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Assignment: Dermatology Case Study essay assignment
According to the Centers for Disease Control and Prevention (CDC) (2020), the first-line medication for onychomycosis is terbinafine (lamsil). The course of treatment is 12 weeks for toenails, while fingernails require 6 weeks of treatment (CDC, 2020). Based on the patient’s symptoms and diagnosis, the recommended dosage for Terbinafine is 250 mg, 1 tablet, PO daily, for 12 weeks.
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The labs for baseline when prescribing terbinafine include complete blood count (CBC) and platelet count, which are collected if the patient is immunodeficient, serum creatinine, Alanine Aminotransferase (ALT), and Aspartate Aminotransferase. The protocol for monitoring include baseline labs, the CBC should be repeated after 6 weeks of continuous use of the drug if the patient is immunodeficient, and liver function tests (LFT) every 4-6 weeks, if the patient is at the risk of drug-induced liver injury due to use of hepatotoxic medication s or if there are symptoms of liver problems. Baseline laboratory tests are checked before prescribing terbinafine and periodic monitoring of the laboratory results is required for early detection of abnormalities (Stolmeier et al., 2018).
A follow-up would be ordered for E.D. since she has type 2 diabetes mellitus (T2DM). Type 2 diabetes mellitus is associated with the development of nonalcoholic fatty liver disease (Dharmalingam et al., 2018). As such, it would be advisable to do LFT every 4 weeks to 6 weeks on the course of her treatment to monitor her liver function and discontinue the treatment if abnormalities are detected. The follow-up protects the patient from potential harm that could arise from abnormalities.
References
Centers for Disease Control and Prevention (CDC). (2020, May 27). Fungal nail infections. https://www.cdc.gov/fungal/nail-infections.html#:~:text=Topical%20antifungal%20agents%20can%20be,and%2012%20weeks%20for%20toenails.&text=Azoles%20can%20also%20be%20used.
Stolmeier, D. A., Stratman, H. B., McIntee, T. J., & Stratman, E. J. (2018). Utility of laboratory test result monitoring in patients taking oral terbinafine or griseofulvin for dermatophyte infections. JAMA Dermatology, 154(12), 1409–1416. https://doi.org/10.1001/jamadermatol.2018.3578
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Adelisa Bencomo
36 minutes ago, at 7:56 PM
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Onychomycosis Case Study
Question 1
Proximal subungual onychomycosis is a fungal infection that affects the patient’s proximal nail fold from its undersurface. Effective systematic antifungal therapy has been developed in recent years, with options like fluconazole, terbinafine, and itraconazole being more effective than the griseofulvin (Lipner & Scher, 2019). An ideal prescription for the patient, based on the AAFP/CDC guidelines, would be:
RX: Terbinafine
Dispense: 250 mg capsules
PO: Orally once a day
Notes: Take with food
Duration: 12 consecutive weeks
RX: Itraconazole
Dispense: 200 mg capsules
PO: Orally once a day
Notes: Take with food
Duration: 12 consecutive weeks.
The two antifungal medications will be effective in treating the patient’s conditions with careful monitoring. Close monitoring will help identify if the proposed treatment approach is effective, which, when done on time, will ensure that other treatment options are adopted in time, as Mikailov et al. (2016) describe.
Question 2
The ideal labs for this patient for the base and follow-up therapy will be determined by the antifungal medication administered and when the medication was prescribed for the treatment plan. According to Tverdek et al. (2016), a complete blood count and a live blood test to determine ALT and AST levels would be recommended. An interval of 5 weeks during the therapy would be recommended for these tests. Similarly, a lab test for itraconazole will be recommended every five weeks as this drug was used as an antifungal agent. Gupta et al. (2016) have noted that these tests are important for this patient, as they will help monitor if the prescribed medications are working to relieve onychomycosis and the symptoms of the condition.
