What is the diagnosis and treatment for a 42-year-old male patient presenting with photodistributed skin lesions, onychomycosis (fungal infection of the fingernails and toenails), and left ankle pain, with normal range of motion (ROM) and no signs of inflammation?

From the Guidelines

The patient's treatment plan should be adjusted to prioritize terbinafine as the first-line treatment for dermatophyte onychomycosis, given its preference over itraconazole due to its efficacy and safety profile, as recommended by the British Association of Dermatologists' guidelines 1. The patient presents with skin spots exacerbated by sun exposure and signs of fungal infection on his fingernails and toenails, along with left ankle pain. For the fungal infections, considering the guidelines, terbinafine is preferred for its effectiveness in treating dermatophyte onychomycosis with a recommended dosage of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 1. Key points to consider in the treatment plan include:

• The use of terbinafine as the first-line treatment for dermatophyte onychomycosis due to its high efficacy and relatively safe profile 1.
• Baseline liver function tests and a complete full blood count are recommended before starting terbinafine, especially in patients with a history of hepatotoxicity or hematological abnormalities 1.
• For the skin spots, while Miconazole 2% can be used, it's essential to identify the causative agent to ensure the most appropriate treatment is given, but given the context, terbinafine could also be beneficial if the skin spots are due to a dermatophyte infection.
• The liver and kidney function panels are appropriate to establish baseline organ function before starting any medication, especially those that may have hepatotoxic or nephrotoxic effects 1.
• The management of the left ankle pain with ibuprofen 400 mg three times daily as needed and ice therapy is reasonable for addressing pain and potential minor inflammation, given the absence of inflammation and full range of motion 1. It's crucial to monitor the patient's response to the treatment and adjust as necessary, ensuring that the chosen therapies do not adversely affect the patient's quality of life or increase morbidity and mortality risks.

From the FDA Drug Label

Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). Prior to initiating treatment, appropriate nail specimens for laboratory testing (KOH preparation, fungal culture, or nail biopsy) should be obtained to confirm the diagnosis of onychomycosis The patient presents signs of fungal infection on his fingernails and toenails, and Terbinafine is indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes.

• The patient should have laboratory testing to confirm the diagnosis of onychomycosis before initiating treatment with Terbinafine.
• Terbinafine should be prescribed for a duration of 6 weeks for fingernail onychomycosis and 12 weeks for toenail onychomycosis.
• It is recommended to perform liver function tests before prescribing Terbinafine and to monitor them periodically during treatment, as hepatotoxicity has been reported with the use of Terbinafine 2.

From the Research

Patient Assessment and Treatment Plan

• The patient's complaint of skin spots exacerbated by sun exposure and fungal infection on fingernails and toenails suggests the need for a comprehensive treatment plan, as emphasized in 3.
• The prescription of Miconazole 2% for three months for the skin spots and fingernails and toenails is a common treatment for fungal infections, but it is essential to monitor the patient's liver function due to the potential risk of acute liver injury associated with azole antifungals, as reported in 4.
• The patient's complaint of pain in the left ankle, despite the absence of inflammation and full range of motion, warrants further investigation, and the prescription of ibuprofen 400 mg TIDPRN, an ice bandage, and medical ice may help alleviate the pain.

Importance of Patient History and Communication

• Taking a comprehensive patient history is crucial for accurate diagnosis and effective management of health conditions, as outlined in 5.
• The patient's understanding of their treatment plan is essential for improving home care compliance, and factors such as empathy, quality of communication, and patient-physician relationship can impact patient understanding, as found in 6.
• Assessing the patient's needs and planning effective care requires a person-centred approach, and all nursing interventions should be evidence-based, as discussed in 7.

Laboratory Tests and Monitoring

• The prescription of liver panel and kidney function panel labs is essential to monitor the patient's liver and kidney function, especially when prescribing medications that may have potential side effects, such as azole antifungals, as reported in 4.