Yvette Terrie, BSPharm, RPh

Tinea unguium, also referred to as onychomycosis, is a fungal infection that affects the fingernails and toenails and may involve any component of the nail unit, including the bed, matrix, or plate.

The incidence fo onychomycosis is increasing. Statistics show that an estimated 35 million Americans suffer from the condition, which primarily affects men aged 50 to 70 years, although women also can experience it.

 In adolescents or children, onychomycosis is observed most often in those aged 12 to 18 years, is uncommon in children younger than 12 years, and is extremely rare in those younger than 6 years.

 Onychomycosis characteristically begins as a small white or yellow spot beneath the nail and causes detachment of the nail bed, distortion, nail discoloration, irregular surface changes, pain, and/or thickening.

 Risk factors for onychomycosis include diabetes; obesity; older age; peripheral vascular disease; preexisting nail dystrophy such as in a patient with psoriasis, or tinea pedis; and a weakened immune system.

Individuals with diabetes account for an estimated 33% of those presenting with onychomycosis.

 Several nonclinical risk factors also affect an individual's chance of developing fungal nail infections. The prevalence of toenail onychomycosis has increased in recent years, and contributing factors may include the increasing use of occlusive footwear, which consists of boots or shoes that enclose the feet.

Nail trauma can also expand the risk of fungal infection of the affected nail, especially in the geriatric population.

 The American Dermatology Association indicates that healthy individuals typically are at greater risk of nail infections when visiting beauty nail salons that use poorly sanitized instruments, public whirlpool baths, saunas, and swimming pools; and shower facilities in dormitories, gyms, etc.

 the authors attempted to expand the public's understanding of the potential for disease transmission via the common tools and products used in beauty salons.

 They reviewed the results of several studies and found that there is a need to expand salon standards of care used in sterilizing beauty tools and products and storing them properly. In addition, they highly recommended the use of individual cosmetic kids and noted that all these recommendations, if employed, should contribute considerably to a decline in the spread of bacterial and fungal infections in these establishments.

International Journal of Women's Dermatology,

 the authors indicated that gentle nail care and the sanitization of nail tools are crucial in thwarting the transmission and spread of onychomycosis.

Treatment of onychomycosis depends on its clinical type, the number of affected nails, and the severity of nail involvement.

 The self-treatment of onychomycosis with topical nonprescription antifungals is not approved by the FDA.

 states that when no contraindications are present, the affected nail can be treated with prescription topical agents (ciclopirox olamine 8% or efinaconazole 10% nail solutions), systemic prescription agents (itraconazole or terbinafine), a combination of oral and topical agents, or surgical removal of the affected area.

Patients exhibiting signs of onychomycosis should never self-treat and should always seek medical care from their primary health care providers, especially if they have risk factors for developing onychomycosis or other comorbidities, according to the American Dermatology Association.

Although available OTC products are not FDA-approved treatments for onychomycosis, there are a few topical products that are marketed for the management of fungal nail infections, and some marketed to improve the appearance of nails damaged by fungal infections. These products are available in various formulations, including ointments and topical liquids, and may include ingredients such as propylene glycol, tea tree oil, and undecylenic acid.

When encountering patients seeking guidance on the treatment of onychomycosis, pharmacists should encourage them to consult their primary health care providers for further assessment and treatment. They should also remind patients that onychomycosis cannot be effectively managed with the use of topical nonprescription agents. They can, however, use nonprescription agents sometimes in conjunction with prescribed agents to reduce nail discoloration and smooth out rough or thick nails. It is also imperative that pharmacists remind patients that therapy is usually long term, and adherence is essential for effective treatment.

1. Tosti A. Onychomycosis. Medscape. Updated October 5, 2020. Accessed April 7, 2021. https://emedicine.medscape.com/article/1105828-overview

2. Adigun CG. Onychomycosis. Merck Manual, Professional Version. Updated August 2019. Accessed April 7, 2021. http://www.merckmanuals.com/professional/dermatologic-disorders/nail-disorders/onychomycosis

3. Brooks M. FDA OKs first topical triazole antifungal for onychomycosis (Jublia). Medscape. June 10, 2014. Accessed April 7, 2021. https://www.medscape.com/viewarticle/826480

4. Feldstein S, Totri C, Friedlander SF. Antifungal therapy for onychomycosis in children. Clin Dermatol. 2015;33(3):333-339. doi:10.1016/j.clindermatol.2014.12.010

5. Piraccini BM, Starace M. Nail disorders in infants and children. Curr Opin Pediatr. 2014;26(4):440-445. doi:10.1097/MOP.0000000000000116