References
Gupta, A.K., Stec, N., Summerbell, R.C., Shear, N.H., Piguet, V., Tosti, A., & Piraccini, B.M. (2020). Onychomycosis: A review. Journal of the European Academy of Dermatology and Venereology, 34(9), 1972-1990. https://doi.org/10.1111/jdv.16394
Lipner, S.R., & Scher, R.K. (2019). Onychomycosis: Treatment and prevention of recurrence. Journal of the American Academy of Dermatology, 80(4), 853-867. https://doi.org/10.1016/j.jaad.2018.05.1260
Mikailov, A., Cohen, J., Joyce, C., & Mostaghimi, A. (2016). Cost-effectiveness of confirmatory testing before treatment of onychomycosis. JAMA Dermatology, 152(3), 276-281. https://doi.org/10.1001/jamadermatol.2015.4190
Tverdek, F.P., Kofteridis, D., & Kontoyiannis, D.P. (2016). Antifungal agents and liver toxicity: A complex interaction. Expert Review of Anti-Infective Therapy, 14(8), 765-776. https://doi.org/10.1080/14787210.2016.1199272
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Nayaris Reyes
2 hours ago, at 6:47 PM
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1. According to the AAFP/CDC Guidelines, what antifungal medication(s) should this patient be prescribed, and for how long? Write her complete prescriptions using the prescription writing format in your textbook.
There are several antifungal drugs that can be prescribed with the purpose of preventing further complications of proximal subungual onychomycosis. There are systemic and topical drugs. Systemic antifungal drugs include:
Fluconazole and itraconazole, both are fungistatics. They function by inhibiting CYP450 thus inhibiting the fungal growth. Their prescription is 200mg/day PO for 12 weeks.
Terbinafine functions by decreasing ergosterol synthesis hence causing cell death. Its prescription is 250mg/day PO for 12 weeks.
Topical antifungal drugs include: tavaborole, its prescription is: it’s applied to the affected toenails qDay for 48weeks. Eficonazole, its prescription, it’s applied to the affected toenail qDay for 48weeks that is done by the use of an integrated applicator brush. Ciclopirox, it’s applied to the affected toenail plate qDay for 4weeks. ( Rodgers and Bassler, 2001 )
2. What labs for baseline and follow-up of therapy would you order for this patient? Give rationale.
Labs for proximal subungual onychomycosis include histopathology, polymerase chain reaction culture, and direct microscopy. There are special stains with GMS or PAS that are used for the fungal forms assessment. This is supported by the presence of neutrophils and serum in the nail that penetrates the nail tissue. Culture is essential as it identifies onychomycosis species; may be negative up to 30% of onychomycosis cases.
The polymerase chain reaction is used for the detection of onychomycosis DNA in the infected toenail. Direct microscopy is used to identify the presence of fungi using a low-power objective lens, however, it cannot identify onychomycosis-associated specific pathogens.it may be negative results up to 10%. Therefore negative results cannot completely rule out onychomycosis.(Elewski, 1996)
References:
Elewski B. E. (1996). Diagnostic techniques for confirming onychomycosis. Journal of the American Academy of Dermatology, 35 : S6-S9.
Rodgers P. and Bassler M. (2001). Treating onychomycosis. American family physician, 63 : 663.
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Dania Morejon Torres
2 hours ago, at 6:38 PM
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Dermatology Case Study
The 38-year-old Caucasian female is possibly suffering from distal subungual onychomycosis. The most common kind of fungal infection affecting the nails of both children and adults is distal subungual onychomycosis. The patient shows the main symptom of the infection of the great toe to be affected first. Diabetes, nail psoriasis, athlete’s foot, relative with the infection, and weak immune system include risk factors of the patient having subungual onychomycosis. Trichophyton rubrum is the common cause associated with distal subungual onychomycosis. Medical treatment is essential to help in pain-relieving and especially for the patient since she has increased risk factors of diabetes and infection of a family member.
Prescription
The patient should be prescribed oral antifungal therapy. Compared to topical therapy, oral antifungal treatment is regarded as the best therapy because of increased cure rates and little treatment duration for toenail fungus (Lipner & Scher, 2019). The oral medications may be effective for the patient since she had already tried topical medications such as Benadryl and Lotrimin AF cream and never helped the symptoms. Terbinafine (Lamisil) is an effective and safe drug for the patient to take. The patient should take 250 mg of the drug orally once per day. The drug generates few side effects and is taken daily for two and a half months. Fluconazole (Diflucan) is the second type of drug that can be administered to the patient (Lieberman & Curtis, 2018). The patient should take 200 mg orally of Fluconazole once a week within a duration of one year.
