EDUCATION & DEBATE Fortnightly Review

EDUCATION & DEBATE

Fortnightly Review

Fungal nail disease: a guide to good practice (report ofa Working Group ofthe British Society for Medical Mycology)

D W Denning, E G V Evans, C C Kibbler, M D Richardson, M M Roberts, T R Rogers, D W Warnock, R E Warren

The term onychomycosis refers to fungal infection of the nails whether this is a primary event or a secondary Summary points infection of a previously diseased or traumatised nail. Infection may be due to dermatophyte (ringworm, * Onychomycosis is usually caused by tinea unguium), yeast, or other non-dermatophyte dermatophytes (85-90%), but several fungi that (mould) species, and the clinical appearance may are difficult to treat affect toenails indicate the nature of the infecting organism. In * Paronychia is caused by many Candida paronychia chronic infection of the nail fold is most species, some resistant to azole drugs Department ofInfectious often caused by Candida species, but bacterial Diseases and Tropical infection with Gram negative species such as Pseudo- * Samples for mycology should be taken as Medicine (Monsall Unit), proximally as possible in the nail North Manchester General monas may coexist. Acute paronychia (whitlow) due to Hospital, Manchester staphylococcal infection may also occur, and the * Demonstration of hyphae in a nail specimen MS SRB presence of these bacterial infections will influence by microscopy is sufficient to start treatment D W Denning, senior lecturer management. Invasion of the nail plate by Candida * Choice of treatment depends on many factors species may occur in the presence of paronychia, including patient's age and preference, infecting PHLS Mycology Reference immune deficiency states (including chronic muco- fungus, number of nails affected, degree of nail Laboratory, Department of cutaneous candidiasis), Raynaud's disease, or involvement, whether toenails or fingernails are Microbiology, University endocrine disorders. infected, and other drugs being taken ofLeeds This paper reviews the clinical features of onycho- E G V Evans, head mycosis and the differential diagnosis ofnail dystrophy, Department ofMedical gives the reasons for appropriate mycological investi- Microbiology, Royal Free gation, and discusses guidelines for appropriate recent population survey of dermatophyte onycho- Hospital, London treatment on the basis of laboratory findings and mycosis has suggested a prevalence of 2-8% for men C C Kibbler, consultant particular clinical situations. and 2-6% for women in the United Kingdom.' Earlier surveys of swimming pools,4 schools,5 hospital Regional Mycology patients,6 and office workers7 have shown a prevalence Reference Laboratory, Epidemiology of tinea pedis of 8-40%. Of those people with tinea Department of Treating onychomycoses is difficult but is important pedis, 20-30% also have affected nails.8 This suggests of Dermatology, University because do not resolve About that the of in adults could Glasgow they spontaneously. 30% prevalence onychomycosis M D Richardson, head of all superficial fungal infections affect the nail.'2 A therefore be about 3-8%. This is difficult to assess, however, since some reports do not distinguish University Department of between dermatophytosis and other forms of onycho- Dermatology, Hope mycosis or between infection of fingernails and toe- Hospital, SalfordM6 SMD Box 1: Causes offungal nail infection nails. M M Roberts, consultant Common Uncommon Toenails are more commonly infected than finger- Dermatophytes nails.' This applies particularly to dermatophyte and Department ofInfectious Tichophyton rubrum Trichophyton erinacei mould infections, whereas Candida infections are more Diseases and Bacteriology, Trichophyton interdigitale Trchophyton soudanense Royal Postgraduate likely to affect the fingernails and fingernail folds.'" Trichophyton tonsurans Mixed infection can account for up to 5% of Medical School, London Tichophyton violaceum onycho- T R Rogers, professor Epiderinophytonfloccosum mycotic infections.'12 There is wide geographical and Microsporum canis ethnic variation in the causative species, but in Britain PHIS Mycology Reference Yeasts about 5% ofcases are due to non-dermatophyte moulds Laboratory, Public Health Candida albicans Candida glabrata * such as Scopulariopsis (see box 1) and these almost Laboratory, Bristol Candida parapsilosis Candida guillermondii exclusively affect nails. There are many cases of D W Warnock, head Candida krusei* patients who have been inappropriately treated for Candida tropicalis years because the correct diagnosis has not been Public Health Laboratory, Non-dermatophytes (moulds) established. Nail infection due to will Royal Shrewsbury Hospital Scopulariopsis Fusarium spp Aspergillus spp not respond to the standard treatments for dermato- R E Warren, director Scopulariopsis brevicaulis Acremonium spp Scytalidium dimidiatum phyte or yeast onychomycosis. Correspondence to: (Hendersonula) The increase in foreign travel has led to the intro- Dr Roberts. Scytalidium hyalinum duction of some exotic species. In addition fungi *Primanly causes ofparonychia. previously considered to be non-pathogenic may now BAM 1995;311:1277-81 be found as pathogens in patients with immune

