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Diagnosis and Management of Onychomycosis

Perspectives from a Joint Podiatric Medicine–Dermatology Roundtable

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  • 1 Department of Podiatric Medicine and Orthopedics, Temple University School of Podiatric Medicine, Philadelphia, PA.
  • | 2 Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Huntingdon Valley, PA.
  • | 3 General Dermatology, Weill Cornell Medical College, New York, NY.
  • | 4 Dermatology and Cutaneous Surgery, Leonard Miller School of Medicine, University of Miami, Miami, FL.
  • | 5 Professional Foot Care Specialists PC, Chicago, IL.
  • | 6 Department of Dermatology, Eastern Virginia Medical School, Norfolk, VA.
  • | 7 The Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
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Onychomycosis is a fungal infection, and, as such, one of the goals of treatment should be eradication of the infective agent. Despite this, in contrast to dermatologists, many podiatric physicians do not include antifungals in their onychomycosis treatment plans. Before initiating treatment, confirmation of mycologic status via laboratory testing (eg, microscopy with potassium hydroxide preparation, histopathology with periodic acid–Schiff staining, fungal culture, and polymerase chain reaction) is important; however, more podiatric physicians rely solely on clinical signs than do dermatologists. These dissimilarities may be due, in part, to differences between specialties in training, reimbursement patterns, or practice orientation, and to explore these differences further, a joint podiatric medicine–dermatology roundtable was convened. In addition, treatment options have been limited owing to safety concerns with available oral antifungals and relatively low efficacy with previously available topical treatments. Recently approved topical treatments—efinaconzole and tavaborole—offer additional options for patients with mild-to-moderate disease. Debridement alone has no effect on mycologic status, and it is recommended that it be used in combination with an oral or topical antifungal. There is little to no clinical evidence to support the use of lasers or over-the-counter treatments for onychomycosis. After a patient has achieved cure (absence of clinical signs or absence of fungus with minimal clinical signs), lifestyle and hygiene measures, prophylactic/maintenance treatment, and proactive treatment for tinea pedis, including in family members, may help maintain this status.

Corresponding author: Bryan C. Markinson, DPM, Icahn School of Medicine at Mount Sinai, 17 E 102nd St, New York, NY 10029. (E-mail: bryan.markinson@mountsinai.org)