Onychomycosis

Diagnosis/Definition

Fungal infection of one or more nails.  Infection suggested by thickened, yellow or brown discolored friable nail plates.

Initial Diagnosis and Management

• History and physical examination.
• Differential diagnosis includes psoriasis, lichen planus, nail trauma, and median nail dystrophy.
• A positive potassium hydroxide (KOH) preparation (done in clinic) or positive culture to confirm the diagnosis.
• Entry into the patient’s Master Problem List by the provider confirming the diagnosis.

Ongoing Management and Objectives

• Primary care treatment should include continued documented education.  This counseling should state that onychomycosis is often resistant to treatment and recurrence following successful treatment is common.  If patients desire a conservative trial of therapy it should consist of not less than a 6-month trial of topical clotrimazole solution or Loprox cream bid and removal of thickened or loose nails with standard nail files or clippers.
• Patients failing the above regimen who are "foot-at-risk" due to chronic diabetes or significant vascular compromise of the legs may be referred to Dermatology or Podiatry for consideration of further oral therapy with terbinafine, itraconazole or fluconazole.  
• Patients with asymptomatic or "cosmetic" onychomycosis who are not at significant risk for amputation should be given topical therapy or no therapy at all.

Indications for Specialty Care Referral

The following may be referred to Podiatry:

• Patients who request nail removal (temporary) as augmentation to the primary care regimen.
• Patients requesting permanent nail ablation via chemical cautery.
• Patients with confirmed onychomycosis who meet "foot-at-risk" criteria (see above) can be referred to either Dermatology or Podiatry for consideration of systemic therapy.
• All Retiree's, VA and dependents with foot conditions 30, 31, 01, 02, 03, 04 etc.. Respectfully need to be routed to Schofield Barracks Podiatry or net worked out for treatment. Tripler Podiatry unfortunately does not provide orthotics or inserts for dependents, VA or Retiree's.

Criteria for Return to Primary Care

After completion of the surgical procedure or systemic therapy, patients may be managed at the primary care level.