Medical Directive. Medical Director: Date Revised: January 23, Executive Director: Date Revised: January 23, 2019

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Kenneth Rose
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1 Medical Directive Assessment and Treatment of Onychomycosis and Tinea Pedis Assigned Number: 026 Activation Date: January 1, 2019 Review due by: December 1, 2020 Approval Signature & Date Medical Director: Date Revised: January 23, 2019 Executive Director: Date Revised: January 23, 2019 Order and/or Delegated Procedure: Appendix Attached: Yes No Assessment and treatment of Onychomycosis and Tinea Pedis (See Appendix 25) Tinea Pedis: Terbinafine 1% cream apply to affected area once to twice daily until affected area resolved or for 2 weeks than reassess. Onychomycosis: Terbinafine 1% cream apply 1-2 times daily to affected nails try to rub in and around for 1 month and then 2 x week for 6 months and reassess. OR Efinaconazole 10% solution, 1 drop per affected nail daily x 4 weeks than 2 x week for 6-12 months. Recipient Patients: Appendix Attached: Yes No Appendix 2 Authorizer Approval Form All active patients of Thames Valley FHT physicians, identified on the attached Authorizer Approval Form (Appendix 2), who require assessment and treatment of Onychomycosis and Tinea Pedis Authorized Implementers: Appendix Attached: Yes No Appendix 1 Implementer Approval Form Appendix 8 Implementer Readiness Approval Form Medical Directive 026 Assessment and Treatment of Onychomycosis and Tinea Pedis Page 1

2 Thames Valley FHT Registered Nurses (RN) and Registered Practical Nurses (RPN) The implementing RN/RPN must receive orientation from the authorizing physician, with regards to the task. The RN/PRN and authorizing physician must sign the Implementer Performance Readiness Form (Appendix 8) after successful completion of the orientation. Following review of this directive, the Implementer Approval Form (Appendix 1) must be signed by the RN/RPN indicating acceptance of this medical directive. Indications: Appendix Attached: Yes No 1. Verbal consent received from the patient or a suitable decision maker for the implementing RN/RPN to assess and treat the Onychomycosis and Tinea Pedis. 2. Patient symptoms consistent with Onychomycosis and Tinea Pedis ( see Appendix 25) 3. Patients who are contraindicated for oral treatment; heart disease, liver disease, kidney disease EFR >50, medication interaction. Contraindications: 1. No verbal consent from patient or substitute decision maker for RN/RPN to implement this medical directive. 2. Patient presents with signs of bacterial infection including redness, swelling or purulent drainage around the area to be treated with antifungal 3. Patient has documented allergy to Efinaconazole (Jublia) and/or Terbinafine (Lamsil) 4. Pregnancy or breastfeeding Consent: Appendix Attached: Yes No 1. Patient of Thames Valley FHT family physicians. 2. RN/RPN obtains verbal consent from patient or substitute decision maker prior to the implementation of care Guidelines for Implementing the Order / Procedure: Appendix Attached: Yes No Appendix 25 Assessment and Treatment of Onychomycosis - Ensure to review non medication procedures for preventing reoccurrence of fungal infection inclusive of hygiene, treatment of socks and shoes, footwear assessment. - Thorough review of how and when to apply medication and when to stop and seek medication attention if any sign of infection or further skin breakdown. - If diagnosis is not clear nail scraping sample should be sent. - Advised patient to follow up if no improvement in 2-4 weeks. Documentation and Communication: Appendix Attached: Yes No 1. Documentation in patients medical record needs to include; name and number of directive and name of implementer and name of physician/authorizer responsible for the directive and patient. 2. Information on assessment and implementation of the procedure and patient response should be documented in accordance with standard documentation practice. Medical Directive 026 Assessment and Treatment of Onychomycosis and Tinea Pedis Page 2

3 Review and Quality Monitoring Guidelines: Appendix Attached: Yes No 1. The directive remains in force until and unless amendment occurs. Review will occur biennially or if the situation occur. In the case the Medical Director identifies the need to change the medical directive, at least one TVFHT member of the implementing discipline will be consulted. 2. At any such time that issues related to the use of this directive are identified, the team must act upon the concerns immediately by identifying these concerns to the Medical Director. The Medical Director will review these concerns and consult at least one TVFHT member of the implementing discipline before the necessary changes are made. 3. If new information becomes available between routine renewals, and particularly if this new information has implications for unexpected outcomes, the directive will be reviewed by the Medical Director and a minimum of one implementing RN. Approving Physician(s)/Authorizer(s): Appendix Attached: Yes No Appendix 2 Authorizer Approval Form 1. TVFHT Family Physician Authorizer Approval Form (Appendix 2). Medical Directive 026 Assessment and Treatment of Onychomycosis and Tinea Pedis Page 3

Appendix 25: Assessment and Treatment of Onychomycosis Is progressive, reoccurring and requires treatment 1 Cause: Different factors predispose a person to develop fungal infections; 1.

