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05/20/2022 Charles Morelli, DPM
OTC Topical Nail Antifungals vs. Prescription Products (Elliot Udell, DPM)
Dr. Udell asks the question "which products are most effective, the OTC products or the ones that require a prescription?". My answer is unequivocally, neither of them, and I am sure there are many of you who disagree. That's fine. After 32 years of practice, and with the exception of those few patients who presents with superficial white onychomycosis, I never see topicals being an effective treatment for the types of severe fungal nails that we see on a daily basis. Certainly not infections that permeate the nail plate, and go deep into the nail bed.
My treatment of choice for almost 100% of patients who want to get rid of their fungal toenails is oral terbinafine. It is the gold standard for onychomycosis and has been for years and after prescribing for 3 decades, it has been proven to be quite safe and effective. I vary between 90 day dosing or pulse dosing for either one or two years, depending on the patient's response. And even patients who are afraid to take terbinafine based on what they read on Dr. Google, will then agree to pulse dosing as it is fewer pills and a safer option in their minds.
At times, I will prescribe a topical after oral terbinafine as a preventative going forward, but for patient whose nails grow slowly and still have a substantial amount of fungus presents after 90 days, I will give them a year of pulse dosing (7 pills every 3 months) and they get better. Then prescribe a topical as a preventative
One of the main reasons why topicals are fair to poor at best is due to patient compliance. Its almost impossible to get a patient to agree to apply a topical to their nails either once or twice a day, depending on the product you've chosen. It gets old very fast. Once they understand that they are more than happy to take terbinafine.
Take an appropriate history, rule out hepatic disease, check their last blood test and do another after therapy has been completed if it puts your mind at ease. As Google will tell you acetaminophen overdose is the leading cause for calls to Poison Control Centers (>100,000/year) and accounts for more than 56,000 emergency room visits, 2,600 hospitalizations, and an estimated 458 deaths due to acute liver failure each year."" I have never had an adverse reaction to terbinafine because I monitor my patients, and if and when that should happen, stop the medication and the patient will be fine in a few days.
Charles Morelli, DPM, Mamaroneck, NY
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05/24/2022 Allen Jacobs, DPM
OTC Topical Nail Antifungals vs. Prescription Products (Elliot Udell, DPM)
People seek care for, and in most circumstances may be treated for, onychomycosis. In some populations, such as patients with diabetes, PAD, chronic edema, immunosuppressive, onychomycosis is associated with increased incidence of repeated cellulitis, ulceration, and other significant poor outcomes. We have known this ever since the classic study of Jeffrey Robbins, DPM.
The use of ineffective therapies denies patients who should be treated, or who desire treatment, of effective treatment.
Here is my approach to onychomycosis;
1. Read and consider following the guidelines of the American and/or British dermatology associations. 2. Speciation testing to verify fungal infection and the pathogen. Itraconazole, fluconazole, may be more appropriate in some patients. Some patients may not have presumptive onychomycosis. As Ronald Reagan said, “ trust (your judgment) but verify ( it is fungal and fungal alone ). 3. Perform PAS or other appropriate studies for the presence of repetitive micro-trauma. This is commonly a cormorbid condition increasing therapeutic failure rates. In some patients, a tenotomy or arthroplasty or arthrodesis is needed to affect a cure. 4. Read the studies you are told support the use of topical antifungal therapy. Pay particular attention to inclusion criteria and total cures (mycological and clinical appearance). If you do do, you will restrict the isolated use of topicals to those with less than 50% of nail plate disease (i.e.: early distal disease). 5. Statistical protection is not absolute protection. When providing systemic therapy, obtain baseline laboratory studies and monitor at least initially. 6. Consider topicals as adjunctive to systemic therapy. Or possibly to lower the incidence of recurrence following cure (theoretical). 7. Consider concurrent treatment of interdigital or pedal tinea pedis when present. Also reduction of repetitive trauma. Also consider treatment of other confounding factors ( eg: hyperhidrodis, xerosis, shoe/sock materials, edema reduction ). Step back and take a global view. 8. Get over terbinaphobia. This includes diabetic patients and geriatric patients. Read the relevant studies. They are supportive of use. 9. Educate your patients on the realities of onychomycosis. Remember, you may bill for time including time of consultation if that is what it takes to have you do so. 11. If you are prescribing a costly topical therapy, confirmation, speciation, r/o repetitive micro-trauma to justify the thousands of dollars these topicals cost. 12. Read and research on the subject. Do not simply take the word of paid consultants and lecturers on ANY subject. And that includes onychomycosis just the same as bunion surgery or PTTD surgery. 13. Remember, to the patient who has come to you for this problem, it is not a minor or insignificant issue. They are in your office requesting direction and effective treatment. As such they deserve nothing less.
Allen Jacobs, DPM, St. Louis, MO
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