At Arya Foot & Ankle, our commitment is to provide you with the safest and most effective care. We understand that navigating treatment options for nail fungus can be complex, and we want to explain our approach to oral antifungals.
Recently, a patient expressed concern when immediate oral anti-fungal treatment for suspected nail fungus wasn't provided after looking at the nail. An oral anti-fungal medication protocol requires culture and lab work. This is crucial for two reasons:
Accurate Diagnosis: A culture confirms the presence of fungus and identifies the specific type, ensuring we prescribe the most effective medication.
Patient Safety: Oral anti-fungal medications can impact liver function. Lab work allows us to monitor your liver health throughout treatment, prioritizing your safety.
We recognize that laboratory tests incur additional costs with the lab itself, and we understand this can be a concern. However, these tests are essential to avoid prescribing unnecessary medication or causing potential harm. While we understand the desire for a quick fix that allows for polished nails without testing, a safe and effective solution of that nature, particularly with oral medication, requires these diagnostic steps.
Our priority is always your long-term health and well-being, and our protocols are designed to achieve the best possible outcomes safely and accurately.
This experience prompted me to write this blog post as an acknowledgement: Yes, it's true, we don't have a perfectly safe oral option for nail fungus that can be prescribed without first confirming the infection with a culture and regularly monitoring your liver enzymes. The reason for these steps is precisely because we are doing our best to keep patients safe and ensure the treatment actually works. Simply prescribing oral medication with systemic side effects, based on how a nail looks isn't responsible care with the data we have related to liver toxicity with use of oral anti-fungals So, let's talk about why these "extra steps" are so important and ultimately protect health.
When an abnormal nail presents, it's natural to assume it's fungus. However, up to half of all abnormal nails are not caused by fungus at all [3]. Conditions like trauma, psoriasis, eczema, or even bacterial infections can mimic fungal nails [5]. Prescribing powerful oral antifungal medications without confirming a fungal infection exposes patients to unnecessary risks and costs, with no potential benefit.
A culture helps identify the specific type of fungus causing the infection [5]. This is crucial because different fungi respond to different medications. For example, while terbinafine (Lamisil) is excellent for the most common type of nail fungus (dermatophytes), it's less effective against yeast infections, which might require a different drug [5]. Without a culture, treatment would be based on guesswork, potentially leading to wasted time, money, and prolonged frustration because the treatment simply isn't working. This is why leading medical organizations consistently recommend lab confirmation before starting oral antifungal therapy [2, 5].
Oral antifungal medications, like terbinafine, are processed by the liver. They carry a known, albeit rare, risk of liver toxicity, which can range from minor enzyme elevations to severe liver failure [4, 6]. While severe cases are very rare, even small increases in liver enzymes can occur, sometimes requiring the medication to be stopped [1, 6].
To minimize this risk, it's standard best practice to get baseline liver function tests (AST and ALT) before starting any oral antifungal medication [1, 3, 6]. If treatment continues, these levels are typically monitored again after about 4-6 weeks [1, 6]. This helps ensure the liver is healthy enough to start the medication and allows for early detection of any issues, preventing more serious complications. Patient safety is always a top priority.
It's understood that the requirements for oral medication can feel inconvenient, which is why alternative options like topical antifungals or laser therapy are always discussed.
Topical treatments can be very effective if the patient understands how to use the product, but they do have their limitations. We carry a high quality, great topical option for patients in the office, however it’s not as easy as taking a pill every day. Nails typically need to remain unpolished during use, and the product usually requires application once or twice daily, every day. These treatments are also generally not billable to insurance. They often require longer treatment times (sometimes up to a year) and consistent application. As noted, they can't effectively penetrate the nail if polish is being worn [7]. A benefit of topicals is that alcohol consumption is not a concern regarding liver clearance. Oral medications, however, do require caution with alcohol consumption during treatment, which is another consideration for many patients. For those considering laser therapy for toenail fungus, we advise you to be aware that outcomes can differ, and you'll typically be responsible for the cost, as it's often not covered by insurance.
At Arya Foot & Ankle, our ultimate commitment is to provide the safest and most effective care possible. We believe in a comprehensive approach because, while it might involve a bit more upfront work, it truly ensures you receive the most correct and responsible treatment. Your foot health is our priority, and we're dedicated to helping you get back on your feet comfortably and confidently. For consultation, schedule an appointment with us via phone call at (602) 309-8788 or scheduling online at www.aryafootandankle.com.
