Onychomycosis, This Little Piggy Needs Terbinafine

Transcript

Jason Marker: Welcome to CME on the Go, the podcast crafted specifically for family physicians and by family physicians. Whether you're seeking clinical insights, professional development or simply a sense of camaraderie, you'll find all of those here with us. Plus, you can earn CME credit with every listen. So grab your favorite brand of Sparkling water, hit play and let's embark on this journey together.

I'm Dr. Jason Marker, an associate director of the Memorial Hospital Family Medicine Residency Program in South Bend, Indiana.

Nailing a dad joke

Lauren Brown-Berchtold: I am Lauren Brown-Berchtold, and I'm the program director for VCME Family Medicine Residency in Modesto, California.

Tamaan Osbourne-Roberts: And I'm Tamaan Osbourne-Roberts, a federally qualified health center, family lifestyle and obesity medicine physician from Denver, Colorado.

Lauren Brown-Berchtold: Jason? Jason. Jason?

JM: Yes. Yes, Lauren.

LBB: OK, I have a joke for us. I have a dad joke in honor of you guys.

JM: OK, dear. Oh, thank you. OK, what you got?

LBB: All right. How is my love for Taylor Swift just like onychomycosis?

JM: Oh, my gosh. How? Tell us.

LBB: Are you ready? It's very obvious, and it's almost impossible to get rid of.

JM and TOR: [laughter] Wow.

TOR: So the only response, the only response I have to that, Lauren, is: I knew you were trouble when you walked in.

LBB: Oh, whoa! Hey, are we ready for it?

JM: I really hope that you drop some onychomycosis folklore on us before the end of this epic episode. OK, gang, today we are talking about the very sexy topic of toenail fungus, and I am totally excited get for the root of this topic with y'all. So we're going to go and put our best foot forward and we're going to nail this episode, for sure.

TOR: Dear lord.

LBB: I'm so excited for the density of jokes in this episode right now.

Onychomycosis (toenail fungus): causes and diagnosis

JM: Oh, for me, this topic is right up there with ear wax and lipomas: problems that aren't too hard to diagnose, and they have a relatively finite treatment plan and an easy explanation for patients. So whenever I see, like, usually an older adult reaching for their sock toward the end of a visit and they say, Let me show you one more thing before you go today, Doc, I know what I am about to see: a big, brown, overgrown hyperkeratotic toenail that started back when the Red Hot Chili Peppers were a popular band. Does that track for you two?

TOR: Well, it, it almost tracks. Are you telling me the Red Hot Chili Peppers are no longer a popular band?

LBB: Oh, absolutely, absolutely.

TOR: Showing my age. No, that definitely tracks. Oftentimes for some reason, my variants tend to be yellow, but yeah, like, that's how it is.

LBB: Mm-hmm. And then I have to fight my internal voice that says, “Keep the sock on. Keep the sock on.” Because I have whatever the opposite of a foot fetish is.

JM: You know, the AAFP has periodically had journal articles about onychomycosis. We're going to put those in the show notes, and really what we're going to do today is kind of talk through some of the salient things that come up with in our conversations with patients with toenail fungus. I'm just going to start with some general stats for us, and then we're going to get into some causes and diagnosis and treatment.

This is actually really common. This is why we're kind of joking about it. Twenty percent of persons older than 60 years, 50% of persons older than 70 years—like, that's a lot of people, and it has a 10% to 50% recurrence rate. So even when we're at our best, almost half the time, this is going to come back.

It's something that we're going to have to continue to deal with along the way for our patients and decide: Does this need to be treated? Do they want it to be treated? Can I educate them about the pros and cons of treatment? That's really what we want to get into.

I tend to focus on my patients who might be immunocompromised. They're having a lot of pain in their toes because of this. It's causing some gait disturbance, increasing their fall risk. Like, those are the main reasons why I think, you know, I really do need to figure out how to. How to treat this and, and maybe I do need to treat it for this person, but maybe not the next person.

How do you two go about sorting out who actually needs to have this treated?

TOR: You know, it really depends. Interestingly enough, I actually think that oftentimes cosmesis is really important. Some patients are kind of like, well, I mean, they’re feet. Ther aren’t supposed to be perfect, whatever. And if that's kind of their approach, we can kind of go, OK, if there's no other underlying reason, we can let it go.