6. Westerberg DP, Voyack MJ. Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11):762-770.

7. Tan JS, Joseph WS. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging. 2004;21(2):101-112. doi:10.2165/00002512-200421020-00003

8. Ghannoum M, Isham N. Fungal nail infections (onychomycosis): a never-ending story? PLoS Pathog. 2014;10(6):e1004105. doi:10.1371/journal.ppat.1004105

9. Onychomycosis (fungal nail infection). Ada Health GmbH. Updated December 14, 2018. Accessed April 7, 2021. https://ada.com/conditions/onychomycosis-fungal-nail-infection/

10. Alharbi NM, Alhashim HM. Beauty salons are key potential sources of disease spread. Infect Drug Resist. 2021;14:1247-1253. doi:10.2147/IDR.S303461

11. Reinecke JK, Hinshaw MA. Nail health in women. Int J Womens Dermatol. 2020;6(2):73-79. doi:10.1016/j.ijwd.2020.01.006

12. Gardner A, Walkup N. Fungal skin infections. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. American Pharmacists Association; 2018.

Articles

Pharmacists can educate patients about recommended treatment strategies to manage onychomycosis.

Prevent and Reduce Fungal Nail Infections

Ms. Terrie is a clinical pharmacy writerbased in Haymarket, Virginia.

Check the expiration date of testing kitsbefore use.

Read the instructions before testing andadhere to the step-by-step directions.

Understand the testing procedure andfactors that may interfere with theaccuracy of the selected test.

If unsure about the testing procedure orresults, contact the primary care provideror the manufacturer.

Use an accurate timing device whenperforming the tests.

If using collection testing kits thatrequire mailing, proper collection, storage,and shipment are critical to obtainingaccurate results.

Report positive test results immediatelyto the primary care provider to confirmresults and obtain further medicalevaluation.

Question negative test results andconfer with the primary care provider,especially if experiencing any symptomsor have any concerns.

Patients with visual impairments orproblems with dexterity-ask forassistance when performing tests or bereferred to their primary care providerfor testing.

Patients with bleeding disorders ortaking anticoagulants-because excessivebleeding may occur with tests thatrequire a finger stick blood sample-confer with the primary care providerbefore using.

Pharmacists can be a patient'sbest resource with regard to theproper selection of the variousat-home diagnostic and monitoring testscurrently on the market. These productsfall into the personal diagnostics category.At-home diagnostic tests may assistpatients in detecting or monitoring certainmedical conditions, according tothe FDA's Office of In Vitro DiagnosticDevice Evaluation and Safety.

 At-hometesting provides various advantages,such as privacy, convenience, ease ofuse, and low cost. The FDA classifies athometest kits into 2 categories

&#8212;the patient collects thesample, performs the test, and readsthe results.

&#8212;the patient collectsthe sample, mails it to a laboratory,and obtains the results via phone.

Self-diagnostic kits provide patientswith information about their currenthealth condition, which enables themto make informed decisions. Althoughthe use of diagnostic kits may be convenient,the kits should never replace afollow-up visit with a physician. Properuse of these tests and adhering to themanufacturer's directions regardingtesting protocol are crucial to obtainingaccurate results.

 At-home diagnostictests may provide a patient with valuableinformation and enable patients toseek medical intervention earlier, preventingfurther medical complications.The Table lists some of the varioustypes of at-home tests available.

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The FDA requires that at-home testsperform as well as those used by healthcare professionals; however, thesetests must be used properly to ensureaccurate results.

 Pharmacists can bea fundamental source of informationfor patients seeking the use of at-homediagnostic test kits, as well as makingcertain that patients are adequatelycounseled on their proper use. Oftenthe selection of appropriate at-hometests may be based on ease of use, easeof interpreting results, presence of acontrol, and cost.

During counseling, pharmacists alsomay assess the patient's symptoms andascertain if immediate medical evaluationis warranted. It is important forpatients to consult with a health careprofessional, if needed, as well as thepatient information hotlines found inmost kits, if patients are unsure abouttest results or testing procedure. Patientsalso should be reminded thatalthough these testing kits may be beneficial,patients should always maintainroutine visits to their primary healthcare provider.

