Considerations in Evaluating and Diagnosing Onychomycosis

This podcast is supported by Ortho Dermatologics. 

Welcome to Podiatry Today podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. This episode kicks off a multi-episode series on a common condition every podiatrist encounters regularly in practice, onychomycosis. Our guest that's here with us to share her experience and insights is Ebonie Vincent, DPM. She practices in Orange County, California and is a Diplomate of the American Board of Podiatric Medicine. She's the director at large for the California Podiatric Medical Association, and you may also recognize her from her participation in the TLC show, My Feet Are Killing Me. Welcome to the podcast, and we're looking forward to talking about your observations surrounding this condition. So when we're talking about diagnosing onychomycosis, Dr. Vincent, what is that typical patient presentation that you see in your practice?

Ebonie Vincent, DPM:

So, typically people come from all different backgrounds as to why they might have contracted a fungal nail. I know the majority of the time people are coming in with diabetes who have associated nail fungus, but that's not their priority in which they're coming in. I think that that's mostly a secondary reason as to why or what the conversation is about. Other people who don't have diabetes are there because they want to have their toes out and they look good. I live in California where there's a lot of beaches and people have their toes out 100% of the time all year round. So having even the slightest nail fungus, people can come in a really big rage. Nothing systemic might be going on, they could have picked it up at a nail salon, maybe they are avid swimmers, or they are at the ocean a lot surfing, and cosmetically they just want a better looking nail.

So, diagnosis is a huge thing when it comes to a nail fungus because I always educate people and figure out, okay, so how did you contract this? Usually fungus like warm, moist, dark areas. So you either got this somewhere at the gym, in your shoe, maybe you have associated athlete's foot with it and your feet are doing this nice healthy exchange of athlete's foot and onychomycosis, and we have to address both. But finding out the root as to when you started to see the symptoms. Do you have an associative other pathology like athlete's foot or like diabetes associated with it? Getting those kinds of backgrounds and stories are all going to drive your diagnosis and then formulate a treatment plan.

Jennifer Spector, DPM:

You already started to touch on this a little bit, but are there any specific aspects of the history of present illness that you find to be important when you're working up a patient for possible onychomycosis?

Ebonie Vincent, DPM:

Yes. The biggest thing, like I said before, is the diabetic component, because obviously if you're dealing with more of a systemic issue, you have to address that first. Largely, onychomycosis is more so cosmetic and you should be dealing with other more pressing things like neuropathy or any other type of pressing wounds or maybe getting them diabetic shoe care or diabetic shoes and inserts in order to prevent things from happening. But you can definitely start to treat the onychomycosis, for sure. But at the same time, you want to be cognizant that you're not just brushing over it, all the other more important systemic illnesses that need to be addressed and kind of prepping them, saying that, "Hey, you have diabetes, which makes everything to be healed a little bit harder. Whereas a person without diabetes who doesn't have a lot of sugar in their bloodstream, they could heal potentially a lot quicker than somebody like you. So you really do need to address the root of the problem in order to have a favorable outcome with this cosmetic reason as to why you came in."

And then just trying to find the source of when they contracted it and why, it's a big situation, because oftentimes people have done their Dr. Google research and they know they have a fungus, and they've tried something already, and so when they come into your office, you're going to have to have answers as to why X, Y, and Z hasn't worked and why what they're potentially doing is making no difference.

Jennifer Spector, DPM:

Are there any other medical conditions or medications that patients might be on that are of value when you're gathering all this data?

Ebonie Vincent, DPM:

Yeah, I always ask people what they've tried in the past. Typically, in order to get or to try something else, I don't want to be the doctor that tries the same thing that your other doctor might have tried, or continues to throw medications at you that just simply don't work, so I always ask what you have tried before. Some people have tried at some form of topical before, but then my follow-up question is, okay, but for how long? And that's always a big deal because people are very... They're not well-educated on how long it actually takes to treat a fungal nail. And so some people will say, "I was on it for two weeks, I was on it for a month and it didn't do anything," and they're so frustrated and I'm like, "Well, first of all, you're not supposed to see any type of improvement if you just use a topical for... Even if you use the best topical for three months," I'm like, "You have to, first of all, be incredibly consistent. A pill is not going to solve your problems all the way. A topical may not solve all your problems all the way. There are so many parameters around fungal nails that need to be addressed in order for you to have a successful treatment regime."