Follow-Up Therapy
Baseline tests such as cholesterol levels should be recorded to help identify changes and follow-up signs of recovering. Maintaining trimmed and filed nails are one of the best ways to minimize the amount of fungus in the nails. The general hygiene of the feet and nails is essential for the patient to reduce the risk factors of fungal infections such as subungual onychomycosis accumulating in the nails. Trimmed and well-maintained nails also help to get pain relief when swelling nails produce pain. Finally, the patient should eat healthy meals to improve the immune system and help in maintaining good blood sugar levels.
References
Lipner, S. R., & Scher, R. K. (2019). Onychomycosis: treatment and prevention of recurrence. Journal of the American Academy of Dermatology, 80(4), 853-867.
Lieberman, A., & Curtis, L. (2018). Severe Adverse Reactions Following Ketoconazole, Fluconazole, and Environmental Exposures: A Case Report. Drug safety-case reports, 5(1), 1-5.
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Laura Rosa Alonso Salido
5 hours ago, at 3:27 PM
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According to the AAFP/CDC Guidelines, what antifungal medication(s) should this patient be prescribed, and for how long?
The most prevalent nail problem is onychomycosis, which is caused by fungus such as dermatophytes, no dermatophytes, and candida. When the fungus infects the nail through the proximal nail fold, it is termed as proximal subungual onychomycosis. This kind is prevalent in immunocompromised individuals (HIV, Diabetes), following trauma, and in people with blood circulation disorders, although it is uncommon in healthy people (Lipner & Scher, 2019). Due to the presence of tinea pedis (athlete’s foot), it is critical to examine the rest of the foot, particularly between the toes.
Treatment varies based on the intensity, the organism involved, and concerns regarding drug-drug interactions and adverse effects. Cure measures are used to determine effectiveness such as mycotic (no organism discovered), clinical (with normal morphology in 80-90 percent of nails), and complete (all of the above). Oral azoles and allylamines, topical analgesics, and physical treatments have all been tried in the past. It’s a time-consuming treatment that can take months or even a year to work, causing dissatisfaction among those who are affected.
Prescriptions must be written on a preprinted prescription pad that includes the prescriber’s name, address, phone number, and NPI number. The patient’s name and date of birth must also be supplied. When it comes to children, weight is important.
The following can be used :-
Terbinafine 250 mg po once a day for 12weeks Dx. Onychomycosis.
Itraconazole 200 mg po once a day for 12weeks Dx. Onychomycosis.
Itraconazole 200 mg po dose for one week each month, repeated for two to four months, has also been recommended in conjunction with a pulse treatment. If you have tinea pedis, it’s a good idea to use a topical antifungal ointment. Information on good foot care is vital as part of the treatment, as is wearing breathable shoes, 100 percent cotton socks, and keeping feet dry. Trimming and debridement are advised as physical therapy (Alqahtani et al., 2022) We can also utilize the following local agent:
8 percent ciclopirox solution (nail lacquer) At night, put one layer over the nail and surrounding region for 48 weeks. Onychomycosis is the diagnosis.
*Daily applications should me made over the previous coat after which it is removed with alcohol every seven days.
What labs for baseline and follow up of therapy would you order for this patient? Give rationale.
The identification of the causative agent by direct microscopy utilizing periodic acid Schiff stain (PAS) and methenamine silver stains is required for a positive diagnosis of onychomycosis. Fungal culture is another scientific approach that requires at least 10 days to see colonies grow in a culture foundation. The use of a real-time polymerase chain reaction (PCR) technology to detect the agent has been made possible thanks to advances in modern science. This approach is quicker, and studies have shown that it is reliable (Watanabe & Ishida, 2017). To maximize the chances of a correct diagnosis, the sample collection site must be carefully chosen and the collection technique must be precise.
Before starting continued therapy, the liver enzymes and function must be checked, as well as every four to six weeks throughout oral treatment. This is due to the possibility of toxicity and liver damage associated with antifungal medication metabolism (Jazdarehee et al., 2022). This approach is not recommended when pulse therapy is utilized because the danger of injury is lower. A complete blood count is often advised to establish a baseline and rule out other infectious disorders.
