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02/28/2024
RESPONSES/COMMENTS (PUBLISHED PODIATRISTS) - PART 1 B
From: William P Scherer, DPM, MS, Wayne L. Bakotic, DO
Dr. Ivar Roth may indeed have subjective success in treating onychomycosis without laboratory testing; however, this is certainly not the case universally. Essentially, all dermatology and podiatry peer-reviewed literature on this topic have demonstrated that only '50% of dystrophic nails are, in fact, onychomycosis. Visual assessment by a physician, while an essential part of a patient encounter, is unreliable at discerning an accurate etiology of the nail changes observed, as demonstrated by multiple referenced studies. The level of precision required to render an accurate and proper diagnosis of onychomycosis is best obtained through laboratory confirmation following appropriate clinical evaluation.
Onychodystrophy can have varying etiologies both infectious (fungal and bacterial) and non-infectious (microtrauma, psoriasis, lichen planus, melanonychia, etc.), which is the precise reason why laboratory confirmation prior to definitive pharmaceutical therapy is recommended. Additionally, terbinafine resistance, which requires laboratory evaluation to identify, is an omnipresent issue with a current rate >5% in those with confirmed onychomycosis in the U.S., although the rates overseas are far higher and increasing. It is for these stated reasons that laboratory confirmation, no matter which laboratory or testing methodology is chosen, is recommended by the CDC, American Academy of Dermatology, British Association of Dermatologists, and others. Our recently published paper with 96,293 samples supports and reinforces these recommendations. It goes without saying that the accurate characterization of nail pathology utilizing evidence-based medicine, no matter the etiology, allows for individualized treatment plans that ultimately result in improved patient outcomes and overall satisfaction.
Disclosure: Drs. Scherer and Bakotic are affiliated with Bako Diagnostic Labs.
William P Scherer, DPM, MS, Delray Beach, FL, Wayne L. Bakotic, DO, Alpharetta, GA
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02/29/2024
RESPONSES/COMMENTS (PUBLISHED PODIATRISTS) - PART 1 B
From: Ivar Roth, DPM, MPH
I would like to state my findings and observations concerning the comments by the esteemed doctors Scherer and Bakotic. They wrote that 50% of dystrophic nails are, in fact, onychomycosis and that onychodystrophy can have varying etiologies, both infectious (fungal and bacterial) and non-infectious (microtrauma, psoriasis, lichen planus, melanonychia, etc.). They state that is the precise reason why laboratory confirmation prior to definitive pharmaceutical therapy is recommended.
Unfortunately, while what they state is accepted dogma in the academic world, the reality is I have found that by using my treatment for “ugly” nails, whether fungal or onychodystropic, the fact remains that they almost all can be cured to perfectly normal nails. This is why I stated the testing does not matter anymore and is a waste of time and money.
I will offer as proof photos of my patients' nails to PM News so everyone can see for themselves. I will send in dystropic 2nd and 5th toenails that everyone says is from micro-trauma and very deformed nails that until now most docs would say are impossible to treat. I hope our profession takes note and gets behind the idea that what was once dogma concerning “ugly” nails is no longer true.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
02/27/2024
RESPONSES/COMMENTS (PUBLISHED PODIATRISTS) - PART 1 B
From: Kathleen Neuhoff, DPM, Robert Kornfeld, DPM
Dr. Jacobs, I have a cash-only practice and have never claimed “possession of advanced skills and knowledge not understood or provided by the rest of us mortals.” Sweeping generalization or just bias?
Kathleen Neuhoff, DPM, South Bend, IN
While I can neither support nor refute Dr. Roth’s claims to a 98% success rate treating onychomycosis without a culture, I do take offense to Dr. Jacobs’ short, off-the-cuff condemnation of those of us who do not accept insurance. A lot was said in those couple of sentences. First of all, in a profession with a long history of struggles (which continue to this day), the last thing we need is someone coming along and dividing the profession into “them” and “us”. This same thing happened back when...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
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