Onychomycosis/ (suspected) Fungal Nail and Skin Protocol
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Description of Condition:
Onychomycosis is a common nail condition. It is a fungal infection of the nail that differs from bacterial infections (often referred to as paronychia infections). It is very common for a patient to present with onychomycosis without a true paronychia infection. It is also very common for a patient with a paronychia infection to have secondary onychomycosis. Factors that can cause onychomycosis include: (1) environment: dark, closed, and damp like the conventional shoe, (2) trauma: blunt or repetitive, (3) heredity, (4) compromised immune system, (5) carbohydrate-rich diet, (6) vitamin deficiency or thyroid issues, (7) poor circulation or PVD, (8) poor-fitting shoe gear, (9) pedicures received in places with unsanitary conditions. Nails that are acute or in the early stages of infection may simply have some white spots or a white linear line. Chronic nail conditions may appear thickened, discolored, brittle or hardened (to the point that the patient is unable to trim the nails on their own). The nails may be painful to touch or with closed shoe gear or the nail condition may be purely cosmetic and not painful at all.
*Ask patient to remove nail polish prior to visit
Evaluation Questions:
□ Which toenails appear to be affected?
□ How long have your nails looked this way?
□ Are your nails painful?
□ Is the problem getting worse or better, or is it unchanged?
□ Have you had any treatment for this problem?
□ Have you tried any at home treatments?
□ Did you have an injury to your nail that might have caused the infection?
□ Do you play any sports? If yes, what type of shoes do you wear?
□ Do you get frequent pedicures? □ Do you notice that your feet perspire excessively or that your socks are wet/damp at the end of the day? □ How often do you change your shoes?
□ Do you currently have/have you ever had Athlete’s Foot?
□ Do you have a family history of psoriasis?
□ Do you have a family history of fungal nail infections?
Post-Evaluation Actions:
□ Brochure on onychomycosis and laser treatment options. If patient is diabetic, also include a brochure on diabetic foot care, which stresses the importance of prevention. □ X-rays if nail is dystrophic (misshapen). o To include: AP or DP/lateral/medial oblique o Evaluate for any bone changes such as a bone spur or old fracture that could be contributing May see an arthritic condition referred to as hallux limitus (limited range of motion of the great toe) and contracted toes, which may put repetitive strain on the nail □ Debridement of nails (mechanically/with drill) o If nails are very thick, place a gauze pad lightly soaked in water over the nail and gently keep it in place prior to treating.
o Staff to apply Tri-Soft or other softening agent to nails prior to debridement □ Nail culture/biopsy o A small 1cc lidocaine/epinephrine block is given with a tuberculosis syringe when performing a nail biopsy. o Place culture in a specimen bag for a dtm/koh prep. Site (which toe/site of specimen) must be placed on the lab form. o Double check that the lab accepts the insurance. o Culture/biopsy results must be shown to the DPM prior to scanning.
□ Topical preparations o Recommend or dispense Oil based treatment for nails: Clarus solution, Fortinia , Formula 3, etc. (1% tolnaftate) o Recommend or dispense Kera Nail Gel (47% urea) if nails very thick o Recommend or dispense Skin Cream; Clarus, Fortinia, Fungi-Foam, etc. o Rx for Spectazole, Naftin, Zulu or tincture of fungoid with 3 tabs of Lamisil mixed in o Recommend or dispense Drying agents and Shoe treatments such as: . Gordons No. 5 powder to be applied to the foot 2x daily, if the patient complains that feet perspire excessively . Clarus shoe spray to maintain dryness and to rid the shoe of bacteria and fungus, if the patient exercises regularly . Mycomist . Aarica . DryFeet Wipes . Rx for a topical cream in addition to the suggestion of using Clarus cream, if patient has a secondary athlete's foot infection . Sterilization of shoes (Steri-Shoe) Oral preparations o Oral biotin and acidophilus to promote nail and skin health (Theranail) o Oral medications such as Lamisil (liver function test before patient starts medication and 6 wks into protocol to ensure liver enzymes are not elevated) o Rx for alternative oral medication Laser treatment Options include: o Minimum of 4 sessions and to include DPM recommendations for at home nail/skin/shoe treatment between visits) o May begin at current visit, or schedule for 1st laser treatment o All staff should be trained on treatment procedure, cost and efficacy
At-Home Care Recommendations o File nails gently after a shower o Soak with warm water + 2 capfuls white vinegar; 15 minutes, 3-4 times/week o Purchase socks with “wicking” properties that keep moisture away
o UV light appliances to be inserted into shoes o Hyperhydrosis (dry body wipes) o Any DPM recommendations listed above Schedule follow-up visit:
4 weeks 6 weeks 8 -12 weeks (at DPM discretion)