From the Guidelines
The treatment plan for this 42-year-old male prisoner with multiple conditions appears appropriate, but it is crucial to ensure the patient completes the full course of antifungal medications and follows preventive measures to avoid reinfection, as highlighted in the British Association of Dermatologists' guidelines for the management of onychomycosis 1. For the skin spots exacerbated by sun exposure, Miconazole 2% for three months is prescribed, which will address potential fungal elements. The fingernail and toenail fungal infections are being treated with oral Terbinafine 250 mg daily for three months, which is the standard treatment for onychomycosis, as supported by guidelines for treatment of onychomycosis 1. It is essential to note that Terbinafine is superior to itraconazole for dermatophyte onychomycosis, with expected cure rates of 80–90% for fingernail infection and 70–80% for toenail infection 1. For the left ankle pain, despite normal range of motion and no visible inflammation, the combination of Ibuprofen 400 mg three times daily as needed, an ace bandage for support, and medical ice for pain relief represents a reasonable conservative approach. The liver and kidney function panels are important to monitor, particularly with Terbinafine therapy, as this medication can occasionally cause hepatotoxicity, as mentioned in the guidelines for treatment of onychomycosis 1. Key considerations for the patient include:
- Completing the full course of antifungal medications even if symptoms improve earlier
- Using sun protection for the skin spots
- Avoiding sharing toenail clippers with family members and friends
- Keeping nails as short as possible
- Wearing protective footwear to avoid re-exposure to fungal elements
- Applying antifungal powders inside shoes to ensure all infective fungal elements are eliminated Regular follow-up would be beneficial to assess treatment response and monitor for any adverse effects from the medications.
From the FDA Drug Label
Patients should take one 250 mg tablet once daily for 6 weeks for treatment of fingernail onychomycosis or once daily for 12 weeks for treatment of toenail onychomycosis The patient is being prescribed Terbinafine 250 mg QD for three months for fingernail and toenail infections. However, according to the label, the recommended treatment duration is 6 weeks for fingernail onychomycosis and 12 weeks for toenail onychomycosis. The prescribed duration of three months is longer than the recommended duration for fingernail onychomycosis, but close to the recommended duration for toenail onychomycosis. It is essential to follow the recommended treatment duration to ensure the best possible outcome and minimize potential side effects 2.
From the Research
Treatment of Fungal Infections
- The patient is presenting with signs of fungal infection on his fingernails and toenails, and skin spots that are exacerbated by sun exposure 3.
- Terbinafine 250 mg QD for three months is prescribed for the fingernail and toenail infections, which is a common antifungal drug used for the treatment of fungal infections 4, 5, 6, 7.
- Studies have shown that terbinafine combined with itraconazole achieves better therapeutic effects in fungal skin diseases 4, 5.
- However, other studies have found that itraconazole seems to be more effective than terbinafine in the treatment of tinea infection 6, 7.
Treatment of Skin Spots
- Miconazole 2% is prescribed for three months for the skin spots, which is an antifungal agent that is widely used for the prevention and treatment of fungal infections 3.
- The patient's skin spots are exacerbated by sun exposure, which may indicate a need for additional treatment or precautions to prevent further exacerbation.
Treatment of Ankle Pain
- Ibuprofen 400 mg TIDPRN, an ace bandage, and medical ice are prescribed for the patient's left ankle pain.
- The patient's ankle does not appear to be inflamed and has a full range of motion, which may indicate a minor injury or strain.