ONYCHOMYCOSIS LET S HELP OUR PATIENTS ELIMINATE IT

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Solomon Phelps
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1 ONYCHOMYCOSIS LET S HELP OUR PATIENTS ELIMINATE IT

2 WHY AM I STANDING IN FRONT OF YOU TODAY? TO PRESENT MY PROTOCOL ON HOW I HELP MY PATIENTS CURE THEIR ONYCHOMYCOSIS Erin King Registered Practical Nurse/Podortho Nurse

MOST COMMON DISEASE OF THE NAILS AND CONSTITUTES ABOUT HALF OF ALL NAIL ABNORMALITIES 1 AFFECTS TOENAILS AND OR FINGERNAILS ONYCHOMYCOSIS TOENAIL INFECTIONS ARE PARTICULARLY COMMON OCCURRING IN ABOUT

3 MOST COMMON DISEASE OF THE NAILS AND CONSTITUTES ABOUT HALF OF ALL NAIL ABNORMALITIES 1 AFFECTS TOENAILS AND OR FINGERNAILS ONYCHOMYCOSIS TOENAIL INFECTIONS ARE PARTICULARLY COMMON OCCURRING IN ABOUT 10% OF THE ADULT POPULATION 2 A RECENT STUDY INDICATES THAT ONYCHOMYCOSIS IS THE SINGLE MOST DIFFICULT PROBLEM FOR PODIATRIC AND DERMATOLOGICAL PHYSICIANS TO DIAGNOSE AND TREAT. 1 SZEPIETOWSKI JC, SALOMON J (2007). "DO FUNGI PLAY A ROLE IN PSORIATIC NAILS?". MYCOSES 50 (6): WESTERBERG, DP; VOYACK, MJ (2013 DEC 1). "ONYCHOMYCOSIS: CURRENT TRENDS IN DIAGNOSIS AND TREATMENT.". AMERICAN FAMILY PHYSICIAN 88 (11):

4 AFFECTS ON PATIENT Pain Mobility Limitations (difficulty walking) Footwear Limitations Psychosocial/Cosmetic Nuisance Cross Contamination Skin Infections (Tinea Pedis) Ingrown Nails/Wounds

NAIL GROWTH IS CONTINUOUS THROUGHOUT LIFE APPROXIMATELY 0.5-1.

5 NAIL GROWTH IS CONTINUOUS THROUGHOUT LIFE APPROXIMATELY MM/WEEK NAIL THE LONGER GROWTH THE DEVELOPMENT FINGER OR TOE, THE MORE RAPID THE GROWTH TOENAILS GROW AT 33%-50% THE RATE OF FINGERNAILS REGENERATION OF A FINGERNAIL AFTER AVULSION IS 160 DAYS (4 MONTHS, WEEKS) 40 DAYS TO EMERGE FROM THE NAIL FOLD AND ANOTHER 120 DAYS FOR GROWTH TO THE FINGERTIPS TOENAILS TAKE BETWEEN MONTHS TO COMPLETELY GROW OUT

6 WHY SHOULD TOENAILS REMAIN INTACT AND BE HEALTHY? PROTECTS DISTAL PHALANX FROM TRAUMA HELPS IN PICKING UP SMALL OBJECTS AIDS IN THE APPRECIATION OF FINE TOUCH USED FOR SCRATCHING AESTHETIC ORGAN PROVIDES STRUCTURAL INTEGRITY TO THE DISTAL END OF TOE

7 WHEN YOU ARE TREATING A PATIENT WITH YELLOW, THICKENED DYSTROPHIC NAILS WHAT DO YOU DO? Are you a fungus undertaker?

8 MR. C: TX#1 JULY 31, 2018 AGE : 53 GENDER : MALE MEDICATION : NONE COMORBIDITIES : PSORIASIS, IBS ALLERGIES : NONE PREVIOUS TREATMENT : NONE

9 MR. C: TX#4 SEPTEMBER 6, WEEKS LATER NAIL DEBRIDEMENT LASER THERAPY HOME CARE REGIMENT PATIENT USING JUBLIA (EFINACONAZOLE)

