Fungal nail disease can be challenging to diagnose and treat, especially when patients have concomitant diseases that can cause nail dystrophy. DERM faculty member April Armstrong, MD, MPH provides practical guidance on the diagnosis and management of nail disease. Also in this edition, DEF Founder Joe Gorelick, MSN, FNP-C reveals the 2024 Contact Allergen of the Year and DEF Advisory Council Member Andrea Nguyen, PA-C talks skincare.
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Fungal nail disease can be challenging to diagnose and treat, especially when patients have concomitant diseases that can cause nail dystrophy. DERM faculty member April Armstrong, MD, MPH provides practical guidance on the diagnosis and management of nail disease. Also in this edition, DEF Founder Joe Gorelick, MSN, FNP-C reveals the 2024 Contact Allergen of the Year and DEF Advisory Council Member Andrea Nguyen, PA-C talks skincare.
Like what you're hearing? Have a topic you want to hear more about? Hit us up and spread the word on Instagram!
Transcript provided as a convenience and has not been edited for accuracy. Errors may be present.
Speaker 1 (00:09):
Welcome to the Dermalorian podcast from the Dermatology Education Foundation. In this edition, we take a look at the role of dermatology, NPs and PAs in recommending skincare, and we introduced the 2024 allergen of the year. But first, did you realize the global nail cosmetics market is valued at $23.4 billion and it's anticipated to grow by more than 10 billion in the next 10 years? According to Fortune Business Insights nail polish and top and base coats account for the vast majority of the nail cosmetics market. Most patients see nail cosmetics as a fun form of self-expression, but others rely on these products to camouflage nail disease. Dr. April Armstrong reviewed common nail diagnoses and their treatment. She begins by presenting a patient who complained of dystrophy of the nails of both feet and one hand.
Speaker 2 (01:14):
This is the one hand and two feet syndrome, and we typically think about the one hand two feet in terms of, for example, tinea manuum in combination with, for example, tinea pedis. But oftentimes we can also get this presentation with regards to onychomycosis . It's important to note that when we're looking at onychomycosis very frequently caused by agents suggest T rubrum , that toenails are about 25 times more likely to be infected than fingernails. So that is a reason oftentimes when we're looking at onychomycosis , we're looking at the feet. And the reason is because that these causative molds are oftentimes very ubiquitous fungi that are seen in the soil water or decaying vegetations. And when we're looking at this particular type of onychomycsosi infection, again, we see it can involve both feet commonly and also one hand now. So when we're thinking about and approaching our patients with nail disease, therefore it is importantly that we look at all 20 nails.
(02:42):
So regardless of the cheap complaint, so for example, if the patient comes in and only talk about or complaint about their fingernails, it's very important that we also look at their toes and to look at whether the same findings can be seen on the toenails. Or if the patients come in say they're only interested in having us evaluate their toenails, we want to also look at their fingernails because the location of where the disease affects our nails is critical in terms of diagnosis of nail disease. Keeping in mind our concept about looking at all 20 nails in this particular case, again, another case of onychomycosis , as you can see involving the hand. And however, if you look at other cases, you can have, for example, in patients where both hands are involved, have some kind of pathology, but the toenails are not too abnormal. So in those cases where you find that there's nail dystrophy in the fingernails bilaterally, however, the toenails are relatively more spared than we are really actually thinking about more in the case of nail psoriasis.
(04:00):
So with that, let's take a look at nail psoriasis. So in nail psoriasis, the fingernail involvement is very common, and one of the theories is that the inflammation that's typically focused in our distal joints, so in the DIP joint is very close to where the nail matrix is, and therefore when we're looking at nail psoriasis, oftentimes the hands, the fingernails, and the hands are involved and it's oftentimes bilateral. So what do we see? There are two common findings with regards to nail psoriasis. Number one is pitting. You have these little holes that represents pits on the nail. Another common finding that you will see in nail psoriasis is something called oil spots. And this is as if someone really put a drop of oil on the nail. So you see this yellowish discoloration typically in the distal part of the nail, but there are a number of other nail findings, and we typically divide those into the nail findings involving the nail matrix on the above or whether it involves the nail plate.
(05:20):
Now, earlier we talked about pitting, but you can also see things like Leia. You can also see red macules in the lunula. You can also see crumbling of the whole nail plate or stria. So these are all findings that denote the involvement of psoriasis in the nail matrix itself. Now what about the nail bed, the area where the nail plate sits on? Can psoriasis involve nail bed as well? Absolutely. And those present as either splinter hemorrhages or hyperkeratosis in combination. Hyperkeratosis is a tough one because it can really mimic onychomycosis we talked about earlier with regards to oil spots. So sometimes also called salmon patch. Now you may want to say, well, why is it important to distinguish between nail matrix disease versus nail bed psoriasis? The reason is because if you decide that as a treatment regimen that you want to inject the nails, then it's very important that we treat diseases that really involve the nail matrix.