When toenail fungus is an emotional stressor

TOR: But you know, and I've noticed that there actually might be a bit of a cultural flex on this. There are, it appears, entire cultural groups for whom feet and nice toenails are like a thing. Like, this is a big deal in their community, and they're, they're very concerned that they can't step out in open-toed shoes and that this is a real issue for them.

So if it's causing that much psychological distress, given the treatments we have, which we'll talk about later, and the relatively low risk of side effects, it's oftentimes for me, a reasonable thing to do.

LBB: Yeah, same for me. If the patient's really worried about it, then I will treat it. I will recommend treatment.

Like you said, when I'm worried about the pain and that fall risk. What's really interesting is that I seem to deal a lot with patients who are like, Well, my toenail is still not normal, but it's because they haven't seen their real toenail without a fungus for, like, 30 years, maybe. And so, so when they see normal, it looks abnormal. And that can be pretty frustrating.

But I think that it bothers patients enough that if I can confirm the diagnosis, then sure, I'll treat.

TOR: And the other group I'd add to that is, I definitely agree with you: recurrence is a real thing here, and it all seems like truffles want to return to the roots of the same trees. And at the end of the day, yeah, recurrence is usually a good enough reason to treat as well.

JM: Yeah. Do you two take the time to like do a scraping or clip off a little part of the nail at the end and send it in for culture? Is that part of your general diagnostic approach to this?

TOR: You know, Jason, you mentioned this word I don't recognize, I think it was time. I'm a family physician. Yeah, I think there's, I think you can guess what my answer is. The answer is generally not. One is, It is an additional time in the visit. Two is, how much of a value add is it for me?

Onychomycos can be diagnosed potentially microscopically, and as we know with all scrapings, there's a chance it won't be, and even more so than that, like, generally the clinical features of it are usually specific enough that I believe it's appropriate for me to consider a treatment. The nail's hyperkeratotic, it's got specifically subungual debris, color change, a very diffuse and relatively even pattern of thickening: These are sorts of things that are very specific to that. If I see a toenail that looks maybe a little , uh, Oh, my God, but maybe something else, something in that huge, wonderful big basket of dermatological wonders that as family physicians, we always love to see, and I might consider whether or not it makes sense to consider a different sort of a diagnostic process.

LBB: I'll tell you that until we prepped for this episode, I didn't even know that we were supposed to diagnose like that. I thought this was always a clinical diagnosis, and then I learned that clinical diagnosis is only accurate, like, 50% of the time. And I thought back over the last decade of practice and was like, Oh, man.

And so what I can say is, man, I've never done, I've never done a scraping and I've never done a clipping. And again, I'm not sure that I can because, because of my previously stated feelings about the feet.

JM: I know I had one of my attendings, when I was a resident, sort of, like, force me to do a clipping scraping and send it off just so that like they felt like I knew how to do it. And I never did it again after that. I don't know necessarily what the benefit of sorting out a trichophyton infection versus a candidal infection is when it comes to nail disease like this. And I agree that there may be a time when there's enough of a clinical conundrum that you need to do that to really make sure you're using it. Maybe there's some relative contraindication for one of our medications. And before you decide to prescribe that for a patient, you need to know that you've got the right diagnosis. But most of the time, I think that's not going to be necessary for us to get to where we want to go.

Onychomycosis treatment options: oral vs. topical

JM: I know we're just not really very far into this episode already, and we're already sort of into the world of treatment, but when it comes, for us as family doctors, managing this very common problem that usually is. The only part of it that has some nuance to it for us to sort out. So let's talk about it: topicals or orals? Where do we start? It seems like there's a lot of topical options for patients. Are you two using those, or is that something you bypass entirely? How do you decide where you want to begin with this?

LBB: I'm bypassing entirely. I'm going straight to oral.

TOR: Yeah, if a patient comes to me and they indicate that they had good effect from topicals previously and want to retry them, sure. They may have a particular variant or a particular toenail anatomy that works well for that. Aside from that, I don't ever suggest starting with them.

LBB: Yeah, and the recommendations are you can consider using topicals only if it's superficial fungal infection or early and distal, and I am never seeing that. I'm not having people who just noticed a little bit of a change on their toenail. I'm having patients who've been ignoring this problem for quite a long time. And so I, based on guidelines, wouldn't be appropriate for me to generally be reaching for topicals.