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Examples of Available At-Home Diagnostic Tests

MyAllergyTest Tests for Airborne and Food Allergens (ImmuneTech)

BIOSAFE Anemia Meter (BIOSAFE Medical Technologies Inc)

BIOSAFE Cholesterol Panel (BIOSAFE Medical Technologies Inc)

CardioChek HDL Cholesterol Test Strips (Polymer TechnologySystems Inc)

EarlyDETECT Cholesterol Test (EarlyDETECT)

First Check Home Cholesterol Test (First Check Diagnostics LLC)

Home Access Full Cholesterol Panel (Home Access Health Corp)

EarlyDETECT Colorectal Home Screening Test Kit (EarlyDETECT)

BIOSAFE Hemoglobin A1C Test (BIOSAFE Medical Technologies Inc)

EarlyDETECT Glucose Home Screening Test Kit (EarlyDETECT)

First Check Home 12 Drug Test (First Check Diagnostics LLC)

When used correctly, at-home diagnostic tests can prompt patients to seek early medical intervention, which is why proper counseling is important.

At-Home Diagnostic Kits: A Growing Trend

About 10 million Americans suffer from hemorrhoids. The occurrence of hemorrhoids is more prevalent among men than women, especially between the ages of 45 and 74 years, and increases with age.

 Hemorrhoids are varicose (swollen or dilated) veins that can be classified as 

 Some patients may experience both types simultaneously.

The symptoms associated with hemorrhoids vary from mild to severe. The most common symptoms of mild hemorrhoids include itching, pain, burning, discomfort, and inflammation. Symptoms such as bleeding, changes in bowel habits, severe pain, thrombosis, and seepage are indications of a more severe case of hemorrhoids or other anorectal disorders that may require medical evaluation by a physician.

 Various factors can be attributed to the etiology of hemorrhoids, including lack of dietary fiber, episodes of prolonged sitting or standing, pregnancy, history of constipation or diarrhea, and obesity.

Currently, there are a host of OTC hemorrhoid preparations on the market in formulations that include gels, creams, ointments, medicated wipes, and suppositories. These preparations may contain one or more of the following

?benzocaine, benzyl alcohol, dibucaine, lidocaine, pramoxine

?zinc oxide, shark liver oil, coca butter, topical starch, lanolin

These OTC products are intended for the self-treatment of mild cases of hemorrhoids. Individuals with preexisting conditions, such as diabetes, hypertension, cardiovascular disease, hyperthyroidism, and enlarged prostate, should avoid the use of preparations that contain vasoconstrictors. In addition, patients taking monoamine oxidase inhibitors, tricyclic antidepressants, or antihypertensive agents should avoid the use of topical vasoconstrictors.

 Pregnant or breast-feeding women should use only products designed for external use and should consult their primary care physicians prior to use.

Before recommending any of these products, pharmacists should ascertain the appropriateness of self-treatment and refer patients to seek medical care when warranted. Pharmacists should determine if the patient has any allergies or preexisting medical conditions. It is imperative that patients adhere to the recommended directions for use of the selected product. Pharmacists can assist patients in the selection of the dosage form that best suits their needs. Pharmacists can also make recommendations of nonpharmacologic measures, including eating a well-balanced diet, ensuring adequate fluid intake, increasing dietary fiber, or the use of a fiber supplement and/or stool softener. Pharmacists can advise patients to practice good personal hygiene, avoid lifting heavy objects or straining, take sitz baths if needed, and incorporate an exercise regimen into their daily routines. Patients should be encouraged to immediately seek medical care if symptoms worsen or new ones appear, such as severe pain or blood in the stool, or if symptoms are not showing signs of resolution after 7 days of self-treatment.

 Children under 12 years of age and patients with a history of colon cancer should always be referred to their primary care physician.

1.	Berardi RR, Kroon LA, McDermott  J, et al, eds. 

. 15th ed. Washington, DC: American Pharmacists Association; 2006: 351-369.

2.	Hemorrhoids. WebMD Web site. Available at: 

www.webmd.com/a-to-z-guides/digestive-disease-hemorrhoids

Hemorrhoid Preparations

Any signs of scalp infection or inflammation

Hair loss due to illness, use of certain pharmacologic agents, dietary changes, etc

Pharmacists can assist patients experiencing hair loss by reviewing medication profiles and possibly identifying those pharmacologic agents that may be associated with an increased risk of hair loss. Pharmacists should ensure that patients using minoxidil products are properly counseled on their correct use, as well as the importance of adhering to continuous use of the product to maintain regrowth of hair.

 In addition, pharmacists should inform patients that the product may not be effective for everyone and that it is a suppressive therapy and not a cure.

 Patients should also be informed that if there is no sign of new hair growth after 4 to 6 months of therapy, use of the product should be discontinued, and consultation with the primary health care provider is recommended.

1.	Hogue M. Hair loss. Berardi RR, Kroon LA, McDermott  J, et al, eds. 

. 15th ed. Washington, DC: American Pharmacists Association; 2006: 941-951.