Podiatrist Joseph Frenkel reflects on the irony of nail fungus treatments – to find a way for flexibility and consistency to co-exist.
Fungal nail infections are perhaps the most common podiatric dermatological condition seen in clinical practice, with numerous treatment options available ranging from external electric modalities to topical and oral medications.
Since many available treatments are medicinal, research tends to focus on two primary outcome measurements to determine a treatments’ efficacy, namely clinical cure and mycological cure. A simple definition of these terms is somewhat self-explanatory as clinical cure is broadly defined as the absence of the clinical signs of a fungal nail infection. Similarly, mycological cure is defined as a negative fungal culture and negative microscopy.
However, despite the directness of these two terms, studies vary significantly when it comes to how those terms are applied. For example, clinical cure in some research can mean an 80% improvement in the appearance of a nail. So too, mycological cure is prone to errors as numerous false negatives exist (fungus being present, but not being microscopically detected) within fungal nail testing with an error rate of up to 30%.
Taking all of this into account, as podiatrists, we are faced with a number of challenges in determining the most appropriate treatment path for a given case. So, if it helps you in your practice, perhaps consider choosing a treatment plan that is as variable as the fungus research itself and adopt a similarly flexible approach.
Here’s an example for context. Toenails are a typically slow growing appendage which can take up to a year to fully regrow. Though this may be seen as disadvantageous, the lengthy duration of outgrowth means each treatment modality can be trialled for an adequate period of time to accurately determine its efficacy. Topical therapy for a four to six month period can be a helpful introductory treatment, and can even sufficiently resolve a fungal nail infection.
To up the ante further, this variability can also be applied to the number of treatments being selected. We know that treating nail fungus with more than one modality simultaneously often results in greater treatment success. So too, we can be flexible in our choice of treatment modality and the number of modalities we apply. When it comes to treating nail fungus, flexibility and adaptability are key, especially considering the increasing rise of treatment-resistant fungal strains.
Whilst ‘curing’ nail fungus remains a clinical challenge for patients and clinicians alike, additional benefits can be found in the form of conservative nail care which has been found to have significant benefits for patients quality of life.
That said, with ever increasing options becoming available for managing fungal nail infections, the need for adaptability appears to be key in outgrowing both our clinical management as well as our patient’s nails.
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