TOR: Yeah, and the other thing that I think we're seeing are an increase in comorbid conditions that actually mean that when people come in, the onychomycosis is substantially worse. You know, the high increasing prevalence of insulin resistance and diabetes comes immediately to mind.

Efficacy of oral medications

JM: These topicals, I'm sure they do have a role, but you're right: By the time I usually am in the loop, and maybe I just need to ask more commonly. Maybe I'm not having people take their shoes off during an annual Medicare wellness visit or, or some regular opportunity that I would've had to catch a fungal nail early. Maybe that's just, I need to do a better job at that. But by the time there's a full-distance onychomycosis that’s been there for a while, like a little bottle of Penlac is not going to solve the problem.

So, yes, I agree with you. I typically move right onto an oral strategy, knowing that I'm going to get the eradication of the germ that's at the root of that nail, and that as long as a patient doesn't have pre-existing hepatic dysfunction, in a sense that that medication could be contraindicated for them, I move pretty quickly on into using the medications.

Then, for me, I've seen change over the last 20 years. Like, do we do every day for 90 days? Do we do pulse therapy where you do a week out of every month for six months? There's been so many different ways to try to do this. So when I see all the different ways to do oral treatment, it tells me that we don't have science to tell us what the right way is.

What has kind of been your approach to using these oral medications for you two?

LBB: Great question. My approach to initiating orals is to go find Up to Date or whatever other clinical look that I have and remind myself: What's the dose of this again? Because to be fair, I don't treat it that often. I think that maybe the incidences of how often I am treating it sticks out because of the hatred of the toenails and the feet. But all I end up remembering about terbinafine before I walk out of the room is, you're going to be on this for a really long time.

The other thing that I'm doing is checking labs because I need to make sure that my patient doesn't have active liver disease. And so generally that's not me ordering new labs. That's just me reminding myself of what previous labs that I've had for this patient.

TOR: Yeah. I'll say for my part, it oftentimes is ordering new labs, just because what I'll find is that my patient may not have been in within the past year. And while they come in, like 90% of my patients saying, Oh, I'm here for a physical, they're not here for a physical; they're here for a specific issue. That's kind of where they want to go. So oftentimes I can go, well, I know we weren't planning on labs today, but we have to get this and, “Oh, wait, check out these other preventive labs you needed.” It can actually be a useful opportunity to say, “Well, if we're sticking a needle into your arm to start with, let's do some other pieces of your care.”

But even if not, I know oftentimes when patients do need to have a baseline liver function done just to make sure that terbinafine in particular is an appropriate medication for them.

JM: The 2013 AFP Journal article by Dyanne Westerberg and Michael Voyack is a really nice summary. We've got that down in the show notes, but I want to pull out a statistic that they cite in here, which is that systemic antifungals are the most effective treatment.

Meta-analyses, however, show that mycotic cure rates vary between 48% and 76%. So under the best of circumstances, you might get some improvement three-fourths of the time. Like, this is definitely not the home-run statistics our patients are looking for.

And so sometimes that alone, what used to be inexpensive medication, there really isn't anymore. Terbinafine is reasonably inexpensive now, but you know what? What I used to have to say was, this is going to be pretty expensive. Sometimes it's up to a thousand dollars for a 90-day course of a medicine that might help half of people. Like, that is a little bit defeating for our patients, especially if they've had a full length onychomycosis for several years.

We may be very successful at eradicating the germ at the root of this, but it probably has already destroyed their nail root or matrix, and they're still going to have an abnormal-appearing nail. Like, that usually is enough for them to say, “Well, what else you got for me, Doc? Because it sounds like you're a little down on a medication approach to this.”

Toenail removal and specialist referrals

JM: And then it comes down to, do I need to remove this nail? And if so, do I need to do some work at its root, once the nail is off, to try to make sure that it just doesn't grow back at all? How often … well, I guess I know the answer. Tamaan, you might be removing an occasional toenail, but I suspect that, Lauren, you have not removed a toenail.

LBB: Did you get that impression?

JM: I did get that impression.