10 MR. P: TX#1 NOVEMBER 4 TH, 2017 AGE : 43 GENDER : MALE MEDICATION : NONE COMORBIDITIES : HYPERTENSION, COLITIS ALLERGIES : PENICILLIN PREVIOUS TREATMENT : NONE

11 MR. P: TX#5 SEPTEMBER 17 TH 2018 (10 MONTHS LATER) NAIL DEBRIDEMENT LASER THERAPY HOME CARE REGIMENT PATIENT USING JUBLIA (EFINACONAZOLE) SOMETIMES FORGETS HOME CARE REGIMENT

MS. O AUGUST 22ND 2018 AGE: 65 GENDER: FEMALE ALLERGIES: NONE MEDICATIONS: ATORVASTATIN CALCIUM, BEZAFIBRATE, CLOPIDOGREL BISULFATE, DOMPERIDONE, DULOXETINE, FUROSEMIDE, LEVOTHYROXINE, METFORMIN,

12 MS. O AUGUST 22ND 2018 AGE: 65 GENDER: FEMALE ALLERGIES: NONE MEDICATIONS: ATORVASTATIN CALCIUM, BEZAFIBRATE, CLOPIDOGREL BISULFATE, DOMPERIDONE, DULOXETINE, FUROSEMIDE, LEVOTHYROXINE, METFORMIN, METOPROLOL, POTASSIUM, LANTUS, HUMALOG, RAMIPRIL, PANTOPRAZOLE, CEPHALEXIN. COMORBIDITIES: DIABETES, ARTERIAL DISEASE PREVIOUS TX: HOME CARE WET DRESSINGS TX: IRRIGATION, DEBRIDEMENT, LUNULA LASER 2X/WK, IODINE, SEA SORB AG DRESSING

13 MS. O AUGUST 22ND, 2018 FOLLOWING DEBRIDEMENT

14 MS. O SEPTEMBER 23RD, 2018 (1 MONTH LATER)

15 SO HOW DID WE DO IT?

16 TREATMENT OPTIONS Home remedies Topical preparations Systemic medications Surgery Laser therapy

ONTARIO PODORTHO NURSING ASSOCIATION PROTOCOL NURSING ASSESSMENT-GATHERING SUBJECTIVE AND OBJECTIVE DATA PREFORM SKIN AND NAIL INSPECTION DETERMINE WHETHER

PATIENT GOALS CURE MAINTENANCE UNDERSTAND THE PATIENTS EXPECTATIONS- DO THEY EXPECT THIS TO BE CURED IN A WEEK? CAN YOU DELIVER?

17 ONTARIO PODORTHO NURSING ASSOCIATION PROTOCOL NURSING ASSESSMENT-GATHERING SUBJECTIVE AND OBJECTIVE DATA PREFORM SKIN AND NAIL INSPECTION DETERMINE WHETHER THE PATIENT RECEIVED A FORMAL DIAGNOSIS FROM EITHER THERE PHYSICIAN OR PODIATRIST IDENTIFY PAST TREATMENTS AND EFFICACY DISCUSS TREATMENT OPTIONS AND PATIENT GOALS CURE MAINTENANCE UNDERSTAND THE PATIENTS EXPECTATIONS- DO THEY EXPECT THIS TO BE CURED IN A WEEK? CAN YOU DELIVER? HELP PATIENT SET A REALISTIC GOAL CLEANSE AND DEBRIDE MYCOTIC/INFECTED NAIL(S) DELIVER LASER THERAPY TREATMENTS PROVIDE PATIENT EDUCATION ON HOME CARE REGIMENT WITH CLEAR WRITTEN INSTRUCTIONS

18 ANTI-FUNGAL KIT ANTI FUNGAL FOOT FOAM ANTI FUNGAL NAIL SPRAY BIOSEN SOCK DETERGENT LUNULA LASER BROCHURE ALLPRESAN BROCHURE PRESCRIPTION FOR JUBLIA INSTRUCTION SHEET

HOME CARE INSTRUCTIONS 1. BIOSEN ULTRASONIC CLEANSER-TO BE USED AS DETERGENT FOR HOSIERY IN WASHING MACHINE WEEKLY 2. ANTI-FUNGAL FOAM FOR FEET (TOLNAFTATE) 3. ANTI-FUNGAL NAIL SPRAY (CLOTRIMAZOLE) 4.

