Special Considerations in Treating Onychomycosis

This podcast is supported by Ortho Dermatologics. 

Welcome back, everybody, to Podiatry Today podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. We've got our fourth and final episode today with Dr. Ebonie Vincent, discussing all aspects of onychomycosis. I'm Dr. Jennifer Specter, the assistant editorial director for Podiatry Today. And in this episode, we're going to dive more into some special populations. So now that we've talked a little bit about diagnosis and treatment and patient expectations and counseling, I think this is a great time for us to touch down on some special populations when it comes to onychomycosis. There are some groups of patients that warrant a little bit of extra consideration or possibly some special strategies. To start off, what's your approach in your practice to kids, pediatric patients that come in with nail fungus?

Ebonie Vincent, DPM:

Right, so pediatric patients, I am giving a topical only. They don't need any oral medications, only if the pediatric patient is above six years old. Anybody else? I have had patients come in with their kids that the kids are the patients and they're maybe 10 months old and their nails are just growing funny or they're growing straight up instead of out, or it looks like a little bit of a fungal situation happening, but you can't quite tell if it's actually a fungus. Those patients, I'm not giving any treatment to, to be honest with you, because you never know what a child might be allergic to. You never know if you might be causing an issue. So I usually tell patients or teach the parents how to trim the nail and file the nail, and then just tell them to be cognizant of what size shoe they're shoving their baby's foot into, especially, if they're toddlers and they're just beginning to walk. You might not notice their toes bumping up against their shoes, and that could be the cause of the nails just growing oddly.

So I always educate the parents on what to look out for as to other signs or reasons as to why the nail could be looking like this, and hopefully they'll grow out of it, but if they don't grow out of it, bring it back when they're six, because then we can try to treat them effectively with just the topical solution. The parents will be the ones applying it, and that's the biggest thing. I'm not going to explain to a six-year-old, you need to do X, Y, and Z with your nails. They're not going to do it. It's the parents that need to be more consistent and make sure they're doing all the things that are necessary to treat their child's nails. When it comes to assessing a six-year old too, again, you have to assess the shoes. They're growing rapidly, and then some parents, they'll throw their kid in shoes that are their favorite because that's what the kid wants to wear, but it no longer fits.

So I have had patients who come in, that's the only type of shoes she wants to wear, and I'm like, well, buy her a different pair of the same shoe, but bigger. And then it maybe solves the issue or wash the shoes, because it's housing a fungus, maybe your kid is developing overactive sweat glands. And then that's when I'll be like, well, they most likely have these overactive sweat glands that need to be addressed. Start putting powders and things to absorb moisture in their shoes. They need to start trying to get these habits early if this is something that they're going to have to be living with. So a lot of times, with kids specifically, it's more of educating the parents and making sure that they're going to be consistent with it.

Jennifer Spector, DPM:

What have you seen with athletic young patients? Do you feel like some of these kids are in environments, I keep thinking of swim team or tight cleat shoe sports where it just seems like it's a really hospitable environment for fungus to grow?

Ebonie Vincent, DPM:

Yeah, athletes have the worst time. They have the hardest time, but fortunately, I feel like athletes do tend to take care of their feet a lot better once they are educated about the issue. Because if their feet don't work, they can't play their sport. So oftentimes I'm like, once you get an athlete and you're like, this is what you need to do, they're the most consistent patients ever, especially when it comes to new athletes, like kids just starting school and they want to be on the basketball team or baseball team, something like that. Their parents will bring them in, but they'll recognize that they don't want to be the only kid in the locker room that has these issues. So they'll have a little bit of social motivation there to be consistent. But yeah, I find that athletes, they need to be educated on not sharing shoes and socks with people, making sure that they're not wearing dirty socks. I know boys, specifically, they'll forget stuff, and they'll be like, I didn't pack any gym socks today, but I have this old pair.

And they'll just wear them. And you're just like, oh, okay. Well, you need to have at least two pairs of clean socks with you at all times, because at least if you forget one pair, you'll have a backup clean pair. Those kinds of things drilling into young athletes early are super important. And then making sure that they're not showering barefoot, like having shower shoes, cleaning off their shower shoes.

Jennifer Spector, DPM:

And those are more at risk populations, patients with diabetes, peripheral arterial disease, or immunocompromised. You've talked about this population in previous episodes, but for the audience that's just tuning in today, why is nail fungus so important to consider in these populations?

Ebonie Vincent, DPM:

So with diabetes, it's always important to consider the onychomycosis because you're fighting an uphill battle already. These patients have high blood sugar. These patients sometimes have peripheral vascular disease and neuropathy, and the thing that they can see right in front of them is the onychomycotic nail. So that's what they want to fix more so than the diabetes that's internal. So when it comes to that population specifically, I always drive home that diabetes is your root cause of all the things that are wrong visibly. If you're not treating your sugar levels, if you're not taking your meds or not checking your blood sugars, or not checking your feet every day, these are all things that are going to prevent you from curing your fungus. So we're going to hone in on the diabetes portion, the fungus we are going to treat, but it is a good second treatment process to what systemically is going on with you.