4 Appendix 25: Assessment and Treatment of Onychomycosis Is progressive, reoccurring and requires treatment 1 Cause: Different factors predispose a person to develop fungal infections; 1. Situational: hygiene, shoe, hyperhidrosis, communal habitat and contagion 2. Trauma and infection 3. Age, genetics PAD, DM, immunocompromised. 4 Pathogen: Dermatophytes, molds, yeast most common are: T rubrum (80%) and T mentagrophytes Types 1. Distal lateral subungal onych (DLSO) dermatophytes most common, starts lateral edge works way down thick friable crumbly nail. Fungus proliferates between nail plate and bed known as dermatophytoma. Non-dermatophyte moulds are resistant to anti fungals and may need nail removed as treatment. 2. Proximal subungal onych (PSO) molds, yeast 3. Superficial white onychomycosis(swo); trichophyton mentagrophytes 4. Total dystrophic onychomycosis (TDO) end stage infection 5. Candida onychomycosis (CO) patients with wet occupations or yeast infections with Reynaud s or psoriatic nails colonized by yeast 4 Signs and symptoms: yellow discolouring and thickening of nail Tinea pedia usually always establishes in web of 4-5 th toe, can be itchy burning Moccasin tinea pedia affects soles and sides of foot dry type dermatitis with scaling, vesicopustular reaction can occur on soles. 4 Diagnosis: KOH test: label (site) black paper and envelope and requisition. Use regular Dynacare req. Get scrapping from nail bed vs. plate, skin scraping from lesion 4 KOH least expensive and proof of diagnosis decrease overall cost 5 Differentials Bacterial infections look for erythema, heat, discharge acute onset

5 Eczema history of and not improving with fungal treatment Psoriasis Keratosis Palmaris et plantaris (PPK): lesions on hands and soles not in nails Dermatitis better to treat antifungal and if not better than treat with steroid because steroid will make fungal much worse 4 Treatment: debridement, prevention of re-infection Note Mycological (MC) vs. complete cure (CC) is rare 100% goal is remission 3,4 If patient has no history of heart, liver, kidney disease (CRCL <50) refer to GP for Oral Terbinafine, they must have confirmed diagnosis with lab so send sample 4 Oral Terbinafine has 70% MC and 38% CC. 3 Tinea Pedis (Athletes Foot) all patients with Onychomycosis have or have had tinea pedis at one point, you need to treat both 1 Terbinafine 1% cream apply to affected area once to two twice daily until affected area resolved or for 2 weeks than reassess. Onychomycosis. Terbinafine 1% cream apply 1-2 times daily to affected nails try to rub in and around nail bed for 1 month and then 2 x week for 6 months and reassess. Efinaconazole (Jublia) 53 % MC and % CC Apply 1 drop per affected nail once daily x 4 weeks than maintenance dose 2 x week for 6-12 months. 2 References 1. Warren, Joseph PRM FIDSA et el 2013 Onychomycosis and the Role of Topical Antifungals. Supplement to Podiatry Today Nov Cochrane Review 2012 Oct. Creams, lotions and gels for fungal infections of the skin and nails of the foot. Accessed 2015; -gels-topicals-treatments. 3. Cochran Review July 2012 Oral treatments for fungal infections for nail and foot. accessed April treating atheletes-foot. 4. Frowen O, O Donnell, M, Lorimer, D, Burrow G. (2010) Neale s Disorders of the Foot Churchill Livingston.

6 5. Aditya K. Gupta, Sarah G. Versteeg, Neil H. Shear. First Published September 27, Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective 2017 ResearchArticle

Onychomycosis (fungal nails) Patient Information: Fungal Infection The fungal infection starts with white or yellow spots, the infection than goes deeper into nail.

7 Onychomycosis (fungal nails) Patient Information: Fungal Infection The fungal infection starts with white or yellow spots, the infection than goes deeper into nail. The nail will discolor, thicken and separate from nail plate and start to crumble. Tinea Pedis (fungal/athletes foot) The fungal infection starts with white peeling skin usually in between toes, 4 th and 5 th web. It can also have red scaly patches on sides of foot moccasin pattern. There are many reasons why you may have developed this infection; exposure, immunity, genetic, trauma. Treatment Wash and dry feet well, apply cream to feet daily for 4 weeks and review. If treating nails with Efinaconazole (Jublia) use applicator to apply 1 drop and then spread thin layer on all over nail and under nail. Wait 10 min after shower, treatment can last 6-12 months for nail to grow out. Notify your doctor if any burning, blistering, swelling or oozing at the application site. Complete cure is when the nail looks 100% normal, mycological cure is the fungus is gone. Most of the time we talk about remission of infection! Re-infection prevention Wash and dry feet everyday especially between toes Avoid bare feet Wear well ventilated shoes Clean Dry socks and shoes everyday Reduce perspiration with powder in shoes

Classification. Distal & Lateral Subungual OM. White Superficial OM. Proximal Subungual OM. Candidal OM. Total dystrophic OM

Classification. Distal & Lateral Subungual OM. White Superficial OM. Proximal Subungual OM. Candidal OM. Total dystrophic OM Onychomycosis Commonest dermatological condition Definition: Infection of the nail caused by fungi that include dermatophytes, non-dermatophyte moulds and yeasts (mainly Candida). 80% of all OM affects