19 HOME CARE INSTRUCTIONS 1. BIOSEN ULTRASONIC CLEANSER-TO BE USED AS DETERGENT FOR HOSIERY IN WASHING MACHINE WEEKLY 2. ANTI-FUNGAL FOAM FOR FEET (TOLNAFTATE) 3. ANTI-FUNGAL NAIL SPRAY (CLOTRIMAZOLE) 4. SHOES IN FREEZER FOR 48 HOURS 5. PRESCRIPTION FOR TOPICAL EFINACONAZOLE WITH INSTRUCTIONS FOR USE OF PRODUCT 6. EXPLANATION OF THE LASER AND WHAT YOUR PATIENT CAN EXPECT 7. EXPECTATIONS CLINIC HAS FOR THE PATIENT AND TO SET A COMMITMENT TO CARE

onychomycosis are now entering a new era when considering treatment options topical modalities are

20 IS POLYTHERAPY/COMBINATION THERAPY THE SOLUTION? According to the journal of Fungi Dermatologists, Podiatrists, and other clinicians who treat onychomycosis are now entering a new era when considering treatment options topical modalities are proving more effective than those of the past. Topical therapies once thought to be ineffective have now been proven more effective and safe in multiple clinical trials.

TOPICAL ANTIFUNGALS, LASERS AND LIGHT SYSTEMS ARE RELATIVELY NON-INVASIVE TREATMENTS ON THE FOREFRONT AND FULFILLING A CRITICAL NEED TOPICAL/ PRESCRIPTION FACTS ROUTE ENTRY INTO THE NAIL BED PLAYS A

21 TOPICAL ANTIFUNGALS, LASERS AND LIGHT SYSTEMS ARE RELATIVELY NON-INVASIVE TREATMENTS ON THE FOREFRONT AND FULFILLING A CRITICAL NEED TOPICAL/ PRESCRIPTION FACTS ROUTE ENTRY INTO THE NAIL BED PLAYS A VITAL ROLE IN DETERMINING THE EFFICACY OF THE DRUG POOR NAIL PENETRATION WILL LIMIT IT S EFFECTIVENESS CHARACTERISTICS IN SOLUTIONS THAT INCREASE NAIL PENETRATION ARE VISCOUS FLUIDS WITH LOW SURFACE TENSION AGENTS THAT PENETRATE VIA THE TRANSLINGUAL ROUTE THROUGH THE SPACE BETWEEN THE NAIL BED AND PLATE ARE OPTIMAL.

22 TOPICAL MEDICATIONS OPTIONS AS ADJUNCTIVE TREATMENT RESEARCH STUDIES FROM SUGGEST THE FOLLOWING (7) CICLOPIROX (PENLAC, LOPROX, CICLODAN) LACQUER BASE WITH POOR NAIL PENETRATION IN STUDIES RESERVED FOR MILD CASES DEPENDANT UPON DAILY DEBRIDEMENT MYCOLOGICAL CURE RATES ARE 29%-54.3% COMPLETE CURE RATES RANGE FROM 5.5%-8.5% EFINACONAZOLE (JUBLIA, CLENAFIN) BROAD SPECTRUM OF ACTIVITY AGAINST NON- DERMATOPHYTES AND YEASTS (T. RUBRUM, T. MENTAGROPHYTES, C. ALBICANS) VEHICLE (FLUORESCEIN) CAN REACH SUBUNGUAL SPACES NAIL POLISH DOES NOT APPEAR TO EFFECT THE PERMEATION GIVING PATIENTS OPTIONS FOR COSMETIC CONCEALMENT (7) DOUBLE BLINDED CT OVER 52 WEEKS WITH 1655 PARTICIPANTS SUGGESTED A 56% MYCOLOGICAL CURE RATE (7)