References
Alqahtani, A., Raut, B., Khan, S., Mohamed, J. M., Fatease, A. A., Alqahtani, T., Alamri, A., Ahmad, F., & Krishnaraju, V. (2022). The unique carboxymethyl fenugreek gum gel loaded itraconazole self-emulsifying nanovesicles for topical onychomycosis treatment. Polymers, 14(2), 325. https://doi.org/10.3390/polym14020325
Jazdarehee, A., Malekafzali, L., Lee, J., Lewis, R., & Mukovozov, I. (2022). Transmission of onychomycosis and dermatophytosis between household members: A scoping review. Journal of Fungi, 8(1), 60. https://doi.org/10.3390/jof8010060
Lipner, S. R., & Scher, R. K. (2019). Onychomycosis. Journal of the American Academy of Dermatology, 80(4), 853–867. https://doi.org/10.1016/j.jaad.2018.05.1260
Watanabe, S., & Ishida, K. (2017). Molecular Diagnostic Techniques for Onychomycosis: Validity and Potential Application. American Journal of Clinical Dermatology, 18(2), 281–286. https://doi.org/10.1007/s40257-016-0248-7
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Joscelyne Lastra
8 hours ago, at 12:46 PM
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Dermatology Case Study
The best antifungal medication for the patient is Terbinafine. Precisely, the patient should be prescribed a terbinafine drug known as Lamisil. The prescription should be Lamisil 250 mg to be taken oral once a day for 12 weeks. According to Leung et al. (2020), Lamisil is 76% effective in treating proximal subungual onychomycosis compared to other Terbinafine drugs, which are Sporanox with an effectiveness of 69%, and Diflucan with an effectiveness of 48% (Leung et al., 2020). In addition to that, Lamisil is safe for use by patients living with type 2 diabetes mellitus (Leung et al., 2020). As such, the most appropriate treatment for the patient based on AAFP/CDC guidelines is Lamisil.
The baseline labs I would recommend for the patient are LFTs (Liver function test) and CBC (complete blood count). The reason for this is that Lamisil is associated with a high risk of hepatotoxicity in most patients with or without liver disease. Accordingly, the patient must take pretreatment serum transaminase examinations before starting the medication. Accordingly, LFTs are necessary to continually examine toxicity levels to eliminate the threat of liver disease that may result from hepatotoxicity of Lamisil. According to Heymann (2019), LFTs should be initiated in patients who present disease indicators that include pale stools, dark urine, anorexia, jaundice, vomiting, and nausea, as they point to a high risk of impaired liver function (Heymann, 2019). The purpose of CBC is to examine the presence of a secondary infection if the indications presented by the patient continue to manifest past 12 weeks of drug administration (Heymann, 2019). Through LFTs, severe side effects of Lamisil can be detected early, thus minimizing the risk of liver damage (Wang & Lipner, 2021). Apart from that, LFTs can inform follow-up therapy through a change of the patient’s medication if severe side effects are detected (Heymann, 2019). Through CBC, additional treatment approaches can be employed if a diagnosis of a secondary infection is confirmed.
References
Heymann, W. (2019). Breaking the terbinafine laboratory habit for onychomycosis. Retrieved February 02, 2022, from https://www.aad.org/dw/dw-insights-and-inquiries/2019-archive/may/breaking-the-terbinafine-laboratory-habit-for-onychomycosis
Leung, A. K., Lam, J. M., Leong, K. F., Hon, K. L., Barankin, B., Leung, A. A., & Wong, A. H. (2020). Onychomycosis: An updated review. Recent Patents on Inflammation & Allergy Drug Discovery, 14(1), 32-45. doi:10.2174/1872213×13666191026090713
Wang, Y., & Lipner, S. R. (2021). Retrospective analysis of laboratory abnormalities in patients with preexisting liver and hematologic diseases prescribed terbinafine for onychomycosis. Journal of the American Academy of Dermatology, 84(1), 220-221. doi:10.1016/j.jaad.2020.09.004