BMJ VOLUME 311 1 1 NOVEMBER 1995 1277 Clinical appearance Box 2: Typical cHnical appearance of The clinical picture of a fungal nail infection varies fungal nail dystrophy according to the nature of the infecting organism (see box 2). Involvement of adjacent skin should be noted, Dermatophyte since ifthis is due to fungal infection the treatment may Distal and lateral nail involvement spreading proximally or be different. If fungal infection is included in the Proximal subungual dystrophy or differential diagnosis then mycological examination is Superficial white dystrophy essential, even if another disease exists. Non- White or yellow thickened nails, crumbling of nail dermatophyte moulds may be present as a secondary plate invader if a nail has previously been diseased or Adjacent web or skin involvement may be present traumatised. This may account for the fact that such Candida infections often affect only one nail. Chronic paronychia Distal or lateral involvement of the nail plate Shiny red bolstered nail fold occurring at the free end of the nail and spreading Almost exclusively affects fingernail folds proximally is particularly associated with Trichophyton Loss ofcuticle rubrum infection or some non-dermatophyte infections. Pus exuding from under nail fold Eventually the whole nail may be affected, and there Usually proximal nail involvement may be proximal subungual nail dystrophy with Distal nail dystrophy-associated with circulatory separation of the nail from the bed. In superficial disorders white onychomycosis, crumbly white areas are evident Total dystrophic onychomycosis-chronic mucocutaneous candidosis on the nail surface particularly in patients with Nails white, green, or occasionally black AIDS. T interdigitale causes this type of appearance. Paronychia is seldom present in a dermatophyte Non-dermatophyte infection, but Candida infection often begins in the Superficial white onychomycosis proximal nail plate and paronychia is common. In Often solitary nail involvement-more often toenail chronic mucocutaneous candidosis, a rare T cell dis- Colour ofnail may be influenced by nature of infecting mould. For example: order with disabling mucosal candidiasis, total nail Acremonium spp-superficial white onychomycosis dystrophy is usual. Scopulariopsis spp-white, yellow, brown, or green Scytalidium spp-white or black Fusatium spp-white Differential diagnosis Alternaria spp-brown Several conditions may be associated with nail Aspergillus spp-green or black dystrophy, including bacterial and fungal infection (see box 3). Sometimes bacterial infection may coexist with fungal infection and may require treatment in its deficiency and are often associated with a high own right. Many other conditions can cause a change in mortality. For example, Fusarium species may cause the appearance ofthe nail, but the nail surface does not onychomycosis, usually with a solitary toenail usually become soft and friable as in a fungal infection. infection and sometimes with paronychia. This If there is any doubt a specimen should be taken for may provide a portal of entry leading to dissemi- mycological examination. nated infection in immunocompromised patients, In some cases of psoriasis and eczema there may be particularly those with haematological conditions fungal superinfection of the nails. Yeasts and bacteria and AIDS. are often found in subungual debris from psoriatic