So I just try to educate my patients as best as I can and tell them that even if people take the oral medication, because oftentimes people come and they're like, "I took the oral medication, I just need it again, and I got infected again." I was like, "So you don't want to keep rinsing and repeating this whole, I take the oral medication, it goes away, and then somehow it comes back. You don't want to keep doing that." So we have to figure out other ways of prevention, because prevention is the best medicine, I think, and you can't keep just exposing your body to all this medication that goes through your liver and then be disappointed when it comes right back. That's the definition of insanity. So I do like to educate my patients, talk to them about several other parameters that can be the cause.

Jennifer Spector, DPM:

You were mentioning about getting to that root cause and diabetes being one potential medical history component that can contribute to that. It also occurs to me it might be important if a patient is undergoing chemotherapy or some immunosuppressive therapy for potentially some autoimmune issues or rheumatological issues. Do you ever see that in your practice?

Ebonie Vincent, DPM:

I do. Unfortunately, when people do have to undergo radiation treatments, their nails do suffer, and similar to diabetes, those folks are going to have a harder time treating their nails. Because sometimes when you're looking at a nail, everything can look like onychomycosis. It looks like it's yellow, it's thick, it's shredded, or raised from the nail bed. Everything can look like that. But at the same time, it's important in the diagnosis to take a culture, to see whether or not what you're dealing with is actually treatable. Because sometimes those folks with diabetes or who have had nails look like that for an incredibly long time, unfortunately the nail is dystrophic or dead, or it's not going to be able to be treated. So taking a culture is something that I do for people. I send it to pathology. They usually do KOH, PAS, and then that comes back to me and then I can tell them like, "Hey, they didn't find anything," or, "They did find something, and this is what we can do to treat it."

Either way, I do tell people, even if we do a nail culture, if they've had a nail culture in the past and it comes up with nothing, that sometimes doesn't mean you don't have a fungus. So I always take one myself to be sure. But in the same time, we can do a lot of treatment in that time span just to see what happens. I'm not the doctor that will see a patient with this parable nail and say, "Oh, let's remove it." I do look at the nail, see if there's a little bit of shining hope in that root of the nail, to see if we can try something conservative before we go and do a nail avulsion. Because I find that if you do that initially, you can traumatize the root of the nail and then cause more damage. So I'm always conservative my first pass around, and then make that decision with the patient if we need to remove the nail later on.

Jennifer Spector, DPM:

So, when you're taking that specimen for culture, is there any particular technique that you use or an area of the nail that you find to be more successful for that culture?

Ebonie Vincent, DPM:

I'm not taking the tip of the nail, I'm usually trimming that off first and getting rid of that and then taking more of the nail that's closer to the nail bed, or the nail root of it, if I can get some more of that off. Because you're liable to have anything at the nail tip when people have sock fuzz stuck in there, and that's also problematic when it comes to treating the nail. You never know what kind of hygiene people have initially when they're starting off. But no, I usually try and cut a little bit of the nail and then take a little bit more of the inner portion of the nail to send to pathology.

Jennifer Spector, DPM:

Do you ever go for any subungual debris too, to include?

Ebonie Vincent, DPM:

I do. I try and send as much of the debris as possible because I think that's where we get the better reading, I think.

Jennifer Spector, DPM:

When you get those results back. You did mention that the lab probably does a KOH, a PAS, and then you get the culture that does take a little bit longer. Are there any particular findings that you're looking for in that culture report that leads you to believe, yes, it's worth me waiting this extra couple of weeks for a final, or are you looking for anything on preliminary results too?

