Treatment: Oral terbinafine(Lamisil) daily for 12 weeks
Oral terbinafine is quite safe and rarely causes side effects.
Confirm diagnosis (with fungal culture or KOH observation under a microscope) before starting treatment.
- Get a clipper in the clinic, cut small pieces of the nails, include scrapings of the whitish debris, put it in a small enclosed cup and send it to the lab. Order a dermatophyte only culture.
- You may also use KOH to observe the dermatophytes under a microscope in the clinic.
- Discuss treatment benefits, harms, success rates of treatment, and the likelihood of recurrence.
- Cure rates generally < 70% for PO meds and much less for topical meds.
- Recurrence rates 40-70%
- Topical treatments usually require 48 weeks for toenails.
- Oral drugs usually require 12 weeks of treatment for toenails and may require blood tests to monitor liver function and ANC.
- Get CMP and CBC to check liver enzymes and ANC if considering PO meds.
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Vignette: You are presented with an HIV patient with onychomycosis of the toes bilaterally who is interested in treatment. How do you approach it? As above, plus, for this patient with HIV, I will do a curbside consult with ID.
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