Onychomycosis Diagnosis and Management: Perspectives from a Joint Dermatology-Podiatry Roundtable

September 2015 | Volume 14 | Issue 9 | Original Article | 1016 | Copyright © 2015

Richard K. Scher MD,a Antonella Tosti MD,b Warren S. Joseph DPM,c Tracey C. Vlahovic DPM,d
Jesse Plasencia DPM,e Bryan C. Markinson DPM,f and David M. Pariser MDg

aGeneral Dermatology, Weill Cornell Medical College, New York, NY
bDermatology &Cutaneous Surgery, Leonard Miller School of Medicine, University of Miami, Miami, FL
cDivision of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Philadelphia, PA
dDepartment of Podiatric Medicine and Orthopedics, Temple University School of Podiatric Medicine, Philadelphia, PA
eProfessional Foot Care Specialists, P.C., Chicago, IL
fThe Leni and Peter W. May Dept. of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
gDepartment of Dermatology, Eastern Virginia Medical School, Norfolk, VA

Abstract

Onychomycosis prevalence is expected to rise as the population ages and the prevalence of diabetes, peripheral vascular disease, and other significant risk factors rise. Until recently, treatment options were limited due to safety concerns with oral antifungals and low efficacy with available topical agents. Efinaconzole and tavaborole were approved by the FDA in 2014 for onychomycosis treatment and provide additional effective topical treatment options for patients with mild-to-moderate disease. Dermatologists and podiatrists both regularly treat onychomycosis, yet there are striking differences between specialties in approach to diagnosis and treatment. In order to explore these differences a joint dermatology-podiatry roundtable of onychomycosis experts was convened. Although it has little effect on mycologic cure, debridement may be a valuable adjunct to oral or topical antifungal therapy, especially in patients with greater symptom burden. However, few dermatologists incorporate debridement into their treatment plans and referral to podiatry may be appropriate for some of these patients. Furthermore, podiatrists may be better equipped to manage patients with concurrent diabetes or peripheral vascular disease and elderly patients who are unable to maintain proper foot hygiene. Once cure is achieved, lifestyle and hygiene practices, maintenance/prophylactic onychomycosis treatment, and proactive tinea pedis treatment in patients and family members may help to maintain patients’ cured status.

J Drugs Dermatol. 2015;14(9):1016-1021.

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INTRODUCTION

Onychomycosis has effects far beyond the cosmetic. It may significantly affect patients’ quality of life,1-4 can infect other individuals,5 may spread to other digits or distant skin sites (dermatomycoses) of infected individuals,6,7 is a risk factor for bacterial cellulitis,8 and is associated with foot ulcers in patients with diabetes.9 Patients regularly seek treatment from dermatologists or podiatrists; however, each of these specialties approaches diagnosis and management differently. For example, few dermatologists incorporate debridement into treatment strategies10,11 while podiatrists are less likely to order confirmatory laboratory tests.10,12 Such differences may be due to a variety of factors, among which are differences in training, practice philosophy, and insurance/reimbursement. Disparities in patient populations may also play a role. Patients managed by dermatologists have greater impairment in onychomycosis-specific quality of life prior to treatment than those managed by podiatrists.11 It is an open question whether these observed quality of life differences among patients seen by dermatologists or podiatrists are due to differences between these patient populations in duration or chronicity of disease,2-4 extent or number of toenails involved,2-4 prevalence of comorbid conditions,3 age,2-4,13 and/or likelihood of onychomycosis being diagnosed as a primary or secondary complaint.10

These differences in approach may be able to be leveraged to optimize patient care based on greater understanding and cooperation between specialties. With this goal in mind, a roundtable meeting of onychomycosis experts from both dermatology and podiatry was convened. This article summarizes the proceedings as pertaining to dermatology with a focus on epidemiology, treatment options, management of unresponsive infections, and when to consider a referral to podiatry. A companion piece, directed toward podiatrists, has also been published and underscores the need for greater cooperation between specialties in order to capitalize on differences in training and practice philosophy.14

EPIDEMIOLOGY

The actual prevalence of onychomycosis in the general population may be somewhat lower than what has been quoted

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