Can Cosmetically Masking Onychomycosis Help Remedy Quality Of Life Concerns For Patients?

As I have lectured across the country on onychomycosis, I have realized one of the commonalities among the professions treating onychomycosis (podiatry, dermatology, family practice) is our patients’ perception of changes in their quality of life due to the presence of nail disease.

A few years ago, my colleagues and I did a small study on quality of life following the application of Keryflex (Pod-Advance).¹ If you are not familiar with KeryFlex, it is a cosmetic resin that a podiatrist applies on any type of dystrophic nail. It is not a gel nail. In other words, it does not damage the nail plate nor does one remove the product via acetone. Patients can use nail polish and nail polish remover on KeryFlex to camouflage the nail further. I have found this useful not only for patients with onychomycosis but those who have psoriatic nails, patients who have had multiple nail procedures and even those who have ingrown (not fulminant) nails. We have used KeryFlex extensively on male and female patients at the Temple Foot and Ankle Institute since 2007.   

We are all in agreement that onychomycosis can negatively affect the patient’s quality of life. In one study examining patient perception of the effect of onychomycosis on their quality of life, 193 (75 percent) of the 258 patients said they were embarrassed about their nails. The extent of embarrassment was mild for 29 percent of patients, moderate for 38 percent and severe for 33 percent. Embarrassment was significantly less frequent for those with toenail involvement alone (66 percent) in comparison to those with fingernail involvement alone (74 percent) or involvement of both fingernails and toenails (85 percent). Onychomycosis was more likely to cause embarrassment for women (83 percent) than for men (71 percent).

The OnyCOE-t™ questionnaire, which we utilized in the 2011 study, has been validated in numerous onychomycosis studies related to patient outcome and perception of their nail disease.^1,2 In this blog, I will discuss a sample size of patients who had specifically paired the cosmetic nail resin on their mycotic nails with completion of the OnyCOE-t questionnaire.

A Closer Look At The Survey Results

Thirty patients, six males and 24 females ranging in age from 35 to 87, who wanted a cosmetic adjunct for their toenail onychomycosis filled out the OnyCOE-t™ questionnaire.¹ Researchers then applied Keryflex here on these patients, who had toenail onychomycosis of any type on one to ten toenails. They used the standard technique of debriding the nail, applying the bond, applying the resin in the desired color, shape and size, and doing subsequent curing of the resin by an ultraviolet light. Patients were allowed to use nail polish and nail polish remover over the resin in this study, and were not prohibited from performing any activity. 

Of the 30 people surveyed, 27 reported some degree of embarrassment associated with mycotic nails.¹ People were most concerned with the embarrassment of physical contact in social and intimate situations (60 percent) and the freedom to wear any type of shoes (60 percent). Patients felt a need to conceal their nails (57 percent) and were embarrassed about walking barefoot in public (43 percent) or revealing their fungal nails during social activities (43 percent). 

Seven patients reported that they had pain related to their fungal nails “very often” or “fairly often.” When patients were in shoes, they experienced more than "a little bit of a problem" doing any hobbies or work that required a lot of time on their feet (40 percent).

Those who reported these problems with embarrassment and discomfort also reported deformities (80 percent), identified as thickening, swelling, splitting, loosening, yellowing, discoloration or disfigurement of toenails. Those enrolled in the study all had some degree of onychomycosis but some did not report their deformity as a frequent or persistent problem.

Section 4 of the survey asked patients to report their satisfaction with the KeryFlex cosmetic nail resin application program.¹ Of 30 patients completing the OnyCOE-t questionnaire, 29 answered at least one question in this category. Study participants reported feeling "very satisfied" or "somewhat satisfied" and 19 participants reported satisfaction with at least one aspect of the KeryFlex treatment. The survey results also indicated that even when patients were not satisfied with the current appearance of their nails, they were satisfied with either the improvement in their nails or the result of the KeryFlex application. There were no significant differences between genders in the OnyCOE-t questionnaire but in our questions about KeryFlex, the six men enrolled in the study were significantly less satisfied with the appearance of their nails, the improvement in the condition of their nails and the application of KeryFlex in comparison to women in the study. In Section 4, 89 percent of questions answered by these three men indicated that they were “very dissatisfied” or “somewhat dissatisfied.”

Surveys of patients with mycotic nails at my workplace in Philadelphia reaffirmed the study findings at Massachusetts General Hospital, Columbia University and the University of Texas: people with mycotic nails are embarrassed and experience social discomfort that significantly impacts their quality of life.^1-4 Surveys showed these same patients found relief from KeryFlex and were satisfied with its treatment application. The dissatisfaction among men in this study is important to note, but is not statistically significant. 

In Conclusion

This survey showed that the novel technique of cosmetically masking onychomycosis facilitates patient satisfaction and positively affects the patient’s perception of his or her nail disease.¹ This adds yet another positive tool in the podiatric physician’s armamentarium when a patient wants an alternative to the current onychomycosis treatments available.

Overall, it is important to listen to patient concerns and recognize that they are dealing with an inherently embarrassing issue that warrants intervention. KeryFlex is a modality that might be appropriate for a certain population of your patients just as oral and topical antifungals are appropriate for certain subsets as well. 

References 

1. Vlahovic T, Robinson L, Beights E. Patient satisfaction measured by the OnyCOE-t™ Questionnaire following cosmetic application of a resin gel for toenail onychomycosis. Poster presented at the American Podiatric Medical Association National Annual Scientific Meeting, Boston, July 28-31, 2011. 

2. Potter LP, Mathias SD, Raut M, et al. The OnyCOE-t™ questionnaire: responsiveness and clinical meaningfulness of a patient-reported outcomes questionnaire for toenail onychomycosis. Health Qual Life Outcomes. 2006;4:50.

3. Tabolli S, Alessandroni L, Gaido J, et al. Health-related quality of life and nail disorders. Acta Derm Venereol. 2007;87(3):255-9.

4. Cham PM, Chen SC, Grill JP, et al. Reliability of self-reported willingness-to-pay and annual income in patients treated for toenail onychomycosis. Br J Dermatol. 2007;156(5):922-8.