Podiatry - Onychomycosis
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Fungal infection of one or more nails.
Infection suggested by thickened, yellow or brown discolored friable nail
Initial Diagnosis and Management
- History and physical
- 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
- 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
- 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 dependants with foot conditions 30, 31, 01, 02,
03, 04 etc.. Respectfully need to be routed to Scholfied Barracks Podiatry or net worked out for
treatment. Tripler Podiatry unfortunately does not provide orthotics or inserts for dependants, VA or
Criteria for Return to Primary Care
After completion of the surgical procedure
or systemic therapy, patients may be managed at the primary care level.