Ebonie Vincent, DPM:

Just for preliminary results, just saying that they do find it, I think that's enough for me to try and treat it. To be honest, I'm really liberal with who I go and treat a nail fungus with because I think that consistency, I can make the nail look exponentially better. Whether or not I can continue to take a culture and then miraculously one day the culture will be free and clear, I don't think people care as much, I think people care that their nails look a lot better and they'll continue with the more hygiene things that need to happen in order for it to look how they want it to look. So I'm rarely doing follow-up cultures. I don't think anyone's ever has asked, "Are you sure it's gone? Do another culture."

Jennifer Spector, DPM:

Well, on your physical exam, obviously you're assessing for the visuals, but what other aspects of the focus physical exam do you look for when on onychomycosis is part of your differential?

Ebonie Vincent, DPM:

I feel their skin. I'm taking mental notes of when they take their shoes and socks off to see if their socks are moist. What color socks they're wearing, if they're always wearing black fuzzy socks, that's something that could be potentially a risk factor of developing another round of onychomycosis. If they are always wearing shoes with no socks, so a lot of people do that. They come in with their little Sperrys or just slide on shoes. I'm taking mental notes of what your habits are, what your style of shoe is. So that plays a role in my thought process and my explanation as well. Feeling the skin, seeing if it's clammy, or seeing if you have associated [inaudible], that mocks information. I ask if it's red or itchy sometimes, inflamed. And then if so, what do you do about it?

I saw a patient the other day and he came in for dry feet, and he was like, "I don't understand why my feet are so dry." He was really oiled up. He was the most moisturized person you'll ever see, from head to the ankle. And then all of a sudden his feet, the bottom of his feet were just dry. And I was like, "Oh, it's not dry. It's athlete's foot. It looks like you might just be ashy or dry," and so the concept is, "Oh, let me just go and get some more lotion. Let me go get some more shea butter. Let me saran wrap my feet with lotion and put a sock over it." And what you're essentially doing is just making the situation worse. You're perpetuating the fungus from happening, and then you have these cracked, dry, gross skin on your feet, plus onychomycotic nails, they're doing this exchange of fungus, and you're none the wiser. And you're like, "I do everything that I'm supposed to do to prevent the dryness," but you're not doing anything to prevent the fungus.

So I definitely talk to people about their lifestyle. If they're avid gym goers, a lot of people do surfing here, or paddleboarding, that's a big one. Or even scuba diving. They shove their bare feet into flippers that may or may not be theirs. So it's a lot of things that people can do and you're just like, "Oh, that's probably where you got it."

Jennifer Spector, DPM:

What about biomechanically? Do you ever look at anything there, possibly assessing for repetitive microtrauma, things along those lines?

Ebonie Vincent, DPM:

I often find runners specifically have a lot of damage that they doof to their toes, especially if they have that Morton's toe, that second toe that's longer, it just gets beat up in their shoes all the time. And then you're just like, "Huh, why is this one nail just terrible looking? None of the other nails are like this." And you're like, "Well, because it's repetitively getting traumatized, first of all. And then second of all, you sweat. You are running 13 miles a day and we don't know what that does to the microtrauma of the nail, and then the sweat gets underneath it, and then boom, you got fungus." So I am talking to people about that.

I'm not just offering up a toe shortening surgery and I'm not recommending that you switch out your shoes, just be cognizant that you're probably going to have to treat your toenail and trim it in a different type of way in order for it to not perpetuate that situation. Now if that doesn't work, then we do have options on the table, but I usually let the patient guide me on what they're thinking with that one.

Jennifer Spector, DPM:

Well, absolutely. It seems really clear that diagnosing onychomycosis and having that in your differential is a really multifaceted process, and I loved what you had to say about patient education so in our next episode, we're going to make sure that we touch down on that.

Be sure to join us next time for more with Dr. Ebonie Vincent and be sure to check out past and future episodes on podiatrytoday.com, SoundCloud, Spotify, Apple Podcasts, and your favorite podcast platforms.