Six ways that podiatrists can assist your patients that may surprise you.
Part 3: Non-pharmaceutical treatment of onychomycosis
Recent TGA approval means that Australian podiatrists can now offer laser treatment as an alternative to pharmaceutical treatment of onychomycosis. The Nd:YAG laser has been shown to have a comparable cure rate to the gold standard of oral Terbinafine treatment. When considering which method of treatment is appropriate for your patients, there are several matters that no doubt come to mind.
- Oral Terbinafine requires a positive nail scraping before prescribing. Around 80% of scrapings return a negative result in the face of a clinically apparent infection creating a significant cost burden shared by the individual and Medicare. This false negative effect denies the patient this intervention leaving only topical applications, which are known to have significantly poorer rates of cure.
- It is recommended that practitioners assess serum transaminases before and during the standard 12 week treatment, again using Medicare resources to do so.
- The soundness of the renal and immune systems should also be considered as Terbinafine has been known to incite immunosuppression via neutropenia.
- Side effects are common and could include nausea, depression and (at the worst extreme) life threatening epidermal necrolysis or liver failure.
- Care needs to be given to fully inform patients that they should control their consumption of alcohol during the treatment and discretion is urged when heavy alcohol use has occurred in the past.
- As Terbinafine inhibits the CYP450-2D6 isozyme, drugs that are predominantly metabolized via this pathway need to be carefully monitored and doses reduced accordingly. This includes (among others) the following drug classes: tricyclic antidepressants, selective serotonin reuptake inhibitors, beta-blockers, class 1C anti-arrhythmics and MAOIs Type B.
- Care should be used where polypharmacy already occurs. This is, of course, a particular concern given the age range of those most commonly afflicted with onychomycosis.
An alternate treatment, newly TGA approved for use in Australia, is the Nd:YAG laser light source. This device has been used in the USA for fungal nail treatment since 2008, frequently by dermatologists as well as podiatrists. It has the following benefits:
- No systemic effects whatsoever
- Requires only a single 30 minute treatment
- Does not rely on long term patient compliance
- No drug interaction concerns
- Painless application not requiring any anaesthesia
- Walk in – walk out procedure
- No need for nail scrapings or blood tests
- Can be used in diabetic, polypharmic and immunosuppressed patients
- Has been used in > 100 000 cases with no significant adverse outcome
- Similar cure rate to the gold standard of oral Terbinafine
- Contraindication is limited to those patients with significant neuropathy
The laser emits light at a wavelength that penetrates through the nail without damaging it and into the dermal tissue / nail bed below. Fungal spores are ablated immediately, both in the nail and the subungal tissue. An inability to penetrate these areas is an obvious failing of the topical treatments. Patients follow a simple routine after treatment to avoid reinfection. The protocol of our clinics then has our podiatrists review each patient after four months where a second ‘touch-up’ can occur to any recalcitrant spots without additional charge.
If you would like to ask any questions or be provided with further reading on the topic, address your communication to Stephanie Cosgrove at [email protected] or to our clinical locations in Hamilton, Indooroopilly, Toombul or Bribie Island by using this Contact Us link.
Further patient-directed information can be found here: Patient Info Pack.
Part 1: Trochanteric Bursitis – A simple cure
Part 2: Nocturnal Paraesthesia
Part 4: Sever’s Disease
Part 5: Patello-femoral Pain
Part 6: Do Podiatrists still do Chiropody ?