"Grand Round" style presentation for Ability Diagnostics for the primary care practitioner.

1. ONYCHOMYCOSIS AND
DIABETES
BY: CHRIS BLAISDELL, DO
ADAPTED FROM MEDSCAPE: “ONYCHOMYCOSIS AND DIABETES: PATIENT CASE
CHALLENGES.”

2. ONYCHOMYCOSIS
• COMMON: 14-20% ADULTS AGES GREATER THAN 60
• 50% OF NAIL DEFORMITIES.
• MAY RESULT IN SERIOUS COMPLICATIONS. RISK FACTORS INCLUDE:
IMPAIRED CIRCULATION, PERIPHERAL NEUROPATHY, IMMUNOCOMPROMISED,
OR DIABETICS.
• TREATMENT REDUCES RISKS, BUT IS COMPLICATED BY THE POTENTIAL FOR
DRUG-DRUG INTERACTIONS BETWEEN SYSTEMIC ANTIFUNGALS AND THE
LARGE NUMBER OF MEDICATIONS OFTEN TAKEN BY THESE PATIENTS.
• FOLLOWING CASE DEMONSTRATES TREATMENT W/ NIDDM POPULATION
AND WILL BRING YOU UP TO DATE ON RISKS AND MANAGEMENT OF
TOENAIL INFECTIONS IN THIS VULNERABLE PATIENT POPULATION.

3. CASE
• ALBERT IS A 55 Y/O MALE NIDDM
PRESENTS FOR ROUTINE EXAM.
• DIAGNOSED 4 YEARS AGO, SUGARS
POORLY CONTROLLED ON
METFORMIN.
• HE ALSO IS ALSO TAKING
SIMVASTATIN.
• THICKENED, ELONGATED,
YELLOWED TOENAILS: YELLOW
SUBINQUINAL HYERKARATOSIS

4. ONYCHOMYCOSIS AND DIABETES
• HIGHLY PREVALENT IN DIABETICS (35% US DIABETES
POPULATION)
• RISK OF DEVELOPING ONYCHOMYCOSIS INCREASED DUE
TO PERIPHERAL NEUROPATHY, COMPROMISED IMMUNITY,
AND POOR CIRCULATION
• THIS MAY → 2ND BACTERIAL INFECTIONS → ULCERATION,
GANGRENE, OSTEOMYELITIS, AND POSSIBLE AMPUTATION

5. ONYCHOMYCOSIS AND DIABETES
• ONYCHOMYCOSIS ASSOCIATED WITH A 2.2-FOLD
INCREASED RISK FOR DEVELOPING ACUTE BACTERIAL
CELLULITIS EVEN IN PATIENTS WITHOUT DIABETES
• ADDITIONAL RISK FACTORS FOR ONYCHOMYCOSIS IN
PATIENTS WITH DIABETES INCLUDE ADVANCING AGE,
MALE SEX, OBESITY, RETINOPATHY, AND A FAMILY
HISTORY OF ONYCHOMYCOSIS.

6. ONYCHOMYCOSIS
• DELETERIOUS EFFECTS ON QUALITY OF LIFE (QOL): NAIL-
TRIMMING PROBLEMS, EMBARRASSMENT, PAIN, NAIL
PRESSURE, AND DISCOMFORT WEARING SHOES
• GIVEN THE POTENTIAL FOR SERIOUS COMPLICATIONS AS
WELL AS ITS EFFECTS ON QOL, ONYCHOMYCOSIS
TREATMENT IS AN IMPORTANT ASPECT OF CARE IN
PATIENTS, ESP WITH DIABETES.

7. WHICH OF THE FOLLOWING WOULD BE THE
MOST APPROPRIATE TREATMENT
RECOMMENDATION?
• MANAGE WITH PRIMARY CARE?
• REFER TO DERMATOLOGY?
• REFER TO ENDOCRINOLOGY (DIABETOLOGY)?
• REFER TO PODIATRIST?

8. WHICH OF THE FOLLOWING WOULD BE THE
MOST APPROPRIATE TREATMENT
RECOMMENDATION?
• REFER TO PODIATRIST.
CURRENT FOOT CARE GUIDELINES IN PATIENTS WITH
DIABETES RECOMMEND OVERALL MANAGEMENT BY A
PODIATRIST OR OTHER SPECIALIST WITH TRAINING IN THE
CARE OF THE DIABETIC FOOT. PODIATRISTS CAN PERFORM
MECHANICAL DEBRIDEMENT OR OTHER SURGERY THAT
MAY IMPROVE RESPONSE TO ANTIFUNGAL THERAPY.

