Practice Protocol: Onychomycosis

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Practice Protocol: Onychomycosis Nature: Discoloration, Dystrophy, Thickness and Pain associated with toenails Epidemiology: 10-15% of total population. Incidence increases with age and comorbidities. Classification: Distal Subungual (most common), Proximal Subungual, Superficial White, Candida Infection of the Nail, Total Dystrophic Onychomycosis. Testing: 1. Biopsy with Periodic Acid Schiff Test – Most accurate way to diagnose. Fungal cell wall Stains Magenta (only works in living fungi) 2. Fungal Culture: Dermatophyte Testing Medium (DTM) used with color indicator to test for fungus 3. K-OH Test: Potassium Hydroxide added a nail or skin scrapings to dissolve keratin. Fungal hyphae are observed under a microscope. Our Treatment Options Conservative 1. Topical Medication: Challenges include compliance to daily application and penetration of the nail plate to reach the fungal infection at the nail bed. a. OTC – Vick’s Vaporub, Witch hazel, Tea Tree Oil, Bleach b. Dr. Office: Not available at pharmacies or stores i. Formula 3: Includes tolnaftate and a jojoba oil carrier ii. Kera Nail Gel: Includes urea, tea tree oil, menthol and eucalyptus. This treatment is designed to breakdown hypertrophic nail iii. Clarus Antifungal Solution: Includes tonaftate and menthol c. Topical Rx – Insurance may or may not cover this medication (FDA approved) i. Jublia – Daily application (~50% cure after 1yr) ii. Kerydin - Daily application (~36% cure after 1 yr) iii. Penlac (ciclopirox) - Daily application, weekly filing (30% cure after 1 yr) 2. Oral Rx: Lamisil – Treats the fungal nail infection from the inside out (72-75% cure after 1yr) a. Standard Dose - 250mg once daily x 3 months (requires liver function testing) b. Pulse Dose - 250mg x 7 days every 3 months for 21 total days (3 pulses in 1year) 3. Laser Nail Treatments – The nail beds are treated with the laser to kill the fungal infection. 4. Periodic Nail Debridement – Mechanically reduce the bulk and length of the nail with manual debridement Surgical 1. Removal of Nail Plate – This will either temporarily or permanently remove the infected nail. .

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Therapeutic Class Overview Antifungals, Topical INTRODUCTION The topical antifungals are available in multiple dosage forms and are indicated for a number of fungal infections and related conditions. In general, these agents are Food and Drug Administration (FDA)-approved for the treatment of cutaneous candidiasis, onychomycosis, seborrheic dermatitis, tinea corporis, tinea cruris, tinea pedis, and tinea versicolor (Clinical Pharmacology 2018). The antifungals may be further classified into the following categories based upon their chemical structures: allylamines (naftifine, terbinafine [only available over the counter (OTC)]), azoles (clotrimazole, econazole, efinaconazole, ketoconazole, luliconazole, miconazole, oxiconazole, sertaconazole, sulconazole), benzylamines (butenafine), hydroxypyridones (ciclopirox), oxaborole (tavaborole), polyenes (nystatin), thiocarbamates (tolnaftate [no FDA-approved formulations]), and miscellaneous (undecylenic acid [no FDA-approved formulations]) (Micromedex 2018). The topical antifungals are available as single entity and/or combination products. Two combination products, nystatin/triamcinolone and Lotrisone (clotrimazole/betamethasone), contain an antifungal and a corticosteroid preparation. The corticosteroid helps to decrease inflammation and indirectly hasten healing time. The other combination product, Vusion (miconazole/zinc oxide/white petrolatum), contains an antifungal and zinc oxide. Zinc oxide acts as a skin protectant and mild astringent with weak antiseptic properties and helps to
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