but inevitably it always comes back. And so I educate people on a maintenance level of protection against the fungus. I say, "Just be cognizant. You could get reinfected." So these practices of always wearing socks, maybe sprinkling some Lotrimin powder in those socks, getting an over the counter type of antifungal cream that you put on once or twice a week even when you're not infected, is probably a good idea for you. And then you can also use the home remedies, like I said, like the eucalyptus oil or tea tree oil as a maintenance dose for your nails.

Jennifer Spector, DPM:

Well, you clearly have a focus on assessing environmental risks and risks that exist within this patient's home environment and in their lives. Do you also assess what their goals are in treatment? I would have to assume that some patients would like to decrease pain that they're getting from these thickened malformed nails. Other patients have more of a visual goal involved. Other patients, it may be that they would like to more comfortably perform physical activities, things along those lines. Do you feel like assessing the goals of a patient helps you in identifying how best to educate them?

Ebonie Vincent, DPM:

Yes. I'm always educating people on, especially if they do have pain, because sometimes if they have pain, they start doing their own barber type of surgery in their bathroom kind of thing. So yeah, sometimes I see people and they have bloodstains on their nail bed. I'm like, "What did you do? What's happening here?" So just kind of educating them on how to best use protection. Instead of just going to town with a nail nipper, maybe use a file. You can just gently file it. I'll get you started, but if you're consistent in filing your nails, you won't have to just go to town and start making yourself bleed. That can also be traumatic to the nail bed and to the nail root and impede your treatment process. But yeah, if someone does have pain associated with their onychomycotic nails, then that's a red flag to me that something else might be going on.

I had a patient once who came in stating that she had an ingrowing toenail, and the toenail looked onychomycotic, but also the skin looked really dusky, and I was feeling around for pulses, and I'm like, "I'm not feeling anything. You don't have an ingrowing toenail. You have an ischemic toe. Your toe doesn't have any blood flow." So I sent her to vascular and they were like, "She's got micro and macrovascular disease. You did a good job of not touching this patient." Because let's say I did do a nail trim on her toenail. First of all, it wouldn't have helped the pain. Second of all, if you nip the patient or do anything like crazy, now you've created a wound that she's incapable of healing. So you've got to be cognizant of all of those other factors when you're dealing with a patient who says they're in pain because that's a red flag, because onychomycosis doesn't really particularly hurt like that.

It could have a pressure, like a unwelcome pressure in your shoe because it's just like a thick nail on top of the toe. That's different than pain, you know? So it depends on the person's language, on what they use. I kind of give them words to see if they agree sometimes in order for us to be on the same page.

Jennifer Spector, DPM:

Well, there's definitely a lot of utility in making sure that patients are properly educated on everything surrounding the diagnostic and therapeutic process for onychomycosis. But that being said, now that these patients have had their comprehensive education, in the next episode, we're going to get into the key aspects of actually treating that nail fungus. Don't miss our next episode with Dr. Vincent. And you can find all episodes of Podiatry Today Podcasts on our website, along with on your favorite podcast platforms.