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Nail Fungus 

Onychomycosis, fungal infections of the nail for a few minutes here. About half the people who come in with nail disorders have a fungal infection, so if somebody has something wrong with the nail, it’s fungus. But then again, half the time it isn’t too. So it’s important not to treat everybody with nails for fungus infection. It’s on the rise due to the aging population and also in the immunocompromised patients. I thought this was interesting. This is the number of times patients with the diagnosis come into dermatologists as opposed to other specialties and if you look down her under diseases for nails, the number for dermatologists is 6, the number for family practitioners is 44. So nail disease is eight times more common in a family practice office.

Also there is a variety of fungi implicated, and that’s becoming more and more of a problem in the United States. What is the fungus due to? Is it all due to dermatophyte ringworm’s? Is it due to … here’s a study that had 40% due to dermatophytes. That’s the ringworm type, 14% due to molds, and 43% due to yeast.

There are four types of infections, and I’m going to concentrate on the most common one you are going to see, which is distal subungual onychomycosis. So called DSO. What happens is the fungus enters from the distal part of the nail, sets up shop in the nail bed under the nail plate and then makes a scaly nail plate and pushes the nail off. What happens is you are going to get this type of appearance. The nail is going to be lifted up.

Subungual of debris, subungual hyperkeratosis and onycholysis, which is the separation of the nail plate from the nail bed. And this is what you are going to see in practice, mainly.

This is thought was kind of neat. This is a study that was published this month in the Archives of Dermatology and what it is, is if you ever snip off nails to send them for culture, they fly all over the room.

How do you treat the patients? Well, I want to only talk about the two main ones now because fluconazole has only one study and there’s going to be one out soon, so I’ll talk about the two that are approved for treatment of nail infections. Terbinafine, which is Lamisil, which is a fungicidal drug, mainly against dermatophytes; ring-worm. And has been approved for treatment of nail infections with a dose of 250 mg once a day for three months. Itraconazole or Sporanox is considered fungistatic in vivo at least, but it has activity against not only Trichophyton.

I won’t go through this thing in detail, but it’s a list of some of the characteristics of the antifungal medicines. Just for terbinafine and itraconazole, the time to reach the nail is only seven days and itraconazole it’s three to 18 weeks for terbinafine. The Sporanox lasts about 6-9 months, maybe 3-5 months for the Lamisil.

This is just one study treating nails with Sporanox, itraconazole, with the pulse therapy and they had, I think, a 84% cure rate in that study. This is the way it looks schematically with itraconazole. Three pulses. Here’s the baseline toenail. You give the first pulse. At the end of three weeks they get the second pulse, and the end of the third week you give the third pulse and that’s it.