Nail Fungus (Onychomycosis) Management: Topical and Oral Antifungals (Nursing)

00:00 Now, let's look at a particularly challenging fungal infection, onychomycosis or nail fungus.

00:07 Now, nail fungus presents special challenges.

00:10 Think about it.

00:11 Why would nail infections be harder to treat than skin infections? Exactly.

00:15 The nail plate is dense, it has poor blood supply, and it grows very slowly.

00:21 Only about 0.1 millimeter per day for fingernails and even slower for toenails.

00:27 So what does that mean? Well, medications have difficulty penetrating the infection site.

00:32 The nail provides a protected environment for fungal growth and complete treatment requires the growth of an entirely new nail.

00:40 Now, let's discuss four specialized topical treatments for nail fungus.

00:44 Now I'm going to warn you ahead of time, they have limited effectiveness.

00:49 The first one is efinaconazole.

00:51 Now this is a newer triazole antifungal.

00:54 It does have better nail penetration than the older agents, but studies still show just a complete cure rate of about 15 to 18 percent.

01:02 The second one is amorphine.

01:04 Now, this is a morpholine derivative, and it's applied as a nail lacquer with complete cure rates of about 12 to 15 percent.

01:12 Tavaparil is a novel boron-based medication that works by inhibiting an enzyme fungi need for protein synthesis.

01:19 Its complete cure rate is about 6 to 9 percent.

01:23 And number four, cyclopyrex.

01:25 Now this is applied as a nail lacquer and requires regular nail filing and weekly removal.

01:31 Complete cure rates here range from 5 to 8 percent.

01:34 So what kind of patient education would be important when these medications are prescribed, these topical nail treatments? Well, you want to make sure they understand treatment is going to take months, and they're not going to see a big difference in days or weeks.

01:49 The client will need to apply the medication exactly as directed.

01:52 They're also going to have to continue the treatment until a healthy nail grows in completely.

01:58 So, success rates are relatively low with these topicals.

02:01 It's usually 5 to 18 percent.

02:03 So make sure the client has realistic expectations.

02:07 Now, let's look at oral treatments for nail fungus.

02:10 For more severe nail infections, we often turn to oral treatments.

02:14 Turbinafine is generally the most effective for demodified nail infections.

02:19 Turbinafine typically lasts six weeks for fingernails and 12 weeks for toenails.

02:23 Complete cure rates are much higher than the topicals that ranges from 35 to 50 percent.

02:29 Iotronicazole is a broad-spectrum triazole.

02:32 Now this can be used as pulse therapy, one week of treatment per month for several months, and complete cure rates are approximately 25 to 40 percent.

02:41 Now it's important that you understand the tradeoffs between topical and oral treatments.

02:45 As far as efficacy, oral treatments have significantly higher cure rates, like 25 to 50 percent, versus 5 to 18 percent for topical.

02:54 But when it comes to safety, topical treatments have fewer systemic effects.

02:59 And monitoring, oral treatments require laboratory monitoring.

03:03 The duration, topical treatments must be used for longer, usually 9 to 12 months, versus 6 to 12 weeks for oral.

03:10 In regards to patient selection, topical treatments are ideal for mild cases or patients with contraindications to oral therapy, while oral treatments are better for moderate to severe infections.

03:21 Last, you're going to think about the cost.

03:24 Topical treatments often have higher out-of-pocket costs compared to oral options, and that may influence the treatment selection for certain patients.

03:32 Now I'm going to ask you a question.

03:33 Think about what we have discussed so far.

03:36 What safety monitoring do you think should be implemented for a patient who is starting oral antifungal therapy? See what you can recall.

03:45 Well, you're going to need baseline liver function tests and periodic monitoring throughout the treatment.

03:53 And this is a perfect segue to our next section.