Box 3: Non-fimgal conditions particularly associated with nail dystrophy Bacterial nail infection Lichen planus Pseudomonas aeruginosa-green or black dis colour- Pterygium formation from cuticle ation Longitudinal ridging ofnails Staphylococcus aureus may present as acute paronychia Total nail loss, usually permanent (whitlow) May be lichen planus elsewhere Onychogryphosis Alopecia areata and alopecia totalis Grossly thickened and distorted horn-like appearance Solitary or multiple nail dystrophy ofnail Variable severity ofnail dystrophy Overcurvature ofnail Diffuse fine pitting, often in transverse lines Great toenails most commonly affected Frequent onychorhexis (fragmented nails) and ridging May follow trauma Onset ofnail dystrophy may not coincide with hair loss

Psoriasis Yellow nail syndrome Yellow friable nails with pitting and onycholysis Slow growing nails (lifting ofnail from bed) Smooth overcurved thickened yellow nails Distal subungual hyperkeratosis All nails affected Usually several nails affected No skin involvement Usually evidence of psoriasis elsewhere, not necessarily Leg oedema and pleural effusions may be present on adjacent skin Twenty nail dystrophy Roughened nail surface, brittle free nail edge Eczema May not involve all 20 nails Irregularly pitted nail dystrophy May resolve spontaneously Irregular transverse ridging and thickening Variable association with autoimmune disorders Cuticles usually maintained (unless associated with (lichen planus, alopecia areata) chronic paronychia) History of eczema on adjacent skin Leuconychia Congenital or acquired Beau's lines Partial, total, or striate forms Transverse lines across nails corresponding to episodes May be associated with general disease ofillness Usually occurs spontaneously or with minor trauma

