by Warren S. Joseph, DPM
Special Guest Author

Onychomycosis is an infection. As such, even after it is completely cured, patients can and will experience a reinfection. The published data suggests that 4 years after an initial 3-month course of an oral antifungal, only 1/3 of patients initially experiencing a complete clinical cure remain cured. In fact, given the genetic predisposition for fungal infections that patients with onychomycosis exhibit, left unmanaged it is probably safe to say that 100% of all patients treated for onychomycosis will eventually re-infect. This in no way implicates the initial treatment, either oral or topical, as being “useless” or “ineffective”. I often hear podiatrists ask, “Well, if its going to come back anyway, why treat it?” This is a shortsighted perspective. Name a condition that we treat that doesn’t or can’t recur. Ingrown toenails with paronychia, plantar fasciitis, diabetic foot ulcerations, corns and calluses, even post-op bunions can and will all come back. That does not mean that they are not worth treating in the first place. Heck, if that is the way you think about things, why go into practice! We are here to treat the patient, cure disease and improve their quality of life. Having a patient return every 61 or so days for toenail debridement maybe accomplishes only one of these.

I am often asked, “Can you ‘cure’ onychomycosis?” My answer is an unqualified YES. We cure these patients every day with effective therapies such as ciclopirox nail lacquer (Penlac) or oral terbinafine (Lamisil). If we take this ability to cure the infection as a given, the podiatric physician may inquire, “Won’t I cure away my practice?” Notice that in the preceding paragraph, I used the term “unmanaged” and not “untreated” when discussing re-infection. That is because even after the infection is cured, these patients need to be managed for a lifetime, presumably in your practice, since you took the initiative to actually cure them. Treating onychomycosis is a practice builder, not a practice destroyer.

Having waxed somewhat philosophically above, when it comes to brass-tacks clinical practice, how do you “manage” these cured patients? The key is to keep the fungus away from the cleared toenails. All of these suggestions are somewhat empiric, since none have ever been completely tested and none of the uses are FDA approved.

 

	This is the perfect place to use ciclopirox nail lacquer 8% (Penlac). We know that Penlac can penetrate down through the nail to the nail bed, the site of the potential reinfection, delivering a “prophylactic” dose of antifungal medicaltion to the site. Furthermore, the vehicle may act to “seal” the hyponychium from future fungal invasion. Have the patient apply the medication once or twice weekly ,“Fungal Friday or Toenail Tuesday”.
	“Booster dosing” of an oral antifungal on an infrequent basis may also be effective. Giving a week or two of Lamisil every 6 months, or some similar regimen, may keep the fungus away.
	The use of a topical antifungal cream or gel on the skin a few times a week for the rest of the patient’s life is important. We know that onychomycosis invariably begins as tinea pedis with the fungus working its way from the skin to under the nail. Keep the fungus off the skin and it should keep the nails clear.
	Control environmental issues, including having the patient change their shoe gear, disinfect shoes, never walk barefooted, especially in damp public places like swimming pool decks, etc.
	Advise your patient to see you back at the first sign of reinfection. It is much easier to treat a reinfection when the patient returns with only mild disease, as opposed to them waiting until the infection involves their entire toenail. Debridement and a short course of Penlac together should easily eradicate the initial evidence of reinfection.

It cannot be overstated: Onychomycosis is an infection that needs to be treated with active, medical therapy. As with any infection, it can be cured but may return. Through patient education and awareness along with some of the unique strategies listed above, most patients are able to achieve long-term control of the process and achieve significant satisfaction beneficial to you, their practitioner.