(06:40):
So if it's a nail bed disease and you inject the nails, which we typically inject the nail matrix, then it wouldn't have much effect on the primarily nail bed disease. So here what we have is really the development of some stria, some crumbling, and you want to probably draw up the concentration of triamcinolone about five mgs Perl concentration. You can dilute that typically comes in the mg per mil. We can dilute that with either saline or lidocaine. The key thing is that no epinephrine because we're working with injection in the digital area and use a 30 gauge needle for patient comfort and then you can then inject here into the nail matrix from the side. Now a few things to note is that there are different ways that you can consider anesthetize the patient. So you could either again, dilute your triamcinolone with lidocaine but no epi, or you can have the patient prior to injection, put some firm pressure in the area where you're about to inject before you inject the area.
(07:57):
Or you can slightly use liquid nitrogen, actually very slightly spray in that area before you inject as well. Now a more preferred way of treating nail disease, nail psoriasis is actually with biologic agents. Overall, what we find is that most biologics actually do work for nail disease and they do work quite well. Our IL 17 class of medications especially work well for our nail disease. It doesn't mean our IL 23 class of medications doesn't they do as well. In this particular network med analysis, they found that, for example, ixekizumab fared really well with regards to the resolution of the nail disease. And when we think about dermatology overall, the two biologics that have been studied most extensively actually for nail disease is secukinumab and adalimumab. But overall, I think that most of our biologics work quite well for nail disease. Alright, so moving on from nail psoriasis to something more common, even more common is onychomycosis .
(09:17):
But before I fully get to that area, this is a reminder. onychomycosis is actually more common in psoriatic nails than normal nails. And you may wonder why that's the case. And the reason for that primarily is that when you have psoriatic nails, these nails are dystrophic due to psoriasis. But because dystrophic, you can imagine for example if they have oncolysis, they have the separation of the nail plate from the nail bed that actually sets up in a very opportune, it is a very opportune setup for fungal pathogens to enter that area. Therefore again, dystrophic nails, natively dystrophic nails, intrinsically dystrophic nails due to psoriasis is a perfect setup for fungal pathogens to enter that area. And less likely there are some theories that fungal infections themselves may also worsen psoriasis via this Koebner phenomenon. I think this can definitely happen as well, but I would typically, for me, I think of it as probably more the former, the Dystrophic nails creating a perfect setup for fungal pathogens to enter as a primary sort of pathogenesis for why onychomycosis is more common in psoriatic nails.
(10:43):
So if you treat a patient with psoriasis and who also has extensive psoriatic nails, for example, if you treat them with what you think is a very effective biologic, you follow them over six months and their nails still look terrible. Think about can there be concomitant on a mycosis that is also going on. So let's think about laboratory evaluation for onychomycosis . So you can evaluate for these fungal forms, there are two ways evaluating them. You can scrape for KOH or you can obtain clippings of the nail and do order PAS stain and to see if that is positive for fungal identification. So if you really want to know what kind of fungus is there, you have to do fungal culture or PCR analysis to get the identity of the fungus. Sometimes you may need it to see the sensitivity of certain medications if a patient is not responding.
(11:53):
Have you had situations where you've treated patients with an oral, a course of oral tur benefit, for example, three months standard course and their onychomycosis is not getting better still it didn't budge at all? Well, if that has happened to you, then you may be looking at something called dermatophytoma. So there could be several things happening. Number one, maybe there's dermatophytoma present. Number two is that patient may have a resistance strain to oral terin. Number three is that perhaps the patient is not taking the medication as directed. So few things, why is dermatophytoma an important topic and that we want to address here? Dermatophytoma are these pretty intensely yellow or sometimes white, but mostly yellow streaks or patches in the subungual area? What is in these are these dense fungal masses and they're considered dermatophytoma because these are dense fungal masses that are encased surrounded by this layer of biofilm underneath the nail plate. So even though your patient may be taking the oral therapies religiously, it will not touch these dermatophytomas. So dermatophytomas are considered dermatophyte abscesses and unfortunately they do not respond to oral therapy.
Speaker 1 (13:27):
Once you've made the diagnosis, it's time to approach treatment. We'll get to that in just a moment after this episode's Dermalorian clinical clip. Do you know the contact allergen of the year? DEF President nurse practitioner Jo Relic brings us up to date.