1278 BMJ VOLUME 311 1 1 NOVEMBER 1995 primarily a disease of the nail bed. It is desirable to Distal and lateral Superficial white subungual onychomycosis show the presence of fungal hyphae or spores within onychomycosis nail keratin by microscopy to confirm that the nail is actually affected. In chronic paronychia culture of pus from the nail fold is extremely helpful. When the clinical diagnosis of a dermatophyte infection is suspected, it may sometimes be necessary to repeat scrapings to confirm the presence of infection. It may also be helpful to repeat cultures after Proximal white Total dystrophic treatment has started to ensure that the infection is subungual onychomycosis responding to treatment. However, susceptibility onychomycosis (all three sites testing is rarely appropriate unless a treatment fails affected) unexpectedly in a proved infection. Sometimes a fungus may be resistant to a treatment in vivo but not in vitro. In a particular patient drug interactions or failure of absorption may also account for apparent FIG 1-Patterns offungal nail involvement unresponsiveness to treatment. Full laboratory mycological diagnosis is justifiable for the following reasons: nails,"3 but dermatophyte infection is seldom found * Confirmation of fungal infection before starting and is more likely to affect the toenails. Chronic prolonged oral treatment with antifungal drugs since a paronychia due to Candida infection is commonly non-fungal dermatological condition may be present associated with psoriasis and eczema of the finger- * To optimise treatment as certain fungi are less nails.'4 It is important to detect coexisting infection responsive to treatment, especially toenail infections since treatment will ensure a more rapid improvement caused by Trichophyton rubrum and non-dermatophytes in the appearance ofthe nails in these conditions. * On epidemiological grounds to identify contacts (for example, tinea pedis in families or institutions, Mycological diagnosis identification ofunusual fungi, animal contacts in cases When fungal infection is suspected, specimens for ofanimal ringworm) confirmation of the diagnosis should be obtained * To test for mixed infection (important for treatment). before treatment is started. As mentioned above, several dermatological conditions can produce nail The results of direct microscopy should be reported changes that mimic fungal infection, and these can as soon as possible, with an indication of the nature of account for apparent failure of treatment with anti- the fungal elements found. A positive microscopy fungal drugs. result is an indication for starting treatment. Results of culture should be available in two to three weeks but TAKING SPECIMENS are sometimes available earlier. While treatment for An adequate specimen is required for microscopy chronic toenail infection can await the result ofculture, and culture. Having a specimen taken should be it may be desirable to start treatment immediately for painless apart from occasional slight discomfort when more inflammatory conditions such as Candida subungual specimens are taken. Figure 2 shows the paronychia. Candida should be speciated if isolated- appropriate sites from which nail specimens should be rather than reported as "Candida species" or "yeasts obtained. Scrapings taken with a blunt scalpel or isolated"-because some species do not cause clippings should be transported in a folded square of onychomycosis. In the past only Candida albicans has paper, preferably fastened with a paper clip, but been assumed to have a pathogenic role, but it is now commercial mycological packs are also available (such evident that other Candida species, especially Candida as Dermapak, Dermaco, Toddington, Bedfordshire, parapsilosis, may, be playing an active rather than and MycoTrans, MycoTrans, Biggar, Lanarkshire). passive role. A Candida species isolated in culture is much more likely to be clinically important if direct MICROSCOPY AND CULTURE microscopy shows the presence of yeast cells or In the laboratory 20-30% potassium hydroxide pseudohyphae within the nail keratin. In paronychia solution is added to part of the specimen to macerate other Candida species are pathogenic, and some the nail keratin so that the specimen can be examined isolates are resistant to imidazole and triazole drugs. for fungal elements by direct microscopy. The rest of the specimen is inoculated on to several different media to test for the presence ofnon-dermatophytes as well as Treatment dermatophytes and yeasts. This is important because TOPICAL TREATMENTS infection with most non-dermatophyte species-such Localised dermatophyte onychomycosis may be as Scopulaniopsis, Scytalidium, Fusarium, and treated with nail paints such as 28% tioconazole with Acremonium-will not usually respond to oral undecylenic acid (Trosyl) twice daily"5 or amorolfine treatment. The results of culture can be positive even if microscopy is negative, but it is more common for Distal and lateral onychomycosis: microscopy to be positive while culture is negative (30- Scrape or take adequate 50%). Specimens from nails (subungual debris and ------chippings from subungual material and clippings) should be taken as proximally as possible Superficial white onychomycosis: proximal part of since this increases the probability of obtaining a Scrape from diseased nail positive culture result as well as positive microscopy. diseased nail Although fungal elements may be seen in material from surface , the distal end of the toenail, the culture may be Proximal white negative. This probably reflects the slow rate of toenail onychomycosis: growth, so that the fungal elements seen are no longer Scrape from nail surface viable. Subungual material may yield helpful positive culture results since dermatophyte infection is FIG 2- Where to take samplesfrom nails

