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Integ Exam 1 > Onychomycosis Lecture > Flashcards

Onychomycosis Lecture Flashcards

1
Q

Onychomycosis

A

Most common nail disorder

Toenails&raquo_space;> fingernails

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2
Q

Dermatophytes

A

Trichophyton rubrum

Trichophyton mentagrophytes

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3
Q

Yeast

A

Candida albicans

Candida parapsilosis

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4
Q

Nondermatophytes

A

Aspergillus

Scopulariopsis

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5
Q

Why treat?

A 
Quality of life
Physiological stress
Pain
Inflammation
Peripheral circulation
Foot ware
Infection potential
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6
Q

Types of onychomycosis

A

DISTAL SUBUNGUAL ONYCHOMYCOSIS
White superficial onychomycosis
Proximal subungual onychomycosis
Candida Onychomycosis

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7
Q

Distal Subungual Onychomycosis

A

Most common
Infection begins in the distal area of the nail bed (tip of the toe)
THICK toenail

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8
Q

White superficial

A

Toe nail infection only
Involves the surface of the nail –> not a thicker nail
Nail is soft, dry, and easily scraped off

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9
Q

Proximal Subungual Onychomycosis

A

Infection that beings at the nail bed and moves out

Leads to separation from nail bed

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10
Q

Dystrophic

A

Nail deformities

- Increased risk of infection in immunocompromised and diabetic patients

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11
Q

Candida Onychomycosis

A 
Immunocompromised
Seen in dishwashers
Nails appear opaque and does not crumple
Yellow-brown in collor
FINGER NAILS
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12
Q

Differential diagnosis

A 
Psoriasis
Pseudomonal infections
Medications
Exzema
Dermatitis
Trauma
Ischemic conditions (poor blood flow)
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13
Q

People at risk

A

Diabetes
Immunosuppressant and systemic antibiotics
HIV/AIDS: younger age –> proximal subungual onychomycosis
Geriatrics >60
Institutional living
Athletes
Health clubs

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14
Q

Clinical presentation/symptoms

A

Hyperkeratosis (thickening of the nail)
Discoloration of the nail (white or brown)
Brittleness
Onycholysis (separation of the nail from the bed
Paronychial inflammation
Recurrent tinea pedis
Pain

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15
Q

Diagnosis

A 
History/clinical symptoms
KOH prep of nail clippings
Fungal culture
Nail biopsies
- Need test as well as physical observations
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16
Q

Ideal agents

A 
Good concentration in the nail bed
High clinical/mycologic cure rate
Low rate of relapse
Short term therapy
Few ADR's and interactions
Cost effective
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17
Q

Treatment options

A 
Nail removal
Topiocal therapy (ineffective)
Griseofulvin
Ketaconazole (DO NOT USE)
Itraconazole
Fluconazole
Terbinafine
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18
Q

Topical Nail Therapy

A

Nail lacquers (ciclopirox- PenLac)
Antifungal agents: solutions or creams (clotrimazole, tolnaftate, terbinafine) or powders (tolnaftate
– Low cure rate and high relapse rate

19
Q

History of high transaminase levels or have liver disease and want something for fungal infections?

A

PenLac bc others raise transaminase levels

20
Q

Cons of Topical Nail therapy

A

Cannot penetrate harden nail mass
Requires multiple daily applications and long duration of therapy
- Can be used with other oral treatments

21
Q

Griseofulvin

A

First oral agent; Fungistatic
Microsize: need to take with a fatty meal to increase adsorption
Ultramicrosize: Increased absorption
- Monitor Baseline AST, ALT, and CBC and repeat AST and ALT if treatment last >6 wks

22
Q

Dosage of Griseofulvin

A

500 mg QD-BID

23
Q

Griseofulvin Disadvantages

A

High rate of resistance, high rate of relapse, low cure rate, long duration, intolerable adverse drug reactions
ADR’s: skin rashes, urticaria, GI, photosensitivity, toxic epidermal necrolysis (sore throat, fever, rash)
- Potential cross reactive with penicillin