23 TOPICAL MEDICATIONS OPTIONS AS ADJUNCTIVE TREATMENT RESEARCH STUDIES SUGGEST THE FOLLOWING TAVABOROLE (KERYDIN) NEWER CLASS OF ANTIFUNGALS PROTEIN SYNTHESIS INHIBITOR (EXHIBIT ANTIFUNGAL PROPERTIES) 48 WEEK RANDOMIZED CT NEGATIVE MYCOLOGY WAS FOUND IN 31.1%-35.9% TAVABOROLE WAS FOUND TO PENETRATE THE NAIL PLATE 250 TIMES GREATER THAN CICLOPIROX (3)

24 LUNULA LASER #1 LUNULA LASER #2 (2 ND WEEK) LUNULA LASER #3 (3 RD WEEK) DEBRIDE & LUNULA LASER #4 (4 TH WEEK) LASER PROTOCOL FOLLOW UP AT 24 WEEKS (INSPECT APPEARANCE OF RE-GROWTH) POSSIBLE LASER 5,6,7,8 RE-EVALUATE AT 12 MONTHS

25 WHAT IS THE LUNULA COLD LASER? CLASS 2 LOW LEVEL LASER THERAPY DUAL DIODE, ROTATING COLLIMATED, MONOCHROMATIC, COHERENT BEAM 405NM VIOLET BEAM 635NM RED BEAM INTENSITY: MW PER DIODE DOSAGE: ~0.95 J/CM2 PER DIODE

26 LUNULA MECHANISM 405nm Damages fungus weakening immune defense 635nm Improves immune response. Increases circulation enhancing immune system attack Fungus is destroyed and the nail clears!

27 START WITH STANDARD 4 X TWELVE MINUTE TREATMENTS TREATMENT WITH LUNULA PATIENTS SIMPLY INSERT FOOT CLINICIAN ACTIVATES THE DEVICE BY PRESSING START BUTTON PROVIDES A PATIENT WITH A COMFORTABLE, UNMANNED TREATMENT

28 WHAT CAN THE LUNULA BE USED FOR? ONYCHOMYCOSIS DAMAGED NAILS PSORIATIC NAILS SLOW GROWING NAILS TINEA PEDIS WOUND HEALING IMPROVING CIRCULATION COMPLICATIONS OF DIABETES POTENTIALLY MUCH MORE

29 ADDITIONAL BENEFITS OF LUNULA DUE TO THE INCREASE IN BLOOD SUPPLY THE LUNULA MAY ALSO; IMPROVE CIRCULATION IN THE EXTREMITIES TREATS THE ENTIRE FOOT INCLUDING SKIN AND NAILS INCREASE RATE OF NAIL GROWTH ASSIST WITH WOUND HEALING REGENERATES DAMAGED NAILS

30 HOT VS COLD Hot (Thermal) Cold (Non-thermal) Uses heat to destroy fungal spores Uses photochemistry to destroy fungal spores One nail at a time All nails on the foot at the same time Treatment takes 30 minutes per foot Treatment cycle is 12 minutes per foot Uncomfortable, often painful No pain or discomfort felt Hands on practitioner Hands free practitioner Can cause burning of tissue, need to wear glasses No known side effects One positive effect (specific to Onycho) Has several positive effects due to increase in blood flow

KATRINA WALLER-PODIATRIST-UNITED KINGDOM BOUGHT LUNULA IN 2014 TOOK CULTURES TO TEST FOR MYCOLOGY BEFORE AND AFTER TREATMENTS POST TREATMENT

31 KATRINA WALLER-PODIATRIST-UNITED KINGDOM BOUGHT LUNULA IN 2014 TOOK CULTURES TO TEST FOR MYCOLOGY BEFORE AND AFTER TREATMENTS POST TREATMENT CULTURES SHOWED NEGATIVE THOUGHT SHE HAD A FAULTY BATCH OF CULTURES UNTIL ONE CAME BACK POSITIVE PURCHASED A SECOND UNIT AND OPENED A NEW CLINIC

CLINIC FEE S 1 ST VISIT INCLUDES INITIAL CONSULTATION AND ASSESSMENT $80.00 1 ST LUNULA LASER SESSION WITH NAIL DEBRIDEMENT AND HOME CARE KIT $330.

00 3 RD LUNULA LASER (DEBRIDEMENT NOT NECESSARY CAN BE PERFORMED BY ASSISTANT) $160.00 4 TH LUNULA LASER (DEBRIDEMENT AND PRACTITIONER ASSESSMENT) $125.

