1medscape llc, new york, new york, usa; 3: 2temple university...

Nailing the Clinical Challenges in Onychomycosis Management Jovana Lubarda, PhD1; Piyali Chatterjee1; Tracey Vlahovic, DPM2

1Medscape LLC, New York, New York, USA; 2Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania, USA

References

Scan here to view this poster online.

1. Leelavathi M, Noorlailiy MN. Onychomycosis nailed. Malays Fam Physician. 2014;9(1):2-7.

2. Ayanlowo O, Oladele RO. Onychomycosis: updates and management challenges. A review. Niger Postgrad Med J. 2014;21(2):185-91.

3. Vlahovic TC. Diagnosis and treatment of onychomycosis: assess your skills. Medscape Education Dermatology. September 24, 2014. http://www.medscape.org/viewarticle/830960. Accessed May 22, 2015.

Study Objectives

Onychomycosis may affect as much as 10% of the general population in the United States, and up to 48% of persons aged over 70.1 Further, onychomycosis is a major public health concern due to its impact on health and quality of life (QOL).2 Yet, despite its widespread and increasing prevalence, and improvements in diagnosis and available treatments, onychomycosis often remains overlooked and/or undertreated. Although clinicians demonstrate basic knowledge about onychomycosis, the specifi c gaps that contribute to suboptimal patient outcomes are not clear. This study was designed to identify the specifi c clinical practice gaps and barriers contributing to suboptimal care in onychomycosis to inform clinicians about their performance and future educational needs in this area.3

The following were fi ndings on clinical gaps in onychomycosis management for PCPs (n=546) and dermatologists (n=530) who responded to the clinical practice assessment during the study period:

• When participants were asked which specialty manages onychomycosis, the majority of PCPs selected primary care (72%), with the next highest specialties being podiatry (12%), and dermatology (12%). Interestingly, dermatologists selected dermatology (46%), followed by primary care (32%), and podiatry (20%).

• Physician performance on case-based challenges were the following:

• Only 59% of PCPs but 80% of dermatologists identifi ed correct diagnostic tests, such as taking nail samples and ordering a KOH test and fungal culture to confi rm the diagnosis and causative organism (FIGURE 1).

• 72% of PCPs and 82% of dermatologists correctly prescribed topical antifungal therapy for mild-to-moderate disease (FIGURE 1).

• 51% of PCPs and 46% of dermatologists understood that factors such as mobility, diabetes, and degree of clinical involvement of diabetes are important when considering topical therapy in a patient (FIGURE 2).

• Only 39% of PCPs and 61% of dermatologists understood that itraconazole in contraindicated in patients treated for cardiac arrhythmia or those with evidence of ventricular dysfunction (FIGURE 2).

• Physician performance on understanding of key onychomycosis concepts were the following (FIGURE 3):

• Less than 50% of PCPs understood the relationship of onychomycosis to tinea pedis and psoriasis.

• An average of 30% PCPs and 48% of dermatologists correctly identifi ed FDA-approved topical and systemic therapies for onychomycosis.

• Less than a quarter of all participants identifi ed the pain-reducing benefi ts of mechanical debridement.

• There was lack of knowledge of onychomycosis clinical trial parameters; an average of 45% of PCPs and 59% of dermatologists successfully defi ned complete versus mycological cure.

• 30% of PCPs and 41% of dermatologists understood the link between untreated onychomycosis and severe consequences (ie. permanent nail damage and pain and infl ammation).

• Treatment duration, disease knowledge, and diagnostic procedures were identifi ed as the greatest clinical barriers towards optimizing care of onychomycosis.

Conclusion An objective online survey, such as the clinical practice assessment conducted herein, is a critical step in determining the current knowledge, skills, attitudes, competence, and barriers of physicians treating onychomycosis. This survey uncovered specifi c clinical practice gaps and barriers in onychomycosis; these included knowledge on effects of onychomycosis on QOL, diagnostic procedures, clinical trial data and defi nitions of complete versus mycological cure, and appropriately tailoring therapies to specifi c patient cases. Based on the gaps identifi ed for PCPs and dermatologists in managing onychomycosis, it is also anticipated that these gaps exist for other specialties including podiatrists and nurses. Hence, future education should be targeted to improve clinical effectiveness amongst various specialists managing onychomycosis.

Methods• A 25-question clinical practice assessment survey

in multiple-choice and case-based format was administered to provide a baseline “snapshot” of knowledge, skills, attitudes, or competence on the pathophysiology, diagnosis, and management of onychomycosis.

• The survey was administered online, through Medscape Education, and data were obtained for 546 primary care physicians (PCPs) and 530 dermatologists.3

• Upon completion of the clinical practice assessment survey, participants were expected to review the epidemiology, pathophysiology, treatment, and management of onychomycosis and be able to assess barriers to early diagnosis and management of onychomycosis.