Speaker 3 (13:45):
How many patients do you see with contact dermatitis and how frustrating is it to get negative patch testing results? Even though you do learn from that, there's nothing more satisfying than actually getting a positive reaction in identifying that needle in a haystack when doing patch testing. Well, perhaps this year's allergen of the year sulfites could be the culprit for some of those negative patch test results. Sulfites commonly used in preservatives in consumer items, including foods, beverages, pharmaceuticals, and tons of personal care products have been named the 2024 contact allergen of the year by the American Contact Dermatitis Society. And remember, most of the patch tests and patch testing series that we use in the office do not contain sulfites experts predict that the acute contact dermatitis or the allergen contact dermatitis associated with sulfites is under-reported and the prevalence is much higher than we see in clinic.
Speaker 1 (14:59):
Notably, research shows that patients who experience side effects from ingested sulfites like headaches from red wine are not more susceptible to contact allergy to sulfites. Let's get back to Dr. Armstrong and her update on nail treatments.
Speaker 2 (15:15):
So how do we think about the overall algorithm for treating onychomycosis ? I want to have us to take a look at this particular chart which was published in journals of drug drugging dermatology, which can be a helpful guide. So first of all, we may want to think about our patient population because how we approach our pediatric patients versus pregnant or lactating women or versus other adults are very different. So overall in our pediatric patients, we are really focused on treating the pediatric patients with topical therapies. And the first line agent in topical therapy for pediatric patients is typically topical econazole. So this is very important in that topical f econazole has been studied in pediatric patients. Importantly, you also want to ask about the entire family just as you want to examine all 20 nails. You also want to ask about other family members, whether they also have onychomycosis or signs and symptoms of. So pediatric patient, the general rule is stay topical, and the first line choice is topical econazole.
(16:39):
Then let's look at the other spectrum of pregnant or lactating woman at this time, no recommendation, probably wait until they're done complete with pregnancy or lactating. Then consider this middle column, which is the adult adult column. So if you have adults less than 65 years of age, consider a relatively healthy, then you want to look at their clinical presentation. Depending on whether they present with mild, moderate, or severe disease, then your approach may be a little bit different. And then the grading for mild, moderate, severe I have showed you here on the side is really depending on the extent of the nail involvement. Whereas mild is less than 20%, moderate is 20 to 60%, severe is greater than 60%. So if you have someone with limited or mild onychomycosis , you want to consider topical therapies. Topical econazole is oftentimes considered first-line treatment due to its efficacy, both psychological cure rates as well as overall complete cure rates.
(17:47):
If you have someone with moderate onychomycosis , then you want to consider a combination of topical oral, either topical or oral terbinafine. So in this particular case, you can either stay a bit more intensely with topical econazole or if it's on a borderline in terms of a bit more moderate, you want to consider oral terbinafine. In those cases, if you have someone who has severe disease, then you definitely want to consider oral therapy for these patients. And here where first line typically is still oral terbinafine, then plus or minus topical treatment. So a lot of us actually are evaluating onychomycosis when it's actually in the severe realm. So again, first line, consider oral terbinafine plus or minus topical treatment. And that topical treatment can be a number of different topical treatment, which we will go over a little bit later. And then if you have someone with dermatophytoma, then your first line is typically topical treatment actually. And among the topical treatment, the first line is oftentimes topical f econazole.
(19:08):
And then we have these special populations and those are patients who are greater than 65 years of age who may have concomitant medications or other special cases. So again, for patients who may have, for example, concomitant medications, you may want to see if there's interactions with terbinafine and then tweak things accordingly. So on the right hand side are some special populations that we may want to consider a bit differently. Alright, so let's go back to oral treatment for onychomycosis in adults. Now, we talked about earlier about terin treatment first line and then the labeled indication for on mycosis for terbinafine is 250 milligrams per day for three months. However, in most patients, this particular treatment regimen is actually oftentimes not long enough. And I find that in some of my patients I have to treat actually up to six months to help to really, especially if it's a patient who this is their recurrence, I then typically treat it for six months to make sure that we're really addressing this.
(20:27):
And if it's a recurrence that's being punctuated by a long period of time. So instead of something that's resistant but true recurrence. Now there are other treatment regimens that are available, and especially in patients who may be resistant to who have developed the type of onychomycosis that's resistant to oral terbinafine treatment. And so other alternative regimens include fluconazole, for example, 200 milligrams per week. So this is the single dose per week, and you can do any day of the week that you choose. So single dose per week, so not 200 milligrams per day, but one dose 200 milligrams per week you do until the nails are completely clear. Another regimen is using itraconazole, especially in benefit resistant cases. You can do itraconazole 400 milligrams per day for one week out of every month. So you essentially do one week every four weeks, and then you do six pulses and over six months period of time and see how the patient do with this particular regimen.
