What is the best treatment for a 67-year-old male with leg pain, toe calluses, and onychomycosis (fungal infection of the nail) of the great toenail, who has improved with shoulder injections and is starting Duloxetine (duloxetine)?

From the Guidelines

The patient's treatment plan should prioritize addressing the fungal toenail infection, foot calluses, and shoulder pain, with a focus on improving quality of life and reducing morbidity and mortality. The patient is a 67-year-old male with multiple issues including leg pain, foot calluses, fungal toenail infection, and shoulder pain.

• The treatment plan includes starting Duloxetine 30 mg once daily at bedtime for pain management, as supported by recent guidelines such as the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1 and the 2019 American College of Rheumatology/Athritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee 1.
• Ordering medical shoes to address foot calluses on the left great and second toes is also appropriate, as it will provide proper support and reduce pressure on callused areas, preventing further irritation.
• Scheduling procedures for permanent removal of the left great toenail is a reasonable approach, given the fungal infection and deformity that hasn't responded to other treatments, as suggested by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.
• The shoulder injections are being repeated based on the patient's reported improvement from previous injections, which is a common practice in managing chronic pain conditions. This comprehensive approach addresses both the mechanical issues causing discomfort and provides pharmacological pain management for this elderly patient with multiple pain complaints, ultimately aiming to improve his quality of life and reduce morbidity and mortality.
• It is also important to consider the patient's overall health and potential comorbidities, such as diabetes, and adjust the treatment plan accordingly, as suggested by the 2021 Standards of Medical Care in Diabetes 1 and the 2019 Standards of Medical Care in Diabetes 1.

From the Research

Treatment Options for Fungal Nail Infections

• The patient's fungal nail infection can be treated with various options, including oral and topical antifungal agents, as well as surgical nail avulsion 2, 3, 4, 5.
• Oral terbinafine is effective in more than 50% of cases, but it can have severe cutaneous, hepatic, and haematological adverse effects 2.
• Topical antifungal agents, such as ciclopirox 8% lacquer and efinaconazole 10% solution, can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions 3, 6.
• Surgical nail avulsion carries a risk of local infection and permanent nail dystrophy, but it can be used when the nail is markedly thickened 2.

Diagnosis and Management

• The diagnosis of fungal nail infections can be confirmed by direct microscopic examination, histopathologic examination, fungal culture, or polymerase chain reaction assays 3, 5.
• Treatment decisions should be based on the severity of the infection, comorbidities, and patient preference 3.
• Nail trimming and debridement can be used concurrently with pharmacologic therapy to improve treatment response 3.

Patient Education and Prevention

• Patients should be educated on preventive measures, such as avoiding walking barefoot in public places and disinfecting shoes and socks, to reduce the risk of relapse 3.
• Patient education tips can help prevent and limit the spread of the disease 4.

Treatment of Onychomycosis

• Onychomycosis can be treated with oral antifungal agents, such as terbinafine and itraconazole, as well as topical antifungal agents, such as ciclopirox and efinaconazole 2, 3, 5, 6.
• The choice of treatment depends on the severity of the infection, the presence of matrix involvement, and the patient's medical history 2, 3, 5.