“….and also can you look at this toenail?”

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SouthPod7

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How many of you guys get patients with fractures and abscesses who also, without fail ask if you can do something about their fungal toenails?

Literally has a patient today. Horrible Charcot. Won’t stay off his foot. Refused to wear his CROW. Has a somber conversation about how he will need to lose another toe on that foot. First thing he says is “But what about my toenails? What can we do about them?”

Is there something about Podiatry that relegates us to toenail technicians first and foremost? I’m talking to patients about surgery, recon, etc but they never fail to bring up why they don’t have supermodel toenails into the conversation.

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How many of you guys get patients with fractures and abscesses who also, without fail ask if you can do something about their fungal toenails?

Literally has a patient today. Horrible Charcot. Won’t stay off his foot. Refused to wear his CROW. Has a somber conversation about how he will need to lose another toe on that foot. First thing he says is “But what about my toenails? What can we do about them?”

Is there something about Podiatry that relegates us to toenail technicians first and foremost? I’m talking to patients about surgery, recon, etc but they never fail to bring up why they don’t have supermodel toenails into the conversation.
Happens all the time to me. It's the worst kind of patient who gets concerned about them as well. They have 50 comorbidities but want perfect toenails. Forgettaboutit
 
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Worst nail patient for me are young females 16-25 with an isolated hallux nail trauma/dystrophy, disappearing nail bed that wants a perfect nail again after several years of putting acrylics further worsening things.
 
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"Yea I dunno, could be fungus. Here's 3 months of Lamisil, if that doesn't work the only other option I can offer you is removing the toenail. Buhbye"
 
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ED consult the middle of the night. Subacute charcot with subluxation of midfoot. Explained xyz, non weight bearing, risk of ulceration, amputation etc etc.

"Why do my toes splay like this?"

Drove home hating life and laughed when i crawled into bed thinking of what @Pronation said.
 
ED consult the middle of the night. Subacute charcot with subluxation of midfoot. Explained xyz, non weight bearing, risk of ulceration, amputation etc etc.

"Why do my toes splay like this?"

Drove home hating life and laughed when i crawled into bed thinking of what @Pronation said.

They woke you up in the middle of the night for a non-acute, non-surgical, stable foot?
 
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"Yea I dunno, could be fungus. Here's 3 months of Lamisil, if that doesn't work the only other option I can offer you is removing the toenail. Buhbye"
This is the way
 
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I could use a nonsurgical podiatrist to take care of some of this stuff, do they exist anymore?

Plenty of podiatrists who should be non surgical. Not all of them will actually take a non surgical job, but still lots of folks that would respond to that job post. Assuming it’s an employed position that pays the applicant like a doctor and not a PA
 
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Wow this thread must have jinxed me because this just happened (again) to me this morning. I was explaining to a patient how he's probably going to loose a toe (for the 3rd time) and he was like "Oh while we're in surgery can you file down this thick toenail on my other foot?"

No.
 
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Wow this thread must have jinxed me because this just happened (again) to me this morning. I was explaining to a patient how he's probably going to loose a toe (for the 3rd time) and he was like "Oh while we're in surgery can you file down this thick toenail on my other foot?"

No.
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They woke you up in the middle of the night for a non-acute, non-surgical, stable foot?
I've been woken up in the middle of the night by a trauma one hospital for non-displaced met fractures because there was a small fracture blister and the ED doc thought it was necrotizing fasciitis despite not meeting one criteria for SIRS. Ridiculous.
 
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I've been woken up in the middle of the night by a trauma one hospital for non-displaced met fractures because there was a small fracture blister and the ED doc thought it was necrotizing fasciitis despite not meeting one criteria for SIRS. Ridiculous.

I was on call once and I got hammered paged by the ER doc at 1:00am to do a wet read of a foot fracture x-ray once.
 
