Treatment Perspectives for Onychomycosis

This podcast is supported by Ortho Dermatologics. 

Hello everyone, and welcome back to Podiatry Today Podcast, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field.

I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today, and we're continuing our series on onychomycosis with Dr. Ebonie Vincent.

We've already talked about the workup and patient education, but today we're diving into treatment. Thank you again for being here, Dr. Vincent, and continuing our discussion.

So now that we're talking more about the treatment for onychomycosis, I think we'd be curious to learn about how you go about determining the best treatment course for a patient where you've identified that they do indeed have nail fungus.

Ebonie Vincent, DPM:

So after I've identified the issue, we definitely have a nail fungus, I'm always going to push that we need to do daily treatment on your nails. And that does not always include an oral pill. That means I love the topical medications, because first of all, they're a lot safer. It's something that I want my patients to get a good practice of, even if we do an oral medication, because looking at your nails daily is probably something you haven't done up until now. And every day, if you treat your nail with the topical, it should get a little better every single day. And that's something that I want to become habitual for patients, even when their nail fungus is gone. I want them to habitually look at their feet. So that's something that I definitely always push.

So there's so many topicals out there. Typically people have already come having tried something, whether it be over the counter, someone has maybe previously prescribed something, though education about the topical needs to really hit home.

I'll say something to the degree of, "You have to use this topical every single day, not once a week, not three times a week. If you are consistent up to a point and then you go on vacation, then you forget it, just know that you're not being treated. Every day. So you got to always have this little bottle with you."

And then teaching the patients how to apply the topical is also a big thing. You'd be surprised what people do. Sometimes patients will try to lift up the nail and get the medication underneath the nail, which I don't want you to do because you're then lifting up the nail and causing nail damage to the root. So you need to have a medication that's topical that is able to penetrate beneath the nail bed. And if you've been given something in the past that just doesn't do that, and what it does just kind of cakes up.

And sometimes people say, "Well, I tried this medication and now it looks worse." So now you have medication residue on top of your nail, and it does make it look a little bit worse until you debride it and you're like, "Oh, well it's actually not doing too bad." But I educate my patients on how to apply the topical.

And then I always educate them too, you just can't take this medication and then just ghost me. You have to follow up. You have to follow up for debridements. Debridements are super important because the best medication, you're going to have topical residue. And after debridement, you'd be shocked about how much treatment you actually will see after only three months, two, three months of medication if applied consistently. So I always have them come back within the two, three month range so I can do a debridement and then we can see where we are.

If someone says, "No, I want to try both, I want to try the topical, I want to try the oral, give me the oral medication, I know it works," that's fine. We can do a liver panel, and once I get the liver panel back, I'll prescribe the oral medication. But we're doing that in stages. I'm not trying to get my patients to think all she needs to do is prescribe me this oral medication, and then a couple of years down the line, I have liver problems. So definitely I sparingly use that and I always tell them what the risk factors are with the oral medication. So I'm driving home the topical.

That's one thing. The other parameters, I think I mentioned this before, is just how best to do your hygiene therapy. Just like in general. Not everybody needs to wake up and put powder in their socks to sop up some of the moisture. Or not everybody needs to be told, "Hey, you need to wear socks with shoes." But some people don't, and some people don't wash their shoes. A lot of people wear Crocs around here, everywhere all the time, every day, and they need to wipe those puppies down. While Crocs are less housing of infection than other shoes because they're airy and stuff, that doesn't mean that just natural sunlight and air can just rid the Crocs of a fungus. It's squishy so your whole body weight can squish and things can funnel up through there. You never know. So your two year old Crocs may be the cause of your reoccurring fungus infection.

So like I said, getting the patient's day-to-day, what they do for work, what they do for activities, all of those parameters we can discuss on how best to go about preventing you from getting reinfected in addition to the topical, the oral, and all the other home treatments that you could do.

Jennifer Spector, DPM:

Once you've decided upon the proper treatment for the patient, let's say they are getting a topical prescription antifungal, are there any particular pearls that you have for its usage? Do you ever counsel on patients as far as use of nail polish or anything along those lines?

Ebonie Vincent, DPM:

Yes. So the first thing is I educate my patients on how not to overuse the prescribed medication. I think sometimes people get really aggressive like, "Oh, she said to use this once a day, I'm going to use it twice a day and see what happens because I can cure myself faster." And oftentimes that leads to adverse reactions. Then they'll come back and be like, "Why do I have blistering on my skin?" Or, "Why have I developed this ingrowing toenail?" I am like, how many times a day have you been using it? What did the prescription say? Once a day, twice a day? Definitely not three times. But people get overzealous and try to do that, and then they could have a negative reaction.

So I definitely educate people on just basically following directions, and basically how to use the medication properly, not uplifting the root of the nail, and not trimming it yourself. Because sometimes too, you can't see what we can see when I'm down there close. You can get as close as you can, but sometimes you don't see the improvement like a podiatrist can.

Jennifer Spector, DPM:

Speaking of looking for that improvement, how do you assess that? Are you looking at the global condition of the nail or are you looking at new growth from the proximal aspect? What parameters are you looking for there?

Ebonie Vincent, DPM:

I always look for the new growth. I tell people all the time, we're treating the new nail. The new nail we're hoping comes back is nice and beautiful. The old nail is going to have to grow back. It's not going to miraculously just change into this beautiful nail overnight. It's the new growth. And sometimes the fungus will cause stunting of the growth of the new nail, so we have to treat it, especially if it's adhered to the nail bed, you don't want to rip it off, but we're going to trim it, treat it, and then the new growth should be better.

So oftentimes people don't understand that concept either, but once you tell them, they're like, "Oh yeah, that makes sense. We're looking at the new nail growth." Even when you're not infected with a fungus, sometimes your nails can grow pretty slow. So other parameters too. If your vitamin B count or vitamin B12 count is low and you don't have good, healthy skin and nail growth, I'll recommend a vitamin. Maybe that will help you.

Jennifer Spector, DPM:

So we know that not every patient that has onychomycosis and undergoes treatment is the same. And in our next episode, we will talk a little bit about some special populations when dealing with onychomycosis.

Thank you again to Dr. Vincent for being with us and to the audience for tuning in. Don't miss any of the episodes in this series. Be sure to check them out at podiatrytoday.com, Apple Podcasts, Spotify, or SoundCloud for these and all other episodes.