Sometimes that's a little harder to get because you don't see a blood sugar, you see this ugly nail, and then you have to have different parameters for them because, based off of all the other medications that they could be on, an oral medication may not be the right choice for them based off of however drug interactions that they might have. And so if you're going to tell a diabetic patient who's not checking their blood sugar every day to use a topical medication every day, this is why they have the long-term fungal problems. So it is a little bit different treating my diabetic patients. I find that I am just wrenching and repeating what I'm saying, but I do tend to see them more often for debridement, so I can repeat myself, and maybe it'll stick.

Jennifer Spector, DPM:

Possibly drive the message home.

Ebonie Vincent, DPM:

Yeah, drive the message home. And I don't expect the world to change overnight. You got here after a long stint of your blood sugar's being high and all these things. So I'm looking for improvement. I'm not looking for a cure immediately. And so I always am gentle with them and tell them like, hey, we're not looking to set the world on fire in three months. We're looking for improvement. And if I get excited, just know that I'm not yanking your chain. I do see that you're trying. If your skin is even a little bit better around the toes, if it's less red or flaky, then I'm excited about it because improved in some way, shape, or form, I will treat them similar with blood tests and see if they can be eligible for the antifungal. But I'm always just looking at them with a little bit more of a microscope, and then I'm continuously checking the other parameters around it.

For instance, if I tell my non-diabetic patients without neuropathy to use a foot soak, like if I'm saying, oh, just do a foot soak with apple cider vinegar and stuff like that, that may not be an option for my diabetic patients because they can't feel their feet. They're not going to be able to tell if the water is too hot, and I don't want you coming here with burns on your feet. So yeah, doing more conservative things, like just the topical solutions for them, would be the best thing. And then seeing them more often to kind of drive home more of the other parameter things for them to prevent the fungal nails.

Jennifer Spector, DPM:

Well, and I think the last patient population we're going to touch on today is one that we've all seen is even if somebody has had successful treatment for onychomycosis and they've listened to everything that you've said and even worked on decolonizing and prevention after the fact, we do get those recurrent cases. And so if somebody comes back with a recurrent case of onychomycosis, how do you approach that? Is it the same algorithm, or do you look at things with a different lens?

Ebonie Vincent, DPM:

I always ask, how long after your last treatment did you have reprieve from this fungus? And then, how long has it been since the new infection showed up? And is there anything new that you've developed in your life? Maybe it's a new diagnosis of diabetes. Maybe you started running or doing a different type of activity that could have reignited your fungus or reinfected you. So I need to know how long has it been since you've had it, and then maybe what started it again? So that's pretty much what I'm asking them. And then my secondary question is, have you continued with all of the treatments that I suggested that weren't prescribed? Like changing your socks, wearing socks, making sure your feet are clean, washing your feet, all of those habits that you were doing while you were treating yourself for the fungus, have you kept them up or have you stopped? And nine times out of 10, they'll be like, well, I don't do this anymore. I don't do that anymore.

And I'm like, well, when you were doing it, you were having a good outcome, and then you stopped, and now it's back. So you're that person that needs that. You just need to always do that. It's like a daily thing. Everyone brushes their teeth in the morning. You just need to do extra stuff.

Jennifer Spector, DPM:

Well, we've definitely learned throughout all of our conversations that treating and diagnosing, and preventing onychomycosis is a very multifaceted process. We really appreciate you sharing all of your insights with us, and we look forward to sharing these in all of these episodes. So, Dr. Vincent, are there any other adjunct options you offer to patients that are undergoing treatment for onychomycosis?

Ebonie Vincent, DPM:

I do a procedure called KeryFlex, and essentially it's a fake nail that can look beautiful. It can make a fungal nail look beautiful, but at the same time, you still can treat it with a topical medication. You're putting the topical right where the cuticle is, and the cuticle is what we're treating anyway. So oftentimes, when I'm applying the KeryFlex, still treating my patients with the JUBLIA, by the time the KeryFlex grows out a bit, you can see still some improvement. That is an option, especially that people like, especially during the summer months when they're trying to go on vacation, they just don't want to hear it. So that's an option. It's most likely not going to treat it as quickly as someone who doesn't have anything covering their nail, but you still can.

Jennifer Spector, DPM:

Right. And it's just another way to address those patients' goals and expectations.

Ebonie Vincent, DPM:

Exactly.

Jennifer Spector, DPM:

And that concludes our four-episode series on onychomycosis with Dr. Vincent. We're so grateful to her for being our guest and sharing her experience and practice with this condition. All episodes in this series and otherwise are available on our website and on your favorite podcast platforms. We hope to see you next time.