BMJ VOLUME 311 11NOVEMBER1995 1279 (Loceryl) once weekly'° provided that there is only localised involvement of the distal ends of nails (see Box 4: Recommended treatments for box4). Thesepreparationshave superseded 8-ciclopirox onychomycosis paint in clinical practice. A 40% cure rate with Trosyl Dermatophyte infection may be possible, especially with dermatophyte and Localised distal nail disease Candida species,5 but treatment needs to be continued 28% Tioconazole with undecylenic acid (Trosyl) paint for at least six months for fingernails and 12 months or twice daily longer for toenails. A similar cure rate for toenails can Amorolfine (Loceryl) paint weekly be obtained with amorolfine, but a rather better cure Dissolution with 40% urea paste rate of 50% after six months is likely with affected Proximal or extensive nail disease fingernails.'0 Terbinafine (Lamisil) 250 mg daily for 3-6 months Proximal nail disease or severe nail bed involvement Itraconazole (Sporanox) 200 mg daily for 3-6 months is extremely unlikely to respond to topical treatment, Griseofulvin 1Omg/kg/daily (500 mg twice daily); for if this is of the 6-9 months for fingernails, for 15-18 months for even preceded by chemical dissolution toenails diseased nail with 40% urea paste.'6 Urea paste should Possibly also a nail paint (see above) especially for normally be applied by a chiropodist. Nail avulsion toenails may occasionally be necessary for non-dermatophyte (mould) disease but is undesirable since it may result in Candida infection damage to the nail matrix and subsequent permanent Chronicparonychia (localised) damage to the nail. Some non-dermatophyte infections Imidazole creams or paints may respond to systemic treatment. When the skin is Nystatin ointment affected as well as the nails this will require treatment Terbinafine cream (Lamisil) in its own right and, if extensive, may be an indication Distal candidal nail infection 28% Tioconazole with undecylenic acid paint (Trosyl) for systemic treatment. twice daily Topical treatment with an imidazole cream or paint Amorolfine (Loceryl) nail paint weekly twice daily for up to six months will often cure chronic paronychia, especially when this is localised to finger- Severe candidal nail infection orsevere chronicparonychia nail folds, which is the common clinical situation. Itraconazole 200-400mg daily for 3 months From a practical viewpoint, paint formulations may be Non-dermatophyte (mould) onychoomycosis easier to use than creams. Measures to reduce Localised nail disease maceration ofthe nail folds should be incorporated into 28% Tioconazole with undecylenic acid paint (Trosyl) the management of such cases. The associated twice daily Amorolfine (Loceryl) paint weekly proximal nail dystrophy will often improve with treat- Possibly also dissolution with 40% urea paste or ment of the nail fold. Localised distal infection of the avulsion nail by Candida species requires use of Trosyl nail Persistent naildisease paint twice daily or weekly use of amorolfine nail paint. months Severe Candida onychomycosis or paronychia is likely Itraconazole 200 mg daily for 3-18 to require systemic treatment, especially since such cases are usually associated with an immune deficiency state. Although it shows some in vitro activity against Scytalidium dimidiatum, its activity in vivo is limited. SYSTEMIC TREATMENTS Its place in the treatment of non-dermatophyte Terbinafine (mould) onychomycosis is not as well defined as that of The allylamine terbinafine (Lamisil) is now the itraconazole,'7 and itraconazole may be preferable for treatment of choice for dermatophyte onychomycosis. some ofthese infections. Terbinafine has fungicidal activity against all dermatophytes and various Candida species, including Candida Itraconazole and other azole drugs parapsilosis. However, it shows only fungistatic activity Itraconazole is active against most Candida species, against Candida albicans.'7 It is therefore inappropriate including Candida albicans, and is also effective in for a mixed dermatophyte and Candida albicans dermatophyte infection. Up to 5% of cases of onycho- infection unless the C albicans infection is localised and mycoses have mixed cultures," and itraconazole will can be treated topically. With more extensive mixed usually successfully treat those requiring oral treat- infection, itraconazole would be more appropriate. ment. Pulsed treatment with itraconazole (in which a Infection of fingernails requires terbinafine 250 mg week of treatment is alternated with three weeks daily for between six weeks and three months, whereas without treatment for several cycles) has been advo- toenail infection requires treatment for three months cated, but this drug is also available for continuous or possibly up to six months. A repeat culture at three treatment and can be taken for at least three months. months may be useful in patients undergoing treat- Itraconazole 200 mg daily for at least three months is ment with terbinafine, since a positive culture at this the most appropriate treatment for severe nail disease stage would indicate whether a longer course was or for immunocompromised patients, especially when required. From a clinical viewpoint, it may be difficult non-dermatophyte moulds such as Aspergillus species to assess whether a fingernail or toenail is completely are implicated. Itraconazole has superseded keto- free of infection at three months since the distal conazole in treating nail infection because of its better dystrophic part of the nail may not have grown out. safety profile. Itraconazole persists in nail keratin for at Treatment with oral terbinafine will also clear any least six months after the end of treatment. Cure rates associated skin infection without the need for for dermatophyte and candidal nail infection are about addtiional topical treatment. Although it is not yet 80% and are similar to those with terbinafine. How- licensed in Britain for use in young children, it may be ever, itraconazole may interact with several other used in children aged 12 and over when other options drugs, and this limits its usefulness in certain situ- are unsuitable or have failed. ations. Fluconazole is not yet licensed for nail disease, Cure rates of 80-95% in dermatophyte nail infec- but it may be required for severe candidal nail infection tion'8 and of about 95% in dermatophyte skin infection or chronic paronychia in doses up to 400 mg daily in can be expected with terbinafine. This drug has the immunocompromised patients. additional advantages that it interacts with relatively Neither itraconazole or fluconazole is currently few other drugs and is generally well tolerated. licensed for use in children. In older children

