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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Not Just a Cosmetic Problem: Best Practices in Prevention and Treatment of Onychomycosis


GOAL
To provide primary care physicians, physician assistants, and nurse practitioners with up-to-date information on the diagnosis and management of onychomycosis.

TARGET AUDIENCE
This activity is designed for primary care physicians, physician assistants, and nurse practitioners. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Describe the pathophysiologic features and epidemiologic aspects of mild-to-moderate onychomycosis.
  • Define predisposing characteristics to enable physicians to identify patients susceptible to onychomycosis.
  • List the consequences and increased susceptibility to other serious complications in patients with onychomycosis and explain the rationale for preventive therapy in susceptible patients.
  • Select appropriate diagnostic procedures for a fungus infection in the nail.
  • Discuss various treatment methods, with specific focus on pharmacologic agents, such as ciclopirox, griseofulvin, itraconazole, and terbinafine, and the rationale of using
    combination therapy.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.5 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity:  1.5 hours.

Release date: June 15, 2005. Expiration date: June 15, 2007.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Dermik Laboratories.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Patrick S. J. McElgunn, MD, FRCPC
Assistant Professor
Department of Dermatology
Johns Hopkins University School of Medicine
Director of Cosmetic Dermatology and Laser Surgery
Johns Hopkins Dermatology and Cosmetic Center
Lutherville, Maryland
Dr McElgunn reports receiving grants/research support from Syneron; serving as a consultant for Advanced Aesthetics Institute; and receiving honoraria from Allergan and Medicis.

PARTICIPATING FACULTY

Sheila Fallon Friedlander, MD
Clinical Professor
Pediatrics and Medicine
UC San Diego School of Medicine
Pediatric and Adolescent Dermatology
Children's Hospital and Health Center
San Diego, California
Dr Friedlander reports receiving grants/research support from Dermik Laboratories, Novartis, and Pfizer Inc.

Warren S. Joseph, DPM, FIDSA
Editor, Journal of the American Podiatric
  Medical Association
Consulting Editor, Podiatry Management Adjunct Professor, Internal Medicine
Temple University School of Medicine
Philadelphia, Pennsylvania
Dr Joseph reports serving as a consultant and receiving honoraria from Dermik Laboratories and Novartis.

Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Friedlander—ciclopirox, fluconazole, itraconazole, and terbinafine.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Onychomycosis: Understanding The Disease And Its Consequences
Patrick S. J. McElgunn, MD, FRCPC*

Onychomycosis is a chronic infection of the nail plate and nail bed (Figure 1) by dermatophytes, yeasts, and opportunistic fungi. Commonly considered as "just a cosmetic problem," onychomycosis can lead to serious, long-term, and permanent damage to the digits. The disease is approximately 20 times more common in toenails than in fingernails.1,2

Onychomycosis is contagious; if not properly treated and managed, it easily can spread to other toes, other body areas, and other people. In patients with diabetes and in those patients with human immuno-deficiency virus (HIV), the fungal infection can become a portal for a secondary superinfection with bacteria.

Onychomycosis can be painful. A quality-of-life study showed that almost 50% of patients with onychomycosis have pain. Another 40% of patients describe nail pressure, and 38% have some discomfort when wearing shoes. Seventy-five percent of patients have difficulty trimming their toenails, and the disease causes significant embarrassment for patients, such as the inability to wear sandals or to participate in sports.3

Onychomycosis is underdiagnosed and undertreated. It is estimated that approximately 10% of the US population has onychomycosis.1,4 Evidence points to an increasing prevalence as the population ages and an increasing overall prevalence. Up to 60% of people who are 60 years and older are reported to have onychomycosis.5 The incidence is also higher in men, smokers, and in those patients with peripheral artery disease or HIV.6

The infection often begins as tinea pedis (dermatophytosis of the feet, particularly between the digits and on the soles), which spreads underneath the nail plate and becomes onychomycosis. A warm humid environment caused by shoes can help promote growth of the organism, and pressure from tight-fitting shoes can break the seal between the nail plate and the nail bed at the distal hyponychium, allowing subungual (beneath the nail) invasion. Tinea pedis can be treated topically, but if the nail infection is not treated, tinea pedis will likely recur. Chronic infection also can disrupt the skin, allowing for easier secondary bacterial infection. It can be a source for tinea to spread to other body areas or other people.

