Why is this so bloody important, as onychomycosis is not thought to be disabling? Although there are few direct studies there is indirect evidence that there is a strong medical need to deal with onychomycosis in at least two different populations: diabetics and the frail elderly. In diabetes, both tinea pedis and fungal nail infection are risk factors for diabetic foot.[10] Onychomycosis is also common in elderly patients, potentially a larger source of concern and one that will increase over the next few years. Among the risk factors for falls, which so often precipitate a crisis in the care of the frail elderly, are nail deformity[11] and foot-related pain, including pain in the nails.[12] At this stage there have been no studies that have investigated the comparative risk of falls in patients with and without onychomycosis, but two of the consequences of nail plate infection are pain and nail deformity. The question, therefore, as to when onychomycosis is really onychomycosis is not simply an academic whim but may have real relevance to the effective management of what is for some a not-so-trivial disease.

I hope this will stir up some deep-felt opinions!!!

http://www.medscape.com/viewarticle/839818?nlid=78464_431&src=wnl_edit_medp_diab&uac=11676BJ&spon=22


 

  • Comments (10)
  • Art:

    Your article is epiphonic as it puts evidence on the table disputing the commercialized care of onychodystrophy by the marketplace which has turned onychodystrophy into onychomycosis IMPO.

    Dennis

  • The British Journal of Dermatology

    Why Should we Care if Onychomycosis is Truly Onychomycosis?

    R.J. Hay, R. Baran

    Disclosures

    The British Journal of Dermatology. 2015;172(2):316-317. 

     

    Onychomycosis, or fungal nail infection due to dermatophyte fungi, is one of the most common infections, with prevalence rates of toenail infection varying from 3% to over 25%. These rates depend on the country and method of case ascertainment;[1] the prevalence increases with age, with those aged over 70 years having infection rates, in some studies, of > 50%.[1] Other covariates include climate, nature of work and presence of underlying disease such as diabetes or psoriasis. It is a difficult infection to treat, as even the most effective measures, such as oral terbinafine combined with topical amorolfine, rarely produce clinical and mycological cures of more than 60–70% at follow-up.[2] These figures depend critically on the methods used to assess end points, and complete cure rates may be lower, even after lengthy treatment.[3,4] Therefore preventing relapse or anticipating infection through early intervention has long been a desirable strategy. Many dermatologists advise patients who have had onychomycosis to treat any new signs of interdigital or plantar tinea pedis at the earliest opportunity, or to seek advice if there are any new abnormal nail signs. This is founded on the belief that a new nail infection can be prevented by treating the infection on the foot or the nail by simple measures such as topical antifungals, before oral therapy becomes necessary.

    That all was not well with such advice was first apparent when two studies showed that, in patients with minimal primary onycholysis, and also in some with apparently normal nails, there was a small risk that dermatophytes could be identified by both microscopy and culture.[5,6] This was subsequently confirmed in patients with clinically normal nails but symptomatic tinea pedis.[7]

    The study by Shemer et al.[8] in the current issue of BJD confirms and extends these earlier observations by showing that a small but significant number of patients with apparently normal nails, and without clinical infection on the skin of the foot, have dermatophytes in their nails. These studies suggest that preventing recurrence of the nail infection by treating tinea pedis or minimal nail abnormalities as soon as these appear might not be effective, as the clinical signs may not be accurate predictors of infection.

    One key observation mentioned by the authors is that the organisms present in normal nail identified in this study might not have evolved into a fully established nail infection. This might be confirmed, or not, by a difficult long-term follow-up study of the presence of fungi in both skin and nails at different time points after successful treatment of onychomycosis. Alternatively, certain genes are switched on when dermatophytes invade keratinized tissue and, if demonstrated in patients with dermatophytes in normal nails, the fungus would be in 'invasive mode'. At least four such gene classes have been identified.[9] These are (i) proteases that can degrade epidermal proteins including keratin; (ii) kinases involved in signalling; (iii) secondary metabolites such as polyketide synthases, involved in interactions between fungus and host; and (iv) LysM (lysin motif) proteins that help the organism evade host surveillance.

    But why is this important, as onychomycosis is not thought to be disabling? Although there are few direct studies there is indirect evidence that there is a strong medical need to deal with onychomycosis in at least two different populations: diabetics and the frail elderly. In diabetes, both tinea pedis and fungal nail infection are risk factors for diabetic foot.[10] Onychomycosis is also common in elderly patients, potentially a larger source of concern and one that will increase over the next few years. Among the risk factors for falls, which so often precipitate a crisis in the care of the frail elderly, are nail deformity[11] and foot-related pain, including pain in the nails.[12] At this stage there have been no studies that have investigated the comparative risk of falls in patients with and without onychomycosis, but two of the consequences of nail plate infection are pain and nail deformity. The question, therefore, as to when onychomycosis is really onychomycosis is not simply an academic whim but may have real relevance to the effective management of what is for some a not-so-trivial disease.

    This is the best I could do as I do not have access to the British Journal of Dermatology, sorry...
  • Great Topic Dr Simonetti:

    Onychomycosis is a weak and relatively impotent pathogen that preys on a compromised host toenails for food and shelter.

    It is opportunistic and needs to have a fragmented, lysed, irregularly, dry, brittle toenail in order preceding successful colonization in most cases.

    Finding a fungal hyphae on a toenail biopsy offers little information as to how to treat that patient successfully both in the short and long term.

    More Importantly:

    "Finding the precursor that compromised the digit is most often the key to both short and long term control of ugly toenails".

