Dermatology Case Study: Chief Complaint My Right Great Toe

Dermatology Case Studychief Complaint My Right Great Toe Has Been Hu

Dermatology case study involving a 38-year-old female presenting with a two-month history of pain, swelling, yellow discoloration, and itching of the right great toe. The patient reports that symptoms worsened over time despite initial topical treatments, with examination revealing periungual inflammation, yellow-brown nail discoloration, and signs suggestive of a fungal infection. She has a history of type 2 diabetes mellitus, obesity, and family history of tinea pedis.

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Introduction

Onychomycosis, a common nail disorder predominantly caused by dermatophytes, yeasts, or molds, presents with varied clinical features, including discoloration, thickening, and subungual debris. Accurate diagnosis and appropriate management are essential, especially in patients with comorbidities like diabetes mellitus, which can predispose to more extensive and severe infections (Elewski, 2011). The case of a 38-year-old woman with proximal subungual onychomycosis underscores the importance of understanding current treatment guidelines for fungal nail infections.

Diagnosis and Clinical Features

The patient's clinical presentation, including yellow-brown discoloration, periungual inflammation, and confirmed fungal culture, aligns with onychomycosis (Gupta et al., 2017). The proximal subungual pattern, especially in immunocompromised or diabetic patients, suggests dermatophyte or yeast involvement. Differential diagnoses such as irritant contact dermatitis, lichen planus, or nail psoriasis were considered but ruled out based on clinical and laboratory findings (Baran & Scher, 2019).

Pharmacologic Treatment Guidelines

According to the American Academy of Family Physicians (AAFP) and CDC Clinical Practice Guidelines, systemic antifungal therapy is recommended for extensive, severe, or resistant onychomycosis, especially in patients with diabetes or immunocompromised states (Kauffman et al., 2020). The preferred agents include oral terbinafine and itraconazole, which have demonstrated high efficacy in eradicating fungal pathogens and promoting nail clearance (López-Robles et al., 2020).

Medication Selection and Duration

In this case, given the patient's diabetes and extent of infection, oral terbinafine is considered first-line therapy. The typical dosing for onychomycosis involves 250 mg orally once daily for 6 weeks for fingernails and 12 weeks for toenails. The treatment duration ensures complete fungal eradication and nail regrowth (Gupta et al., 2017). Itraconazole pulses or continuous therapy are alternative options, but terbinafine remains the first choice due to its favorable side effect profile and shorter treatment duration.

Prescription Details

Based on guidelines, the prescription should be written as follows:

  • Drug: Terbinafine 250 mg tablets
  • Dosage: One tablet orally once daily
  • Duration: 12 weeks
  • Instructions: Take with water, preferably with food to reduce gastrointestinal discomfort. Complete the full course even if symptoms improve before completion.

Monitoring and Follow-Up

Baseline liver function tests (LFTs), complete blood count (CBC), and renal function tests should be obtained before initiating therapy due to risks of hepatotoxicity and hematologic adverse effects (Kauffman et al., 2020). Follow-up LFTs are recommended during treatment at the 6-week mark or earlier if symptoms of hepatotoxicity develop. Additionally, nail cultures are performed after therapy to confirm mycological cure (Gupta et al., 2017).

Additional Laboratory Monitoring

  • Baseline Labs: Liver function tests (LFTs), CBC, renal function tests
  • Follow-up Labs: Repeat LFTs at 6 weeks and at conclusion of therapy

Rationale for Labs

LFTs are vital to monitor for hepatotoxicity, a known adverse effect associated with terbinafine and other systemic antifungals (Kauffman et al., 2020). CBCs help detect hematologic adverse effects. Monitoring renal function ensures safe dosing, especially in diabetic patients who are at increased risk of nephropathy. Regular follow-up ensures early detection of adverse effects and assessment of treatment efficacy (Elewski, 2011).

Conclusion

Effective management of onychomycosis necessitates adherence to current clinical guidelines, appropriate drug selection, and vigilant monitoring to optimize outcomes and minimize adverse effects. In this case, terbinafine remains the preferred systemic therapy, with baseline and follow-up labs crucial for safe administration, particularly given the patient's comorbid conditions.

References

  • Baran, R., & Scher, R. K. (2019). Onychomycosis. Journal of the American Academy of Dermatology, 80(5), 1465-1474.
  • Elewski, B. E. (2011). Onychomycosis: Pathogenesis, diagnosis, and management. Clinical Microbiology Reviews, 24(2), 227-244.
  • Gupta, A. K., Versteeg, S. G., & Shear, N. H. (2017). Clinical aspects and management of onychomycosis. Journal of the American Academy of Dermatology, 76(4), 947-962.
  • Kauffman, C. A., et al. (2020). Clinical Practice Guidelines for the Management of Tinea Pedis, Tinea Unguium, and Tinea Corporis. Infectious Diseases Society of America.
  • López-Robles, R., et al. (2020). Comparative efficacy of topical and systemic antifungal agents in onychomycosis: A meta-analysis. Journal of Fungi, 6(3), 154.
  • van Boven, T., et al. (2014). Treatment of onychomycosis: A review of the literature. American Journal of Clinical Dermatology, 15(2), 139-148.
  • Richards, R., et al. (2019). Pharmacological management of onychomycosis. Pharmacology & Therapeutics, 204, 107392.
  • Roh, J. Y., et al. (2008). Onychomycosis: Epidemiology, clinical features, and diagnosis. Mycopathologia, 166(5), 313-319.
  • Shaikh, M. G., et al. (2016). Onychomycosis: Management strategies. Medical Mycology, 54(2), 147-157.
  • Tosti, A., et al. (2014). The diagnosis and management of onychomycosis. American Journal of Clinical Dermatology, 15(1), 5-15.

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