Trichophyton rubrum (a dermatophyte) is the primary pathogen for onychomycosis, accounting for more than 90% of infections (see "The Majority of Onychomycosis Pathogens" sidebar).7-10 Candida molds and other molds constitute most of the remaining 10%.

Onychomycosis can be divided into 4 clinical types: distal subungual onychomycosis (DSO), proximal subungual onychomycosis (PSO), white superficial onychomycosis (WSO), and candidal onychomycosis. DSO is the most common. More than 90% of cases are caused by T. rubrum, but other nondermatophyte molds may be involved, such as Aspergillus, Scopulariopsis, Scytalidium, and Fusarium. DSO starts with the invasion of the lateral or distal edges of the nail bed and the underside of the nail plate, beginning at the hyponychium (Figure 2). The localized mild inflammation and excess growth of the nail bed is in response to the infection and causes subungual hyperkeratosis (excess growth of the corneous layer of the skin). As the debris builds, the nail plate is lifted off its bed, beginning distally and proceeding proximally, thus exposing more of the nail bed to future infection. Lifting of the nail plate from the nail bed is referred to as onycholysis. The nail has a yellowish-brown appearance.1

Proximal subungual onychomycosis is the least common type of onychomycosis in clinical practice, but it is most commonly seen in patients with HIV. PSO is considered an early marker of HIV infection. The fungus invades through the proximal nail fold at the cuticle area, penetrates the newly formed nail plate, proceeds distally, and eventually penetrates all nail layers and the entire nail. Beau's lines (transverse depressions) may also appear in the nail plate. The end result is total dystrophic onychomycosis with a convex, irregular, and rough nail. Clinical presentation usually is a white or whitish brown area on the proximal nail plate, along with subungual hyperkeratosis, proximal onycholysis, leukonychia (whitish discoloration of nail), and destruction of the proximal nail plate (Figure 3).11

White superficial onychomycosis is much less common than distal subungual onychomycosis, is confined to the nail plate, and usually is caused by Trichophyton mentagrophytes. As its name implies, WSO is a superficial infection of the nail plate, seen as distinct white islands (Figure 4). As the infection progresses, these islands coalesce and the nail becomes soft, flaky, and crumbly. Because WSO is a superficial infection, inflammation usually is minimal.

Candidal onychomycosis is rare in toenails. It may be more common in patients with diabetes, who may have coexisting mucocutaneous candidiasis.12,13 Infection starts at the distal nail, invading the ventral surface in the hyponychium area, and spreads rapidly to involve the entire nail plate. The disease can penetrate the nail plate after it has infected the nail's surrounding soft tissue. Candidal onychomycosis is less hyperkeratotic than derm-atophytic onychomycosis. The infected nail usually has an opaque, rough, or furrowed appearance with a brownish or brownish-yellowish color (Figure 5).

Effective management of onychomycosis requires patient education and appropriate patient expectations. Physicians, nurse practitioners, and physician assistants should be prepared to continually educate their patients on this infection. Treatment is long term and patients may lose their enthusiasm for the care and involvement required to manage this disease.

Patients should understand that onychomycosis is an infection, not a normal consequence of aging. There are several important reasons to treat this disease: Pain and discomfort can become predominant quality-of-life issues, onychomycosis can act as a source of tinea to other body areas or other family members, and the disease can lead to much more serious consequences in patients with diabetes mellitus, such as nail removal, secondary bacterial infection, and increased risk of amputation.