1280 BMJ VOLUME 311 1 1 NOVEMBER 1995 (weighing over 20 kg), however, a 100 mg capsule of avoid unnecessary treatment, especially if the itraconazole or 50 mg capsule of fluconazole may be condition is not life threatening. An exception to this prescribed. In younger children fluconazole suspen- rule may be made if there is extensive disease or if the sion of3 mg/kg may be appropriate. patient is immunocompromised even if the disease process is localised. Griseofulvin Evaluation of recent drugs such as amorolfine, Griseofulvin is effective only for dermatophyte itraconazole, fluconazole, and terbinafine is still infection and is therefore inappropriate in cases of continuing. mixed infection unless it is combined with a nail paint that has a wider antifungal spectrum. Griseofulvin may Funding: The working group was supported by the British cure up to 90% of fingernail infections in four to eight Society ofMedical Mycology. months, but its low cure rate of 40% in some toenail Conflict ofinterest: None. is infections'9 means that it now less appropriate 1 Haneke E. Fungal infections ofthe nail. Semin Dermatol 1991;10:41-53. (treatment with terbinafine or itraconazole gives more 2 Williams HC. The epidemiology of onychomycosis in Britain. Br J Dermatol than double the cure rate). However, griseofulvin is 1993;129:101-9. 3 Roberts DT. Prevalence of dermatophyte onychomycoses in the United currently the only oral drug licensed in the United Kingdom-result of an omnibus survey. Br J Dermatol 1992;126(suppl Kingdom for treating dermatophyte infection in 39):23-7. 4 Gentles JC, Evans EGV. Foot infections in swimming baths. BMJ 1973;3: children. Other considerations that should be borne in 260-2. mind include the relative risk of side effects, the 5 English MP, Gibson MD. Studies in the epidemiology of tinea pedis-I. Tinea cross pedis in school children. BMJ 1959;i: 1442-6. reaction ofpenicillin hypersensitivity with griseo- 6 English MP, Wethered RR, Duncan EHL. Studies in the epidemiology of fulvin, and interactions with other drugs already tinea pedis-VIE. Fungal infection in a long stay hospital. BMJ 1967;iii: prescribed. 136-9. 7 Howell SA, Clayton YN, Phan QC, et al. Tinea pedis. The relationship between symptoms, organisms and host characteristics. Microbiol Ecol COST BENEFITS Health Dis 1988;1:131-5. 8 Alteras I, Cojocaru I. A short review of tinea pedis caused by dermatophytes. When the relative benefits of a particular drug are Mykosen 1971;16:227-37. considered, the advantages-such as shorter length of 9 Clayton YM. Clinical and mycological diagnostic aspects of onychomycoses and lack or and dermatomycoses. Clin Exp Dernatol 1992;17(suppl 1):37-40. treatment, greater efficacy, of side effects 10 Zaug M, Bergstraesser M. Amorolfine in the treatment of onychomycoses and drug interactions-need to be balanced against the dermatomycoses (an overview). Clin Exp Dernatol 1992;17(suppl 1):61-70. cost. When topical and systemic treatments are 11 Walshe MM, English MP. Fungi in nails. BrjDermatol 1966;78:198-207. 12 AndrJ, Achten G. Onychomycosis. IntcDermatol 1987;26:481-90. combined to obtain a higher rate of cure, the total cost 13 Zaias N. Psoriasis of the nail: a clinico-pathological study. Arch Dermatal of such a combination may be greater than that of a 1969;99:567-79. 14 Ganor S. Chronic paronychia and psoriasis. BrJDermatol 1975;92:685-8. single more expensive but more effective drug used for 15 Jevons S, Lees L. Trosyl (tioconazole) Pfizer Kent (clinical experince. A a shorter time. For this reason, terbinafine has become monograph). New York: Academy Professional Information Services, the first line 1985:122-8. treatment of choice for most cases of 16 White MI, ClaytonJM. The treatment offungus and yeast infections ofthe nail dermatophyte infection whereas itraconazole may be by the method ofchemical removal. Clin Exp Dermnatol 1982;7:273-6. preferred for mixed infection. 17 Nolting S, Brautigam M, Weidinger G. Terbinafine in onychomycosis with involvement by non-dermatophytic fungi. Br J Dermatol 1994;130(suppl Costs can be justified if the most appropriate drugs 43):16-21. are chosen according to the nature of the organism 18 Goodfield MJD, Andrew L, Evans EGV. Short term treatment of dermatophyte onychomycosis with terbinafine. BMJ 1992;304:1 151-4. isolated. When the diagnosis is not immediately 19 Davies RR, Everall JD, Hamilton E. Mycological and clinical evaluation of obvious it is worth waiting for the final culture result to griseofulvin for chronic onychomycosis. BMY 1967;iii:464-9.

