by Warren Joseph, DPM
Editor, Journal of the American Podiatric Medical Association
Attending Podiatrist, Coatesville VA Medical Center

Why focus on the lowly fungus nail in a lecture series for podiatric residents?  That's simple. Patients with thickened, dystrophic, fungal nails make up a significant part of many podiatric practices across the country.  For decades, Podiatrists has been the provider of choice for this medical condition…yet the majority of patients do not actually receive TREATMENT when they visit their Podiatrist!  

In the average podiatry practice, 24% of patient encounters involve onychomycosis.  It is for a podiatrist what an upper respiratory infection is for an Internist.  It is estimated that 35 million Americans have fungal nails.  50% of people 70 years of age or greater have it.  In a word, it is ubiquitous, and it will bring huge numbers of patients into your clinical practice. But Dr. Joseph points out that debridement alone does not actively address the underlying fungal nail infection.  Millions of nail debridement services are performed each year by podiatrists.  In fact, Medicare reports that nail debridement is the single most billed code by podiatrists.   Debridement "reduces the infectious load" by removing parts of the diseased nail, and is actually, in infectious disease terms, the drainage of an abscess.  But unlike the drainage of pus from an abscess, debridement of fungus nails never cures the infection.  The body's immune system doesn't reach nail infections as well as abscesses more intimate with the vasculature.  Curing onychomycosis requires medication...and the vast majority of those 35 million patients with onychomycosis never have their infection treated with effective medication.

“Doctor, what are the chances that this medication you are prescribing will get rid of my nail fungus?” or “Doctor, will the fungus come back once I finish the medication?”  These are common questions posed by patients when they are given a prescription oral or topical antifungal.  Relapse, Recurrence, and Re-infection are defined and discussed so that you can better answer these questions and help your patients have realistic clinical expectations.  The heightened concerns of onychomycosis in patients with diabetes are presented along with data showing an increased rate of ulceration and gangrene in diabetic patients with onychomycosis. 

Viewing this lecture will help give you an added understanding of this very common condition.  It will put some science behind something that is often ignored and will likely cause you to question how you treat the patients that come to see you for fungal toenails.