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I was on call once and I got hammered paged by the ER doc at 1:00am to do a wet read of a foot fracture x-ray once.
I used to get these all the time in residency. Jones fracture crutch or boot? Can you read this xray? Etc.
It was pretty annoying and always 2AM.

Luckily that doesnt happen anymore
 
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Recently, I saw an old podiatrist remove 4 nails. The nails looks super healthy on a young physically active patient. After the removal, the patient asked if he could get Narco. I’m pretty sure I witnessed the doctor being greedy and the patient drugs seeking.
 
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Recently, I saw an old podiatrist remove 4 nails. The nails looks super healthy on a young physically active patient. After the removal, the patient asked if he could get Narco. I’m pretty sure I witnessed the doctor being greedy and the patient drugs seeking.
That sounds about right...although it may be less "greedy" and more that the old doctor is just being lazy and doing whatever the patient says they want (regardless of the craziness of the requests)...burnout is real.

And Norco is the drug--Narco is who busts down your door and takes the drugs back after they find out you paid them in failed cryptocurrency for said drugs.
 
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I thought "narco" was short for "narcosleepy."
 
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Don't be a narc on the old pod . He needs his bread since he can't find some idiot to buy his over valued practice.
 
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Old pod is Narc, narc, narcin' on Heaven's Door...

I'll see myself out...
 
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Sounds like a student. No offense to students - but who knows what the reason for avulsions actually was.
I saw a wart removed shadowing. I thought it was a hack job.
Retrospect it actually probably was.
 
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Sounds like a student. No offense to students - but who knows what the reason for avulsions actually was.

With the -51 modifier by the time you get to that 4th toenail you're making d*** on that last toe, so it probably wasn't greed as the main motivator.
 
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"Yea I dunno, could be fungus. Here's 3 months of Lamisil, if that doesn't work the only other option I can offer you is removing the toenail. Buhbye"
Does anyone else ever biopsy nails? Not a DPM but I worked for a few before starting DO school. So I like to read through these as I find them interesting. Nerd I know.

Anyway, any dystrophic nails which may have been fungal were ALWAYS biopsied first before lamisil tx. Seemed appropriate given the considerable liver toxicity. Also avoids wasting 3 months of time and resources. Plus, after failed tx, while you know it’s not likely fungal, you still can’t know what it is. Thoughts?
 
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Does anyone else ever biopsy nails? Not a DPM but I worked for a few before starting DO school. So I like to read through these as I find them interesting. Nerd I know.

Anyway, any dystrophic nails which may have been fungal were ALWAYS biopsied first before lamisil tx. Seemed appropriate given the considerable liver toxicity. Also avoids wasting 3 months of time and resources. Plus, after failed tx, while you know it’s not likely fungal, you still can’t know what it is. Thoughts?
I don't believe this is true. Levels can be 2x normal and still be ok to Rx. If patient has no known liver pathology (goes to doctor often enough that someone has ordered labs....) And doesn't drink etoh I don't check labs before during after.
 
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The risk of acute liver injury among 69830 patients treated with oral antifungal agents was determined in a cohort study in which patients with prior liver disease were excluded (Garcia Rodriguez et al 1999). The incidence rates of acute liver injury were found to be 134.1 per 100 000 person-months; (95% confidence interval [CI]: 36.8, 488.0) for ketoconazole, 10.4 (95% CI: 2.9, 38.1) for itraconazole, and 2.5 (95% CI: 0.4, 13.9) for terbinafine. Ketoconazole was associated with the highest relative risk with 228.0 (95% CI: 33.9, 933.0), when compared with the risk among non-users, followed by itraconazole (relative risk [RR] 17.7; 95% CI: 2.6, 72.6) and terbinafine (RR 4.2; 95% CI: 0.2, 24.9). This cohort study confirms the finding that most case reports of liver injury after administration of oral antifungal agents occur with ketoconazole and itraconazole, and argues against using these agents as initial treatment for uncomplicated fungal infections. While the Rodriguez study (Garcia Rodriguez et al 1999) highlights low incidence of liver injury for terbinafine, the higher rates of hepatotoxicity seen with azole antifungals has adversely affected the perception of terbinafine-induced liver enzyme elevation. The incidence of terbinafine-related hepatobiliary dysfunction in the same studies are even lower at 1 in 45 000–120 000 patients (Hay 1993). To put this finding further into context, the low risk of hepatic injury observed with terbinafine may be comparable to that seen with paracetamol, a medication widely used for pain relief, and perceived as safe by the general population (Friis and Andreasen 1992; Skorepova 2004).