(21:40):
So these are various oral treatment regimen. The use of fluconazole and itraconazole should be considered in patients who seem to have developed resistance, their modified seem to have developed resistance to oral terbinafine. One thing that one could do is once, if you failed oral terbinafine, you could also send the sample, you can do the clipping and send it to ology and then have them evaluate for minimum inhibitory concentration or MIC, and they can evaluate for that in the lab. So another way, if you don't want to try fluconazole or other treatment, if you have low minimum inhibitory concentration, then you could potentially try a second course of terbinafine if you fail the first course and then plus topicals for maintenance. However, if it's a true failure, terbinafine as we talked about before, you can do the oral fluconazole plus or minus topical treatment or the oral itraconazole plus or minus topical treatment.
(22:51):
Okay, so we talked about itraconazole earlier, about 400 milligrams per day times one week per month. Another alternative treatment regimen for the patients is 200 milligrams per day, so a lower dose per day times three months. So consider these. Both of these regimens are okay, depending on what paper you read. Some paper may recommend one versus the other, but overall, both of these regimens are okay to consider. Okay, so we talked about first-line treatment with itraconazole, excuse me, first line treatment with terbinafine and what happens when you fail that how you can extend the treatment course. We also talked about, for example, if it's a high MIC and you want it to try a different medication, you could do either fluconazole or itraconazole in these different regimen. The key is to try to treat aggressively so you can really kill the fungus. And I think a lot of the failures oftentimes come from treating not as aggressively.
(24:19):
And for a lot of patients, three months of oral terbinafine is simply not quite enough. Okay, now I'm going to talk about some other nail diseases in the remaining time. And so the first one here is something that we probably see quite commonly. Green nails, pseudomonas. And now when you see patients with pseudomonas nail infection, what I typically do is actually I do reach for oral ciprofloxacin in this case. You can also use ciprofloxacin otic drops if they don't for any reason, tolerate oral ciprofloxacin to prevent them is because some patients, they're very susceptible to developing this. To prevent this, you can do vinegar soaks or you can have half white vinegar plus half water. I like something that's quick and effective and just really get at this. So I tend to reach for the oral medications if your patients don't have contraindications. But if your patient wants a more natural treatment, you can consider vinegar soaks.
(25:27):
And you can also, if your patients have time, we can do drops under the nail. So you can mix half white vinegar with half isopropyl alcohol, make them and then use a droplet and then put them essentially under the nail. Yellow nail syndrome is diagnosed by the fulfillment of two out of three diagnostic criteria, and they are slow growing, hard yellow and dystrophic nails lymphedema. Typically, patients have some lymphedema and also respiratory tract disease. So yellow nail syndrome is actually a sign. It's a rare disease, but when you see them, it's pretty striking and it's quite sort of pathognomonic and it's typically due to the dysfunction of the lymphatic system. And specifically what we see is that lymphatic drainage is oftentimes affected like complainants of the nail, relatively more common compared to yellow nail syndrome, but definitely something that can be quite challenging to treat.
(26:26):
It's an inflammatory disease involving the nail matrix. And then therefore you see really this destruction of the nail plates. However, there is hope, and this is a paper that was published in JAMA Dermatology that looked at treatment of severe nail lichen planus with JAK inhibitor. In this particular case, they used Baricitinib four milligrams daily and they noticed a clearance after six months and after clearance, they could reduce the medication to four milligrams daily and that they were able to maintain the normal nail appearance there. So definitely some hope in the horizon with regards to treating severe nail lichen planus with JAK inhibitors. I shall say, there are also some case reports of treating lichen planus of the nail with biologic agents. Not uniformly successful, but they're having some case reports of this success
Speaker 1 (27:41):
Turning from the nails. Let's take a moment to talk about facial skincare. DEF Advisory Council member and derm faculty member, physician assistant Andrea Ween says it's important that NPS and PAs provide their patients solid skincare advice.
Speaker 4 (27:58):
I really encourage patients to ask us as healthcare providers their questions because it's important that we talk to them about some of the science behind the products that they're using, and it's better that they get their information from us than perhaps just another opinion online, which may or may not be medically founded. And so I like to educate patients on the benefits of photo protection and what to look out for in their sunscreens. Many of our over-the-counter lotions, now, they have niacinamide in it. So that's a nice added benefit. Things with antioxidants. So you use vitamin C, which can bind a lot of these free radicals and then also potentially helps keep off the unwanted effects of aging and those unwanted things from free radicals. And who doesn't want anti-aging these days, right?
Speaker 1 (28:45):
There's no denying that desire to keep a youthful glow. Thanks for joining us for this edition of the Dermalorian Podcast. If you've just found us, catch up on earlier episodes, wherever you get your podcasts, and be sure to refer a friend. We appreciate you listening.