32 CLINIC FEE S 1 ST VISIT INCLUDES INITIAL CONSULTATION AND ASSESSMENT $ ST LUNULA LASER SESSION WITH NAIL DEBRIDEMENT AND HOME CARE KIT $ (VALUE OF KIT IS APPROX. $80.00 RETAIL AND MUST BE REPLACED EACH MONTH) 2 ND LUNULA LASER (DEBRIDEMENT NOT NECESSARY CAN BE PERFORMED BY ASSISTANT) $ RD LUNULA LASER (DEBRIDEMENT NOT NECESSARY CAN BE PERFORMED BY ASSISTANT) $ TH LUNULA LASER (DEBRIDEMENT AND PRACTITIONER ASSESSMENT) $ WEEK MARK 5 TH LUNULA LASER (POSSIBLE DEBRIDEMENT) $ INITIAL PROTOCOL REVENUE = $ /PATIENT PLUS $100 FOR EACH ADDITIONAL LASER TREATMENT THERE AFTER AND REPLACEMENT OF HOME CARE PRODUCTS

33 WHEN YOUR PATIENT HAS COMPLETED YOUR PROTOCOL DO YOU STOP TREATING THIS PATIENT ALL TOGETHER? IN A STUDY CONDUCTED BY; JENNA N. QUELLER AND NEAL BHATIA PUBLISHED IN THE JOURNAL OF FUNGI AUGUST 19 TH, 2015 CONCLUDED THAT IN ORDER TO TREAT THE ENTIRE DISEASE THE PRACTITIONER MUST OPTIMIZE TOPICAL AGENTS AS SUSTAINED THERAPY AFTER INITIAL CLEARANCE TO REDUCE RE-OCCURRENCE OR RE-INFECTION

34 REFERENCES 1. MICHALIK M, ORWICK-RYDMARK M, HABECK M, ALVA V, ARNOLD T, LINKE D (2017) AN EVOLUTIONARILY CONSERVED GLYCINE- TYROSINE MOTIF FORMS A FOLDING CORE IN OUTER MEMBRANE PROTEINS. PLOS ONE 12(8): E MARTIN, E. (ED.) A DICTIONARY OF NURSING (5 TH ED). OXFORD: OXFORD UNIVERSITY PRESS. 3. MENZ, H. (2008). FOOT PROBLEMS IN OLDER PEOPLE. MALVERN. PHILADELPHIA, PA: ELSEVIER S HEALTH SCIENCES RIGHTS DEPARTMENT. 4. BY R. S. W. THORKE, PH.D. (JOURN., 1944, 186), YEAST GROWTH INHIBITIVE EFFECT EXHIBITED BY TYROSINE AND GLYCINE. INSTITUTE OF BREWING RESEARCH LABORATORIES, UNIVERSITY OF BIRMINGHAM. 5. PIRACCINI BM. NAIL DISORDERS DUE TO DERMATOLOGICAL DISEASES. IN: NAIL DISORDERS: A PRACTICAL GUIDE TO DIAGNOSIS AND MANAGEMENT. BOLOGNA, ITALY: SPRINGER-VERLAG ITALIA; 2014: MAYO CLINIC STAFF. NAIL FUNGUS. MAYO CLINIC WEBSITE. JULY 26, ACCESSED OCTOBER 2, BONIFAZ ET AL., 2007; GIANNI AND ROMANO, 2004; GUPTA ET AL., 2007; HILMIOĞLU-POLAT ET AL., 2005; ROMANO ET AL., 2005). ABOUT 10 MILLION CASES OF ONYCHOMYCOSIS ARE ATTRIBUTABLE TO ASPERGILLUS SPECIES. 7. QUELLER, J. N., BHATIA, N. (2015). THE DERMATOLOGIST S APPROACH TO ONYCHOMYCOSIS. JOURNAL OF FUNGI 2015./ ;DOI: /JOF

35 MORE DETAILS/ASSISTANCE ON THE IMPLEMENTATION OF MY PROTOCOL CONTACT ERIN KING REG. PRACTICAL NURSE/POD. NURSE

36 Lunula Laser Serge Magne-tec

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