The risk of hepatotoxicity with terbinafine should not be exaggerated, but should be taken into account, together with any other relevant factors.
Patients with chronic or active liver diseases should not be treated with terbinafine, and baseline (pretreatment) liver transaminase testing is recommended. While some physicians continue to monitor liver enzymes during the course of terbinafine treatment, this is no longer recommended by the revised current labeling. After many years of experience with terbinafine, the FDA subsequently removed the LFT monitoring recommendation from the terbinafine label (MedWatch 2001). This is in line with early safety data reported for 1508 patients with toenail onychomycosis, with a mean age of 50 years, and extensive intractable disease, averaging over 11 years in duration (Pollak and Billstein 1997). The incidence of hepatic or biliary disorders was 2.8%, of which the most common was abnormal liver function tests (2.4%). A recent study of 504 patients, in which patients with baseline abnormal liver enzymes were excluded, showed no clinically significant alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation in plasma levels when tested 6 weeks into the treatment (250 mg/day) (Pollak et al 2004). For griseofulvin, there is a clear dosage-dependent association with hepatic toxicity, particularly in patients with prior liver damage (Skorepova 2004).
 
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Does anyone else ever biopsy nails? Not a DPM but I worked for a few before starting DO school. So I like to read through these as I find them interesting. Nerd I know.

Anyway, any dystrophic nails which may have been fungal were ALWAYS biopsied first before lamisil tx. Seemed appropriate given the considerable liver toxicity. Also avoids wasting 3 months of time and resources. Plus, after failed tx, while you know it’s not likely fungal, you still can’t know what it is. Thoughts?
I actually do toenail histo when I want to talk the person OUT of terbinafine PO...
If they want tabs for toenails but I think they're a sketchy candidate (statins, other p450 Rx, just older, many Rx, etc) and/or I simply don't think they necessarily have onycho - probably just dystrophic/traumatized nail(s) - from my eval, then I'll tell them we'll send sample for histo before starting.

As mentioned, 90d of terbinafine PO for toenail onycho is very well tolerated overall. It is also not needed to check LFTs again after starting therapy in a good candidate (unless there is obvious adverse rxn)... a ton of pharmacists and DPMs seem to not realize that, and they hang onto antiquated literature and guidelines on Lamisil from a couple decades ago.

I just screen AST/ALT and ask basic hep, cirrho, liver CA personal or fam, heavy EtOH, etc questions prior to Rx'ing oral terbinafine... and check list for other p450 meds. It would be better for my bottom line if I did clippings or even "biopsy" on everyone, but I very seldom do. The nail "biopsy" is pretty over-utili$ed. That's my honest guess as to the primary motivation for the "ALWAYS biopsied" logic you witne$$ed. Plenty of guys do a tonnnn of toenail histo... very rare false pos but common false negs (could be sampling, transport, path lab... who knows). In terms of actual good care and good medicine, it has its limited place and usefulness. If the reimbursement dropped, hardly anyone would do it, though; let's put it that way. Nail clipping histo is often used when there is zero chance it'll change the treatment (pt will still get antifungal cream or tablets or OTC or do nothing anyways), but also gotta be careful hanging your hat on the result... esp if you want to bill 11721 for onychomycosis for years and years after a neg PAS PCR histo result :giggle:
 
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Does anyone else ever biopsy nails? Not a DPM but I worked for a few before starting DO school. So I like to read through these as I find them interesting. Nerd I know.