TOR: You know, it's interesting. It depends a bit on the nature of the exact toenail. So, this is one of my few indications, aside from diabetic concerns, for referral to podiatry. If somebody comes in with an onychomycotic toenail or toenails, but they're mild to moderate, this is a situation in which I do find there's reasonable cure rates. People really do seem to do well on the oral medications if they take them for an adequate amount of time. I will say there has been a fair amount of debate in medical literature between pulse dosing, which is perceived to be safer, and continuous dosing, which has a higher risk of liver effects and there are questions as to whether or not it's more or less effective. I tend to be a continuous doser. This is part of the reason I always get baseline liver tests so I can understand if a change has happened.

If I look at the toenail and I have a hard time identifying it as a toenail as opposed to a pebble or some new and strange variety of, you know, corn smut that is for some reason growing on this patient's foot, because we have all seen the very severe cases that you certainly look boulderish, I look at it and go, “Well, that is probably too severe for medication to entirely address, and certainly address the cosmesis aspect, because it probably won't grow back or continue to grow out in a normal fashion.” But I also consider: If I remove this, am I going to be able to remove this effectively? Oftentimes, given the friability and the, the difficulty of, of dealing with these nails, it, it can sometimes make sense.

So oftentimes if it's that severe, I'll go, “Let's have a podiatrist talk to you about what their thoughts are and see if they think this needs to come off, or if they think treating it first and then removing it would make sense, or if they think they can really cure it by removal.” It's one of my indications to bring in a specialist.

JM: I'll say that, in my rural practice, before I came to full-time teaching, we didn't have a lot of podiatrists real close by. So I did take off a fair number of these onychomycotic toenails with or without attempting to use phenol or silver nitrate to sort of take care of the roots so the nail didn't grow back. And as we all know, like nails like to grow back and it's hard to do that and often these are going to grow back in a very dysfunctional manner. So I have sent plenty of folks off to podiatry as well, depending on, again, the size that other comorbid conditions and whatnot. So yeah, there's a role for that.

I think we can do it as family doctors. Anybody who's dealt with a bad ingrown toenail, like, the procedure is the same. Put on your tourniquet, good dorsal block, take the thing off and then deal with the root as you need to. There's nothing different really about that process.

LBB: Yeah, I love my podiatrists, both from personal feelings that I have, but also a lot of times I don't have a lot of the time to be doing this for a lot of my patients. And so even if I did want to be doing a lot of the trimmings and diagnosing and removals, time would feel like a barrier to me.

Alternative treatments and home remedies

LBB: What's interesting is that I do occasionally get questions about non-removal treatment options like laser and photodynamic therapies, and that is such a rare question that I've never seen those used or recommended in my milieu, which is largely FQs or FQHC lookalikes. Have you guys had experience with patients who've had good outcomes from those treatments?

JM: No.

LBB: Asked and answered.

JM: I've heard a few people do those. I think we've all had people who have done those, and I think fairly uniformly in my practice, that's not been the success that they hoped it was. And they will sometimes circle back around to me and have a bigger conversation.

TOR: Yeah, and much like you, I'm in the FQHC world, so this is not something I tend to see. I may see other attempted sorts of home remedies, which also don't work, but yeah.

JM: Yeah. I have had a lot of patients who have, well, I'll tell you, I had a person fairly early on in my career who came in and we were talking about their fungal nail, and he said to me, like, “Well, I've just been doing what my grandpa told me and I've been peeing on that toenail in the shower every day for the last year, and it's not gone away yet.” You know, it led me to a change in how I practice medicine, which was to say anytime I see a fungal nail, I start with: What have you been doing to try to make this go away on your own?

And so I have a framework for like how long they've been working with this, whether they have done anything that they thought was working for a while. Like, you can learn a lot from that. Are they soaking their feet in something and that actually is why their foot has other problems. Take the time to take a little history here. And then we want to try to nudge our patients in the direction of some better researched work, which will be usually moving on into an oral treatment option.

LBB: I have a question. Do you actually ask people, “Do you pee on this?”

JM: I do not ask that specific question.

LBB: OK. Well now I'm sad. OK.

JM: Well, that was the one-time-in-my-career sort of thing. Maybe I just don't want to know, but I don't ask that question.

LBB: If you don't ask, you won't know about it. I like it. I like it.

JM: I do have a lot of people who, at the end of our conversation we've had, we've gone over all the things that we've talked about here in this episode, and they say like, “Well then, then what am I supposed to do about this?” And I say, “You know what? This is what your friendly neighborhood, pedicurist might be able to help you with. They have really great tools. It's essentially like a medical Dremel to smooth out that nail, shape it a little bit more normally, they can make it look a little nicer for you, especially for people who wouldn't mind painting that toenail. Like, you can have it sort of recede into the background of your life with a little bit of help from a pedicurist out there along the way.