• The survey launched on Medscape Education (http://www.medscape.org/viewarticle/830960) on 9/24/14 and data were collected for 103 days.

PATIENT CASE CHALLENGE 1: A 53-year-old woman presents with yellowing and brittleness of 2 of her toenails. She is otherwise healthy and does not feel any pain in her nails. You suspect onychomycosis.

FIGURE 1: Diagnostic test selection and therapeutic choices in an onychomycosis patient case: competence of dermatologists (n=530) and PCPs (n=546)

PATIENT CASE CHALLENGE 2: A 73-year-old man with type 2 diabetes visits

your office for a foot examination as part of his diabetes management plan. His

body mass index is 34.6 kg/m2. He has poor mobility because of his weight and

leg edema. He shows signs of neuropathy affecting his feet. After examining his

feet, you suspect that he has onychomycosis. You confirm this diagnosis with a

KOH test and fungal culture. His nails have greater than 50% involvement.

0%

10%

20%

30%

40%

50%

60%

The patient's poor mobility

The fact that the patient has diabetes

The degree of clinical

involvement of patient's toenails

The patient's sex

Primary Care Physicians (n = 530) Dermatologists (n=530)

15% 21%

15%

49%

12% 18%

13%

56%

0%

20%

40%

60%

80%

100%

The patient's poor mobility

The fact that the patient has diabetes

The degree of clinical involvement of

patient's toenails

The patient's sex*

Primary Care Physicians (n = 546) Dermatologists (n = 530)

0%

10%

20%

30%

40%

50%

60%

70%

Terbinafine Tavaborole Ciclopirox Itraconazole


33%

15% 12%

39%

24%

11% 4%

61%

Terbinafine Tavaborole Ciclopirox Itraconazole


0%

20%

40%

60%

80%

100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Understanding of relationship of

onychomycosis to tinea pedis and

psoriasis

Identifying FDA-approved topical

and systemic therapies for

onychomycosis

Knowledge of onychomycosis

clinical trial parameters and

definition of complete vs

mycological cure

Understanding of consequences of

untreated onychomycosis


45%

30%

45%

30% 23%

80%

48%

59%

41%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Understanding of relationship of

onychomycosis to tinea pedis and psoriasis

Identifying FDA-approved topical and systemic therapies for

onychomycosis

Knowledge of onychomycosis clinical trial parameters and

definition of complete vs mycological cure

Understanding of consequences of

untreated onychomycosis


Understanding the pain reducing benefits of

mechanical debridement

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Topical antifungal therapy

Systemic antifungal therapy

Toenail avulsion Chemical matrixectomy of the affected nails


0%

20%

40%

60%

80%

100%

Topical antifungal therapy*

Systemic antifungal therapy

Toenail avulsion Chemical matrixectomy of the

affected nails


72%

82%

14%

3% 0%

19%

4% 5%

QUESTION 1: Which one of the following is the best next step at this point?

QUESTION 1: When considering whether to recommend topical therapy for this

patient, which one of the following patient factors is least likely to influence

your recommendation?

UNDERSTANDING OF KEY ONYCHOMYCOSIS CONCEPTS

FIGURE 3: Percentage of dermatologist (n=530) and PCP (n=546) participants demonstrating knowledge of key onychomycosis concepts

QUESTION 2: If you discover that the patient described in the question above is being

treated for a cardiac arrhythmia or has evidence of ventricular dysfunction, which one of

the following therapies would not be preferred?

QUESTION 2: You diagnose the patient in the question above with mild onychomycosis of

the 2 visibly affected toenails. The patient is ver y concerned about the cosmetic effect of

her toenail appearance and is interested in starting therapy immediately. Which one of the

following treatment approaches would be the most appropriate first consideration for this

patient?

8%

0%

20%

40%

60%

80%

100%

Assume that the patient has

onychomycosis because it is so

antifungal treatment Immediately

common and start

Perform a thorough clinical examination

and diagnose the patient on the basis of

those findings

Take nail samples and order a

histological biopsy

Take nail samples and order a KOH test and

fungal culture to confirm the diagnosis

and causative organism*

11%

23%

7%

59%

80%

6% 6%


Acknowledgments

The clinical practice assessment educational activity was funded through an independent educational grant from Valeant Pharmaceuticals North America LLC.

For more information, contact Jovana Lubarda, PhD, Associate Director, Educational Strategy, Medscape, LLC, [email protected].

FIGURE 2: Factors affecting therapeutic selection in a diabetic patient with onychomycosis: competence of dermatologists (n=530) and PCPs (n=546)

Results

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