24
Q

Griseofulvin Drug Interactions

A

Anticoagulants, oral contraceptives, cyclosporine and salicylates
Phenobarbital decrease serum concentrations

25
Q

Fluconazole (Diflucan)

A

Fungistatic –> inhibits the synthesis of ergosterol

Toe nails

26
Q

Fluconazole (Diflucan) Advantages

A

Good nail bed and matrix penetration
Detect in toenails 6 months after
Good absorption not influence by gastric acid, food, antacids or H2 blockers

27
Q

Fluconazole (Diflucan) Disadvantages

A

Lacks indication

Not extensively studied

28
Q

Fluconazole (Diflucan) Dosage

A

150, 300, or 450 mg week for 3 months
3-12 months of treatment
80% excreted unchanged via urine

29
Q

Fluconazole (Diflucan) Monitor & Interaction

A

Baseline AST, ALT, CBC; remonitor >6 wk therapy
Increases the effects of warfarin, cyclosporine, theophyline, phenytoin, sulfonylureas
QT prolongation and decreases oral contraceptives

30
Q

Fluconazole (Diflucan)ADR’s

A

GI- nausea, diarrhea and ab pain, elevated liver enzymes

Pulse dosing decrease incidence

31
Q

Intraconzaole (Sporanox)

A

Fungistatic- inhibits the synthesis of ergosterol
For onychomycosis; good concentration in nail matrix and bed
Detectable for 6 months after

32
Q

Intraconzaole (Sporanox) Dosage

A

Toenails: 200 mg daily for 12 weeks
Fingernails: 200 mg BID for 3 days per month for 2 months (separated by 3 weeks)

33
Q

Intraconzaole (Sporanox) Monitor

A

Baseline AST, ALT, CBC; recheck monthly

34
Q

Intraconzaole (Sporanox) Drug Interactions

A

Warfarin, H2 blockers, PPI, DDI, Ritonavir, Indiavir, Benzodiazepines, Lovastatin, Simvastatin, Cyclosporine, Tacrolimus, Phenytoin, Phenobarbital, carbamazepine, rifamycins

35
Q

Intraconzaole (Sporanox) ADR’s

A 
GI- nausea, vomiting, diarrhea, ab pain
Headache
Dizziness
Rash
ELEVATED LIVER ENZYMES
36
Q

Intraconzaole (Sporanox) FDA Warnings

A

Hepatoxicity
CHF, cardiac dysfunction or a history of CHF
- Discontinue if signs or symptoms of CHF

37
Q

Intraconzaole (Sporanox) Disadvantages

A

Drug interactions
Expensive
Must be taken with full meal
Acidic environment for absorption - no antacids, H2 blockers, PPIs; need achlorhydria - soda increases adsorption

38
Q

Terbinafine (Lamisil)

A

First line therapy
FDA indicaiton
More effective than itraconzaole
Fungicidals

39
Q

Terbinafine (Lamisil) Dosage

A

Fingernail: 250 mg QD for 6 weeks
Toenails: 250 mg QD for 12 weeks

40
Q

Terbinafine (Lamisil) FDA warnings

A

Hepatotocicity (rare)

  • Liver failure and death
  • Not indicated for chronic or active hepatic disease
  • NO LIVER DISEASE PATIENTS*
41
Q

Terbinafine (Lamisil) Monitor and interactions

A

Baseline AST, ALT, CBC; recheck after >6 wk of treatment
Tricyclic antidepressants, SSRI’s (fluoxetine, paroxetine)
Venlafaxine and cyclosporine

42
Q

Terbinafine (Lamisil) ADRs

A

GI- diarrhea, ab pain, nausea, and flaulence
Rash
TASTE DISTRUBANCES
ELEVATED LIVER ENZYMES

43
Q

Terbinafine (Lamisil) Advantages

A

Fewer drug interactions, fewer ADR’s, fungicidal activity, pregnancy category B

44
Q

Therapeutic considerations

A 
Concomitant disease states (don't treat liver disease patients)
Drug interactions (azoles)
ADR's (terbinafine and fluconazole = better tolerated)
How much they cost

Integ Exam 1 (7 decks)

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