Anyway, any dystrophic nails which may have been fungal were ALWAYS biopsied first before lamisil tx. Seemed appropriate given the considerable liver toxicity. Also avoids wasting 3 months of time and resources. Plus, after failed tx, while you know it’s not likely fungal, you still can’t know what it is. Thoughts?

A few thoughts

-The experience of people who treat this medically vs medically & surgically may be different. I have a substantial number of people presenting with a severely progressed nail, mycotic/dystrophic whatever in its entirety, present longer than a year etc - who often will be welcoming of matrixectomy without any lab tests, medications etc. In fact I now lead with surgery in my discussion because its easier to start off by saying - you don't have to do this, but we can permanently remove this nail. I kept having people who I spent time describing terbinafine to who would just say "can't we remove it".

-There are other causes of nail dystrophy besides onychomycosis and we try to be aware of them. The most underappreciated cause of nail dystrophy is mechanical microtrauma. In general, I don't need a biopsy to recognize this because it has a moderately specific presentation and is usually accompanied by a digital deformity.

-There are some specific labs that most podiatrists are aware of that perform all manner of testing including PCR. They can be very expensive. Substantially more expensive than terbinafine is to prescribe.

-See above concerning toxicity. I somewhat compare terbinafine to praying when I'm on a plane as it takes off. Yes, there is a devastating side effect but its supposed to be uncommon. I'm more likely to be injured in my car just like most people are more likely to be injured by ibuprofen or tylenol. Unfortunately, a large part of medicine involves clicking "sign" on patients with a plethora of medications and all manner of possible complications. To the best of my ability I try not to give terbinafine to people I think it will be hopeless on which means young people are more likely to get it and obviously if they suffer a side effect it will be more devastating. Its also easy to talk about a side effect and much harder to experience it. I learned that when I developed atrial fib and had to be converted.

-This condition is somewhat a condition of desperation. A lot of medicine doctors won't prescribe terbinafine or won't prescribe beyond one month before asking us for advice (which is very kind of you all, but somewhat comedic considering how limited most DPMs medical experience is). A lot of DPMs won't prescribe because they are obsessed with selling high priced ineffective topicals from their offices. Patients with negative biopsies routinely still want to proceed with therapy because otherwise nothing will be done. Anecdotally I routinely administer terbinafine to people who had a negative test from another DPM and who ultimately respond to the medication. Since often there is nothing else to do (urea, matrixectomy) I don't view the 3 months of therapy as wasted. We learn something we didn't know. They respond to terbinafine or they don't.

-I've occasionally had people tell me - nothing works. Terbinafine really does work..some of the time. I've seen some very good improvements though I caution people about mycological cure, verse "clinical cure" verse patient expectations. Improvement may or may not meet expectations.

-My second line is itraconazole. Ciclopirox 8% doesn't work. Most podiatry in office cures don't work. Reps constantly come claiming that Jublia/Tavoborole etc are covered now. I always still get a prior authorization requesting proof of 6 months of therapy of two other medications.
 
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You want that toenail fungus gone? I am happy to take those nails off. Done end of story.
 
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Nail biopsy = podiatric brain surgery. If it looks fungal, go with PO Terbinafine or Diflucan (esp if you are scared abt liver or for better pt compliance since tab qWeekly).

Nail biopsies theoretically make sense, but man just wait until the patient gets the path bill....
 
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the considerable liver toxicity
My theory is that the common refrain of, "It'll hurt your liver" came about when Lamisil was only available as a brand name drug, was super expensive, and required a ton of prior auth paperwork before getting denied coverage anyway, so doctors started telling patients that it'll hurt the liver just to move on and not have to do the extra work for nothing. Now it's available as a generic and very inexpensive but the liver toxicity mantra lives on.
 
