What is the diagnosis and treatment for a 42-year-old male patient presenting with skin spots exacerbated by sun exposure, 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 treatment plan for this 42-year-old male prisoner with multiple complaints appears appropriate, but it is crucial to monitor liver and kidney function closely due to the potential hepatotoxicity of terbinafine, as recommended by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.

Treatment Plan Overview

The patient's skin spots exacerbated by sun exposure are being treated with Miconazole 2% for three months, which is an antifungal that can address fungal skin infections.

• For the fungal nail infections (onychomycosis) affecting both fingernails and toenails, terbinafine 250 mg once daily for 3 months is an appropriate first-line oral antifungal therapy with good penetration into nail tissue, as supported by the guidelines 1.
• The left ankle pain is being managed conservatively with ibuprofen 400 mg three times daily as needed, along with ice therapy, which is reasonable given the normal range of motion and absence of inflammation.

Considerations for Onychomycosis Treatment

It is essential to note that onychomycosis has high recurrence rates (40–70%), and many patients have a long history of disease recurrence, as mentioned in the guidelines 1.

• The goal of antifungal therapy in onychomycosis is to achieve fungal-free nails, and therapeutic success depends on the newly grown-out nail plate being fungus-free.
• The patient should be advised to wear protective footwear, apply antifungal powders, and keep their nails short to prevent re-exposure and recurrence, as recommended by the guidelines 1.

Additional Recommendations

One suggestion would be to consider adding a broad-spectrum sunscreen for the patient if the skin spots are indeed photosensitive, as this would complement the antifungal treatment and prevent exacerbation of the condition with sun exposure.

• It is also crucial to educate the patient on the importance of good hygiene practices, such as not sharing toenail clippers and wearing cotton, absorbent socks, to prevent the spread of fungal infections, as mentioned in the guidelines 1.

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 Fingernail onychomycosis: One 250 mg tablet once daily for 6 weeks. Toenail onychomycosis: One 250 mg tablet once daily for 12 weeks.

The patient is prescribed Terbinafine 250 mg QD for 3 months for fingernails and toenails infection. However, according to the drug label, the recommended treatment duration is 6 weeks for fingernail onychomycosis and 12 weeks for toenail onychomycosis. The prescription duration of 3 months may not be appropriate for the patient's condition.

• The patient should be prescribed Terbinafine 250 mg QD for 6 weeks if the infection is limited to the fingernails.
• The patient should be prescribed Terbinafine 250 mg QD for 12 weeks if the infection is limited to the toenails.
• If the patient has both fingernail and toenail onychomycosis, the treatment duration should be 12 weeks to ensure adequate treatment of the toenail infection. It is also important to note that liver function tests should be performed before prescribing terbinafine and periodic monitoring of liver function tests is recommended during treatment 2.

From the Research

Patient Assessment and Treatment

• The patient presents with skin spots exacerbated by sun exposure, fungal infection on fingernails and toenails, and pain in the left ankle.
• The treatment plan includes Miconazole 2% for three months for the skin spots, Terbinafine 250 mg QD for 3 months for fingernails and toenails infection, and ibuprofen 400 mg TIDPRN, an ice bandage, and medical ice for his left ankle pain.
• Laboratory tests include liver panel and kidney function panel labs.

Treatment Rationale

• Terbinafine is an effective treatment for superficial dermatophyte infections, including onychomycosis, tinea pedis, and tinea corporis/cruris, with mycological cure rates of > 80% 3.
• Miconazole is a commonly used topical antifungal agent, but its use in combination with corticosteroids may be more effective in treating fungal skin infections with inflammation 4.
• Oral terbinafine is more effective than other antifungal agents, such as itraconazole and griseofulvin, in treating dermatophyte onychomycosis and other superficial fungal infections 3, 5.

Considerations

• Patient preferences should be taken into account when making treatment decisions, as this can affect adherence and outcomes 6.
• The potential for allergic contact dermatitis (ACD) should be considered when using topical antifungal creams, with some ingredients, such as propylene glycol, being more common causes of ACD 7.
• Terbinafine hydrochloride 1% cream contains fewer potential allergenic ingredients compared to other antifungal creams, such as ketoconazole 2% and miconazole nitrate 2% 7.