LBB: I love it. Your friendly nail technician is lovely. It does make me think about my choices in going to a pedicurist, uh, as someone who doesn't have a toenail fungus, but that's OK. I think the messaging is, much like people's love of Taylor Swift and HPV: As you get older, everyone has it.

JM: Oh my gosh. I don't think everybody has HPV as they get older, nor do I think that they all love Taylor Swift.

LBB: Almost everyone.

JM: OK, you put a qualifier in there, sorry.

LBB: Oh, yeah, yeah. Almost, almost. Not everyone, no. We can fight about HPV, but super prevalent. And also, isn't the whole world Swifties? I mean, come on.

What we’ve learned today

JM: Oh, my goodness. So what have we learned today beyond the fact that Taylor Swift is taking the world by storm? This is a common problem. Onychomycosis is something that you'll see. It is rarely medically concerning, but patients would like us to address it. We need to be ready to do that as efficiently as we can. Don't take that as a defeat if you can't get it better, because statistically, you're probably not going to get it better. Just looking at the roll of the dice here.

But you can educate your patients. You can let them choose a treatment pathway and partner with them on that. You can give them a good education. So if they have other people in their family who have a brand-new onychomycosis, there's maybe a moment when the treatment is going to be more successful and you can actually have a role in trying to protect them from ineffective treatments and the people who may proffer those to them. And I think you should be willing to remove a nail when you need to under the right circumstances.

Either of you two have other final thoughts about toenail fungus for us today?

LBB: My learning point was with regards to my overconfidence in visual diagnosis, and so that will be a practice change for me. I'm going to need to be doing these scrapings. I will need to build myself up beforehand, but I'm excited about that practice change to just do a better job for my patients, right? If I truly have a 50% inaccurate clinical diagnosis rate as a physician, then I can do better for my patients and not be subjecting them to 12 weeks of terbinafine if they don't actually have onychomycosis.

TOR: Yeah, I'll say for my point, really, one of the things that has changed since I learned this in medical school and residency and into practice has been the relative overall statistical safety of oral antifungals. I still recall every attending I ever worked with as a resident being like, “Check every single LFT. They could get fulminate hepatitis and die.” Does this happen? It does. It's like every series of medications, oral antifungals have side-effect profiles, but those sorts of serious side effects are rare.

Then you can counsel your patients on what to look for clinically, in regards to that abdominal pain, changes to urine, changes to skin, things like that. And if you are very concerned, in addition to getting a baseline LFT measurement, which some people don't even necessarily do as a clinical practice, you can get an additional measurement after four to six weeks to really ensure that their liver is tolerating the treatment. And that really is generally all you need to give.

JM: That's great. Gang, this has been a great conversation. I've enjoyed doing it. It's such a common topic for us at, at least to my point of gratitude around this is that I think it's great that we have things like this that are in our wheelhouse for our patients. It's a quality-of-life issue for many of them, and we can partner with them to figure out how to do that, and in a day when it's just one cardiovascular case after another, risk reduction, like, this is a fun conversation to have that breaks up the day, and I'm pleased to be able to do that with my patients.

What do you two have for thoughts about gratitude this time?

LBB: I'm grateful for my podiatrist colleagues and the people who like looking at feet. More accurately, though, I am grateful for … no, no, that's it. I'm grateful for my podiatrist colleagues and my colleagues who like looking at feet.

TOR: Goodness, I'll say for my part, I'm grateful for having really, really good food in my life, especially pizza with Italian sausage and mushrooms, pasta with truffles and braised Chinese-style chicken feet.

JM: Wait, are those all fungis?

TOR: The chicken feet aren't, but they had to be thrown in given the topic. Oh, my gosh.

JM: Wow, you've gone deep on this one. Thank you.

Thankfully, that's all the time that we have for today. Thank you for joining us on another episode of CME on the Go.

We appreciate you joining us on this journey to elevate family medicine. To continue the journey, please stay tuned for new episodes twice a month. Visit the show notes for instructions on how to claim your CME credit and find additional resources for today's episode. Until next time, serve from your values, pursue your vision and remember: You've totally got this.