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You want that toenail fungus gone? I am happy to take those nails off. Done end of story.
That's the best treatment right there.
 
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The risk of acute liver injury among 69830 patients treated with oral antifungal agents was determined in a cohort study in which patients with prior liver disease were excluded (Garcia Rodriguez et al 1999). The incidence rates of acute liver injury were found to be 134.1 per 100 000 person-months; (95% confidence interval [CI]: 36.8, 488.0) for ketoconazole, 10.4 (95% CI: 2.9, 38.1) for itraconazole, and 2.5 (95% CI: 0.4, 13.9) for terbinafine. Ketoconazole was associated with the highest relative risk with 228.0 (95% CI: 33.9, 933.0), when compared with the risk among non-users, followed by itraconazole (relative risk [RR] 17.7; 95% CI: 2.6, 72.6) and terbinafine (RR 4.2; 95% CI: 0.2, 24.9). This cohort study confirms the finding that most case reports of liver injury after administration of oral antifungal agents occur with ketoconazole and itraconazole, and argues against using these agents as initial treatment for uncomplicated fungal infections. While the Rodriguez study (Garcia Rodriguez et al 1999) highlights low incidence of liver injury for terbinafine, the higher rates of hepatotoxicity seen with azole antifungals has adversely affected the perception of terbinafine-induced liver enzyme elevation. The incidence of terbinafine-related hepatobiliary dysfunction in the same studies are even lower at 1 in 45 000–120 000 patients (Hay 1993). To put this finding further into context, the low risk of hepatic injury observed with terbinafine may be comparable to that seen with paracetamol, a medication widely used for pain relief, and perceived as safe by the general population (Friis and Andreasen 1992; Skorepova 2004).

The risk of hepatotoxicity with terbinafine should not be exaggerated, but should be taken into account, together with any other relevant factors.
Patients with chronic or active liver diseases should not be treated with terbinafine, and baseline (pretreatment) liver transaminase testing is recommended. While some physicians continue to monitor liver enzymes during the course of terbinafine treatment, this is no longer recommended by the revised current labeling. After many years of experience with terbinafine, the FDA subsequently removed the LFT monitoring recommendation from the terbinafine label (MedWatch 2001). This is in line with early safety data reported for 1508 patients with toenail onychomycosis, with a mean age of 50 years, and extensive intractable disease, averaging over 11 years in duration (Pollak and Billstein 1997). The incidence of hepatic or biliary disorders was 2.8%, of which the most common was abnormal liver function tests (2.4%). A recent study of 504 patients, in which patients with baseline abnormal liver enzymes were excluded, showed no clinically significant alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation in plasma levels when tested 6 weeks into the treatment (250 mg/day) (Pollak et al 2004). For griseofulvin, there is a clear dosage-dependent association with hepatic toxicity, particularly in patients with prior liver damage (Skorepova 2004).
Thank you! Fantastic review and well-referenced. That is how I practice as well.

Doctors of Podiatric Medicine also practice "medicine" and we must use effective medications and understand the true risks.

And the fact that a patient would trust one of us with a question about a condition that concerns them, even if it is "just" their toenail, is a privilege, and I'm disappointed to see it belittled in this thread.
 
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Thank you! Fantastic review and well-referenced. That is how I practice as well.

Doctors of Podiatric Medicine also practice "medicine" and we must use effective medications and understand the true risks.

And the fact that a patient would trust one of us with a question about a condition that concerns them, even if it is "just" their toenail, is a privilege, and I'm disappointed to see it belittled in this thread.
Yeah but "medicine"....ehhhh...

But @diabeticfootdr is 100 percent correct. Whether a patient trusts you to repair their painful flatfoot or prescribe them a medication, never fail to appreciate the fact that they came to you with a problem and trust in your knowledge and expertise to resolve it. It is a great honor that you should never take for granted.

Unless they are coming to you with a bull**** reason to get a handicap sticker then screw them.
 
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