A MEMORABLE PATIENT Hearing voices I spent the winter of 1994-5 in Osho Commune energetic, and the voices did not disturb her any more. International, the largest spiritual health centre in India, She stopped gardening but maintained her progress and where I carried out a research project. A slim, intelligent returned to Europe a few months later. yet distressed European woman in her early 40s asked me I felt I had not done anything for her and yet she for a talk. For about five years she had been hearing voices was grateful. I regard antipsychotic drugs as a mainstay in of several men and women talking to her and each other treating psychosis. But her symptoms reduced with in different European languages. She resisted their methods doctors tend to discount. When she left India she instructions but thought that they influenced her body was not symptom free, but confident and cheerful. and changed her feelings. Friends' advice to "withdraw Psychosis can fluctuate in severity independent of her antennas" had been helpful. Recently she had been antipsychotic treatment. But why had I not seen such hearing plants commenting on her thoughts and actions. improvement in patients with chronic psychosis in These experiences had become so uncomfortable that she Germany or in Britain? Do such patients avoid psy- wanted to get rid of them. She had never mentioned them chiatrists? Are they not referred or seen only once in a to doctors, afraid of being regarded as mad and given clinic, never to return again? Do we treat too hastily? Are medicines. we hindering improvement by reducing self respect, She did not seem a risk to herself or others and had no sensitivity, and motivation through stigma, neuroleptic features of major depression. I explained the benefits of medication, or side effects? antipsychotic medication but she declined, afraid of side I do not expect to find an answer. Osho Commune effects and reduction in sensitivity. What to suggest? She International discourages people with mental health decided to try meditation, painting, and gardening. problems, as a visit can be destabilising and psychiatric A week later the voices were worse and she found it hard facilities for visitors are minimal. So it is unlikely that I to concentrate. I urged her to consider antipsychotic will have a similar experience there. I feel enriched and drugs. She felt devastated. She was determined to get grateful. I became aware of treatment options which I rid of her experiences without medicine. She attended never considered before and probably would not consider painting classes, meditated, and did gardening. She in a Western health service. I learnt to pay attention to the booked craniosacral balancing (soft bodywork) and possibility of improvement without drugs, unusual treat- Tibetan pulsing healing (meditative bodywork) sessions. ments which patients may suggest, and of the value of In the following weeks she flourished. She described their motivation.-KAmiAA-MAwIA MuELLER is a locum increasing self worth and dignity, became more lively and senior registrar inpsychiatry in Colchester

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