9. DIAGNOSIS AND EVALUATION OF
ONYCHOMYCOSIS
THREE COMMON CLINICAL PATTERS:
-DLSO: THE FUNGUS INVADES FROM THE DISTAL OR
LATERAL MARGINS; MOST COMMON; ONYCHOLYSIS;
(TRICHOPHYTON RUBRUM)
-SWO: SUPERFICIAL WHITE ONYCHOMYCOSIS
(TRICHOPHYTON INTERDIGITALE)
-PSA: PROXIMAL SUBUNGUAL ONYCHOMYCOSIS;
ASSOCIATED WITH AIDS; (TRICHOPHYTON RUBRUM)

10. ONYCHOLYSIS

11. WHICH OF THE FOLLOWING DIAGNOSTIC
PROCEDURES WOULD MOST ACCURATELY REVEAL
THE SPECIES OF DERMATOPHYTE INFECTING
ALBERT’S TOENAILS?
• CLINICAL EXAMINATION?
• FUNGAL CULTURE?
• KOH EXAMINATION?
• HISTOLOGY?

12. WHICH OF THE FOLLOWING DIAGNOSTIC
PROCEDURES WOULD MOST ACCURATELY REVEAL
THE SPECIES OF DERMATOPHYTE INFECTING
ALBERT’S TOENAILS?
• FUNGAL CULTURE.
• ACCURATE ID OF MO AND 2ND INFECTION, BUT CAN
TAKE 2-6 WEEKS.
• HIGH RATE OF FALSE NEGATIVES.
• CLINICAL EXAMINATION IS NOT CONSIDERED AN
EFFECTIVE MEANS OF IDENTIFYING THE CAUSE

13. DIAGNOSIS
• HISTOLOGY.
• HISTOLOGY IS MOST SENSITIVE BUT LESS SPECIFIC.
• HISTOLOGY AT ABILITY DIAGNOSTICS TAKES 3-5
DAYS.
• YOU HAVE ACCESS TO PATHOLOGIST AND MEDICAL
DIRECTOR.
• APPROPRIATE FOR NON-COMPLICATED PATIENTS.

14. DIAGNOSIS
• CLEAN DEBRIDE NAIL WITH ALCOHOL TO REMOVE
BACTERIA AND DEBRIS.
• TAKE BIOSY FROM DISTAL EDGE OF NAILS.
• I WOULD SUGGEST BILATERAL BIOPSY EVEN IF TOE
APPEARS CLEAN DUE TO PRESENCE OF SUBCLINICAL
INFECTION.

15. DIAGNOSIS: BIOPSY

16. DIAGNOSIS
• RESULTS OF HISTOPATHOLOGY SHOW THE
PRESENC OF A DERMATOPYTE INFECTION, MOST
LIKELY T. RUBRUM.

17. WHICH OF THR FOLLOWING TREATMENT
OPTIONS WOULD BE MOST APPROPRIATE?
• CYCLOPIROX TOPICAL (8%) I QD X48 WEEKS WITH
• ITRACONAZOLE 200MG I QD X12 WEEKS
• TAVABOROLE TOPICAL (5%) I QD X48 WEEKS
• TERBILAFINE 250MG I QD X12 WEEKS

18. WHICH OF THE FOLLOWING TREATMENT
OPTIONS WOULD BE MOST APPROPRIATE?
• TERBINAFINE 250MG I QD X12 WEEKS
THIS PATIENT HAS SEVERE ONYCHOMYCOSIS BASED ON
THE EXTENT OF NAIL INVOLVEMENT, AND POOR
PROGNOSTIC FACTORS THUS NECESSITATING TREATMENT
WITH A SYSTEMIC AGENT.
TERBINAFINE WOULD BE THE OPTIMAL CHOICE BECAUSE,
UNLIKE ITRACONAZOLE, IT WOULD NOT BE SUBJECT TO
DRUG-DRUG INTERACTIONS WITH THE STATIN THAT

19. CASE CONCLUSION?
YOU INSTRUCT ON LIFESTYLE AND PERSONAL HYGIENE MEASURES
TO REDUCE RECURRENCE. THE PT EXPERIENCES MILD GI UPSET AT
FIRST, THESE SYMPTOMS SUBSIDE AND HE TAKES THE FULL COURSE
OF MEDICATION.
AT 6-MONTH FOLLOW-UP, HIS NAILS HAVE IMPROVED TO
APPROXIMATELY 40% TO 50% INVOLVEMENT.
YOU REASSURE ALBERT THAT IT MAY TAKE AS LONG AS 18 MONTHS
FOR HIS TOENAILS TO FULLY CLEAR AND COUNSEL HIM ON THE
IMPORTANCE OF TAKING PROPER CARE OF HIS FEET, WITH THE AID
OF A PROFESSIONAL IF NECESSARY.

20. THE END
• THANK YOU.
• REFERENCES:
• MEDSCAPE, “ONYCHOMYCOSIS AND DIABETES,”
• THE 5-MINUITE CLINICAL CONSULT,
• EPOCTRATES,
• MARKETING MATERIAL FROM ABILITY DIAGNOSTICS.