    It is the rare patient that has chronic tinea pedis or intertrigo that involves more than 3-4 toenails. Yet we mistakeny treat ugly toenails as if primarily attacked by a potent pathogen for years unsuccessfully for years and then wonder why we have failed tp control or cure mst cases of onychodyatrophy.

    Deciding which type or brand of antifungal pill, antifungal laser, antifungal cream, antifungal polish or antifungal powder is low on my list of questions I ponder when confronted with dystrophic/ugly toenails n=1.

    "Shoe style, fit and environment, precursor biomechanical pathology, toenail health and architecture and pedal sweating factors are more important than killing fungus or preventing it from existing when it comes to diagnosing and treating dystrophic/ugly toenails".

    Dennis Shavelson DPM

    Disclaimer: I am the patent holder of foot typing, foot centering pads and foot centering orthotics and a consultant to Innocutis, the marketers of Nuvail and other dermatological pharmaceutical products

  • The CMS Federal guidelines do not require confirmation of infection, only clinical signs and pain. Some local carrier interpretations of CMS guidelines DO require laboratory confirmation. So yes it is true that whats ok in one region may not be in another.

  • Quote:

    Why is that? Onychodystrophy if painful is covered just the same. The difference I believe is in the treatment one would chose, that's why it's important to know the difference.



    Jeff, last when I was in private practice and billing Medicare they only paid if there was documented positive fungal cultures and pain and/or met the qualifiers. Thus onychoMYCOSIS was covered but onychoDYSTROPHY wasn't. I think that nails painful during or preventing ambulation was also covered at the time.

    I am only responding to the threasd title. I am not on any kind of conversion mission, not even for universalchurchofdave.org [not yet live].

    Dave Gottlieb, DPM

     

  • Can we define terms here as they vary, even in the literature.

    Witness the n=1's of David and I right here.  From Fraud to Deserving Biomedical Engineering covered by insurance.

    "Onychodystrophy, is any alteration of nail morphology and encompasses a wide spectrum of nail disorders. Caused by either exogenous or endogenous factors, nail dystrophy may manifest as a misshapen, damaged, infected or discolored nail unit that may affect the toenails, fingernails or both".

    Vlahovic T: How to treat dystrophic toenails; Podiatry Today; Vol 26-Issue I-Jan 2013

    http://www.podiatrytoday.com/how-treat-dystrophic-nails

    Onychomycosis is but one of the infective agents (bacteria, mold, yeast) that can alter nail morphology producing onychodystrophu.

    Once infected with fungus, a toenail can become onychodystrophic but not always. A positive culture must be correlated with a clinical picture. Finding fungus in a toenail biopsy does not prove Onychodystrophy it only proves there are fungal elements in the biopsied nail.

    All Bees are Insects but not all Insects are Bees. All Onychomycosis is Onychodystrophy but not all Onychodystrophy is Onychomycosis.

    Dennis

     

  • Why is that? Onychodystrophy if painful is covered just the same. The difference I believe is in the treatment one would chose, that's why it's important to know the difference.
  • I would wager that the difference is that onychomycosis should be treated because it's an infection while onychodystrophy should not because it's not an infectous process.

    Infection would be covered by insurance companies. This equates into money into the treating doctors pocket and an incentive to force the diagnosis into this category [possibly fraud? I don't know]

    Dystrophy would not be covered by insurance companie who are likely to consider this cosmetic. This would have to be paid for by the patient out of pocket meaning fewer visits, fewer patients, less money.

  • Quote:

    Why is this so bloody important, as onychomycosis is not thought to be disabling? Although there are few direct studies there is indirect evidence that there is a strong medical need to deal with onychomycosis in at least two different populations: diabetics and the frail elderly. In diabetes, both tinea pedis and fungal nail infection are risk factors for diabetic foot.[10] Onychomycosis is also common in elderly patients, potentially a larger source of concern and one that will increase over the next few years. Among the risk factors for falls, which so often precipitate a crisis in the care of the frail elderly, are nail deformity[11] and foot-related pain, including pain in the nails.[12] At this stage there have been no studies that have investigated the comparative risk of falls in patients with and without onychomycosis, but two of the consequences of nail plate infection are pain and nail deformity. The question, therefore, as to when onychomycosis is really onychomycosis is not simply an academic whim but may have real relevance to the effective management of what is for some a not-so-trivial disease.

    I hope this will stir up some deep-felt opinions!!!

    http://www.medscape.com/viewarticle/839818?nlid=78464_431&src=wnl_edit_medp_diab&uac=11676BJ&spon=22

    Thank you for raising this question which lives under the topic of Onychodystrophy, a topic I have much history with, Imust ask as I am not on Medscape, if you would supply a password or a better link for us to review the article you posted?

    I would prefer reserving my n=1 until then.

    Dennis

    Disclaimer: I am a consultant to Innocutis, the marketers of Nuvail and other dermatological pharmaceutical products

  • Well what if there is the supericial type or tinea mengrophytes which might show a window of opportunity to find out if further workup is needed to determine if an individual is immunosurpressed. What about other systemic diseases manifested in the toenails area.

    Why not send for biopsy analysis that toenail to determine any problems. What about some underlying subungual melanoma.

    Bottom line is to me it does not mattter if it is a DPM, DO, nurse practitioner etc... or whoever is diagnosisng the pathology. The diagnosis is needed. Many elderly have tight shoes and PVD that leads to toenail bed ulcerations. If complicated by a yeast or onychomycotic infection of the toenails this could possibly lead to staph and possible osteomylelitis, possible amputation, etc...

    Then think of gencian violet solution and not an occlusive ointment that does not promote drainage. By the way gencian violet solution might even possibly be effective against methacillin resistant staff.

     

    The above are personal opinions of Dan class of 84