What is the diagnosis and treatment plan for a 42-year-old male patient presenting with skin spots exacerbated by sun exposure, suspected fungal infection of the fingernails and toenails, and left ankle pain, with normal range of motion (ROM) and no signs of inflammation, and prescribed laboratory tests including liver panel and kidney function panel, Miconazole (Micatin) 2% for skin spots, Terbinafine (Lamisil) 250 milligrams (mg) once daily (QD) for fungal infection, and Ibuprofen (Advil) 400 mg three times a day as needed (TIDPRN) for pain management?

From the Guidelines

The treatment plan for this 42-year-old male prisoner with multiple conditions appears appropriate, with Terbinafine 250 mg daily for three months being the standard first-line oral therapy for dermatophyte infections, as supported by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. For the skin spots exacerbated by sun exposure, Miconazole 2% for three months is a reasonable antifungal treatment, though the specific diagnosis (tinea versicolor vs. other fungal infection) isn't clearly stated. The left ankle pain management with Ibuprofen 400 mg three times daily as needed, along with an ace bandage and ice, is appropriate conservative therapy given the normal examination findings (full range of motion, no inflammation). The liver and kidney function panels are prudent before starting oral Terbinafine, as this medication requires monitoring of hepatic function, especially considering its potential for rare but serious hepatic toxicity, as noted in the guidelines 1. Some key points to consider include:

• The importance of monitoring liver function before and during treatment with Terbinafine, as it is not recommended in patients with active or chronic liver disease 1.
• The potential for drug interactions, although Terbinafine has minimal interactions, it's essential to be aware of its effects on drugs metabolized by the cytochrome P450 2D6 isoenzyme 1.
• The value of sun protection advice for the photosensitive skin condition to prevent exacerbation of symptoms.
• The need for further evaluation, including imaging, if the ankle pain persists beyond 1-2 weeks without improvement, to rule out other underlying conditions. Overall, the current plan addresses all presenting issues with appropriate medications and supportive care, prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

Patients should be advised to report to their physician any symptoms of new onset or worsening lupus erythematosus. Symptoms can include erythema, scaling, loss of pigment, and unusual photosensitivity that can result in a rash. Photosensitivity reactions have been reported with the use of terbinafine tablets Patients should be advised to minimize exposure to natural and artificial sunlight (tanning beds or UVA/B treatment) while using terbinafine tablets.

The patient has skin spots that are exacerbated by sun exposure, and photosensitivity reactions have been reported with the use of Terbinafine. It is recommended that patients taking Terbinafine minimize exposure to natural and artificial sunlight.

• The patient should be advised to minimize sun exposure while taking Terbinafine.
• The patient's skin spots may be related to photosensitivity reactions caused by Terbinafine.
• The patient should be monitored for any signs of lupus erythematosus or photosensitivity reactions while taking Terbinafine 2.

From the Research

Patient Assessment and Treatment Plan

• The patient presents with skin spots, which are exacerbated by sun exposure, and signs of fungal infection on his fingernails and toenails.
• The patient is also complaining of pain in his left ankle, but upon assessment, it does not appear to be inflamed and the patient has a full range of motion (ROM).
• The treatment plan includes prescribing liver panel and kidney function panel labs, Miconazole 2% for three months for the skin spots, Terbinafine 250 mg QD for three months for fingernail and toenail infections, and Ibuprofen 400 mg TIDPRN, an ace bandage, and medical ice for his left ankle pain.

Rationale for Treatment Plan

• The use of Miconazole 2% and Terbinafine 250 mg QD is supported by a study on emerging trends in the use of topical antifungal-corticosteroid combinations, which found that these treatments are efficacious choices for combating fungal skin infections 3.
• However, it is also important to monitor for potential side effects, such as liver injury, which has been associated with Terbinafine use 4.
• The study on Terbinafine-induced severe liver injury found that patients who experienced liver injury were typically symptomatic, and that laboratory monitoring may not be effective in detecting asymptomatic cases 4.
• Therefore, it is important to advise the patient to discontinue treatment and seek medical attention if they experience any symptoms of liver injury.

Patient Education and Communication

• Effective communication and patient education are crucial in ensuring that the patient understands their treatment plan and can manage their condition effectively 5.
• A study on patient understanding of their medical care treatment plan found that factors such as knowing the attending physician's name, having a primary care physician, and educational background were associated with better understanding of the treatment plan 5.
• It is essential to ensure that the patient has a clear understanding of their treatment plan, including the potential risks and benefits of each medication, and to provide them with adequate support and resources to manage their condition.

Treatment Plan Adjustment

• The treatment plan may need to be adjusted based on the patient's response to treatment, and it is essential to regularly assess the patient's symptoms and adjust the treatment plan as needed 6.
• A study on diminishing returns in VA patients undergoing prolonged exposure and cognitive processing therapy found that patients who did not experience significant symptom reduction within the first eight sessions were unlikely to achieve meaningful change if treatment was not enhanced or changed 6.
• Therefore, it is crucial to regularly assess the patient's response to treatment and adjust the treatment plan accordingly to ensure the best possible outcomes.