Patients beginning a treatment plan must realize that treatment is a long process—often extending for longer than 1 year and involving maintenance therapy. It is paramount that patients understand the difference between cure and control of this condition. Cost issues may arise, depending on the patient's insurance, and may affect treatment decisions. Treatment costs may offset the long-term "costs" of nontreatment.

The primary care provider frequently is the first healthcare provider seen by a patient with onychomycosis. Primary care providers should be aware of the forms of onychomycosis, the patient populations frequently affected by it and, perhaps most importantly, the serious consequences of the disease if left untreated. Primary care providers can diagnose and initiate treatment for this disease, but they should also work in conjunction with a specialist to ensure optimal long-term care.

This issue of Advanced Studies in Medicine presents several case studies of onychomycosis and discussions of each case by 2 physicians with extensive experience in treating onychomycosis in different patient populations. Dr Warren Joseph discusses onychomycosis in adults—general populations and in special populations, such as patients with HIV or diabetes mellitus and elderly patients. Dr Sheila Fallon Friedlander discusses 2 cases of pediatric onychomycosis, including diagnosis, prevalence in the pediatric population, and unique issues regarding this disease in children, such as the role of infected family members and proper foot hygiene. Both physicians provide important reviews of the currently available treatments and the best approaches to diagnosis and management, especially for primary care physicians.

 

REFERENCES

1. Elewski BE. Onychomycosis: pathogenesis, diagnosis, and management. Clin Microbiol Rev. 1998;11:415-429.
2. Gupta AK, Jain HC, Lynde CW, et al. Prevalence and epidemiology of onychomycosis in patients visiting physiciansÕ offices: a multicenter Canadian survey of 15,000 patients. J Am Acad Dermatol. 2000;43:244-248.
3. Drake LA, Scher RK, Smith EB, et al. Effect of onychomycosis on quality of life. J Am Acad Dermatol. 1998;38:702-704.
4. Elewski BE, Charif MA. Prevalence of onychomycosis in patients attending a dermatology clinic in northeastern Ohio for other conditions. Arch Dermatol. 1997;133:1172-1173.
5. Pierard G. Onychomycosis and other superficial fungal infections of the foot in the elderly: a pan-European survey. Dermatology. 2001;202:220-224.
6. Gupta AK, Konnikov N, MacDonald P, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol. 1998;139:665-671.
7. Elewski B. Diagnostic techniques for confirming onychomycosis. J Am Acad Dermatol. 1996;35:S6-S9.
8. Evans EG. Causative pathogens in onychomycosis and the possibility of treatment resistance: a review. J Am Acad Dermatol. 1998;38:S32-S38.
9. Kemna MF, Elewski B. A US epidemiologic survey of superficial fungal diseases. J Am Acad Dermatol. 1996;35:539-542.
10. Schlefman BS. Onychomycosis: a compendium of facts and a clinical experience. J Foot Ankle Surg. 1999;38:290-302.
11. Joseph WS, Scher RK. Understanding the Realities of Antifungal Therapy. Podiatry Today. 2004;17(11a).
12. Joseph WS. Handbook of Lower Extremity Infections. 2nd ed. United Kingdom: Churchill Livingstone; 2002.
13. Vander Straten MR, Hossain MA, Ghannoum MA. Cutaneous infections dermatophytosis, onychomycosis, and tinea versicolor. Infect Dis Clin North Am. 2003;17:87-112.

*Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine, Director of Cosmetic Dermatology and Laser Surgery, Johns Hopkins Dermatology and Cosmetic Center, Lutherville, Maryland.
Address correspondence to: Patrick S. J. McElgunn, MD, FRCPC, Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine, Director of Cosmetic Dermatology and Laser Surgery, Johns Hopkins Dermatology and Cosmetic Center, Green Spring Station, 10755 Falls Road, Pavilion 1, Suite 350, Lutherville, MD 21093.
E-mail: pmcelgu1@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.