Important Aspects of Evaluating Onychomycosis and Potential Stumbling Blocks

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Podiatry Today recently had the chance to speak with Tracey Vlahovic, DPM,  FFPM, RCPS (Glasg) about a non-CECH lecture given at the APMA National regarding onychomycosis and JUBLIA (efinaconazole) 10% solution. In this first installment, we learn more key insights about the workup for onychomycosis, along with some challenges that clinicians face with respect to successfully treating this condition.

Q: Can you share some important aspects of the history and physical as it relates to onychomycosis?

A:

As far as clinical appearance goes, Dr. Vlahovic shares that there are a lot of different nail diseases that mimic onychomycosis, citing psoriasis is a big one that she sees in her practice. Dystrophy resulting from faulty biomechanics can also look a lot like onychomycosis, she says.

“So, visually we're looking for the changes that we are always looking for in onychomycosis, whether that's subungual debris, discoloration, thickened nails, or a crumbly appearance,” she adds. “It's important that we not only look at the nail clinically, but that we also get an idea of what's going on with the patient overall. Do they have a history of any inflammatory skin disorders? What's their anatomy like? Do we have them walk or stand? Do we look at all of the biomechanical abnormalities that may or may not be present?”

Dr. Vlahovic goes on to say that these things will help her determine what's going on, but that she also uses a dermatoscope to help identify some of the characteristics of onychomycosis.

“But ultimately, a lab diagnosis will help me to determine truly if it is onychomycosis versus something else,” she explains. “So clinically, I'm looking at the visual appearance of it, but I'm also trying to get a feel of what else is going on with that patient and rule out other differential diagnoses that could be present.”

Q: What are some important challenges that clinicians face in treating toenail fungus?

A:

As far as challenges that we face in treating onychomycosis, Dr. Vlahovic, adds that there are several. Number one, she notes, is access to medications for patients.

“We can prescribe the best topical medications or oral medications, but if the patient's insurance doesn't cover it, that certainly is a barrier to obtaining that medication,” she says. “But certainly, adherence is a problem. Again, I can give a patient the best medication on the planet, but if the patient doesn't take the medication or utilize the medication, it's not going to do anything. So, it's really important that we set patient expectations saying, ‘Look, your nail is going to take a year to a year-and-a-half, or maybe even more for it to grow out from cuticle to tip. And it's really important that we maintain the treatment that you're doing.’ And, we must explain to the patient why we're having them use a medication every day for 48 to 52 weeks or longer, or why you're taking an oral medication for three months, but it's remaining in your tissue for a little bit longer.”

Dr. Vlahovic stresses that it is vital to explain to patients what the treatment plan is, and why, and then set reasonable expectations.

“Your nail is only going to grow 1 to 2 millimeters per month, so it's going to take a while for you to see changes,” she advises. “Often at that 3-month mark, after the patient has begun topical therapy, I might see some changes, but more at 6 months, I'm going to see more of a significant change, and certainly beyond that. So, it’s important to set those patient expectations, have them come in and discuss what you are visually seeing with them as well as the next steps. Keep going, doing what you're doing, make sure that you are utilizing the medication and going from there.”

Dr. Vlahovic discloses that she is a consultant for Ortho Dermatologics.