View Full Version : Onychomycosis - how do I deal?
As if anxiety, panic, palpitations, etc. weren't good enough to "entertain" me, I got an onychomycosis on my big toes a few months ago, which in turn is causing me extra anxiety. A topical therapy of ciclopirox hasn't worked so far so the dermatologist prescribed me oral itraconazole (also known as Sporanox, 400 mg/day for 7 days in a row each of 4 months), and amorolfine (topical nail lacquer, twice weekly). I'm afraid to take the pills because that drug has strong reported hepatotoxic side effects (some were fatal in clinical trials). Besides, it decreases the force of contraction of the heart muscle (negative inotropic effect), it can provoke hearing loss and it can cause Stevens-Johnshon syndrome (rarely, but it still can), among a long list of other dreadful adverse effects (one of the hugest list I've ever seen). Do you know of any other therapy to this fungal infection that doesn't involve taking pills (all oral antimycotics have scary side effects) and that is effective??? I'm fed up with them! At the moment I've been applying only the topical agent amorolfine and povidone iodine below the nails but I doubt this will work. Have any of you ever been through a similar situation? Did you get rid of the fungus? How? Thanks...
Think about how many millions of people are prescribed with that medication and I'm sure it didn't kill any of them. Besides if people involved in the trial died whilst taking the drug what's to say that they didn't have an underlying condition already that killed them or a sudden illness unrelated to the drug? Put it this way if it was going to kill people it wouldn't have passed the trials and wouldn't be allowed to be prescribed to anyone, so just take it I promise it won't kill you!!! :)
Why even go to the doctor if you're not going to take the prescribed meds? :doh:
Positive thoughts
Think about how many millions of people are prescribed with that medication and I'm sure it didn't kill any of them. Besides if people involved in the trial died whilst taking the drug what's to say that they didn't have an underlying condition already that killed them or a sudden illness unrelated to the drug? Put it this way if it was going to kill people it wouldn't have passed the trials and wouldn't be allowed to be prescribed to anyone, so just take it I promise it won't kill you!!! :)
Thanks for reassuring me. Yes, those people had underlying conditions I guess. But how do I know that I haven't any of that? I suffer from anxiety, panic and now it seems that I have ectopic heart beats as well (5 supraventricular and 1 ventricular in the last holter I did last month). According to the cardiologist they're normal and benign, but according to me that's too much. Moreover, I'm taking a beta-blocker that is extensively metabolized in the liver, just as itraconazole is. The pernicious effects on the liver might add up, just as the negative inotropic effects on the heart (despite itraconazole being a drug to treat infections by fungi, it also affects the heart)... At the moment I'm not taking any antidepressant, and I hope I don't have to resume any of those "assassin" pills, but one never knows. Additionally I take one to several benzodiazepines almost daily to calm me down. So you see this is sort of a cocktail of drugs. That's why I'm afraid. I think dermatologists take this too lightly. It's like they're telling us to take the drug and if we die they're sorry but they couldn't have done any better... They're just cold and detached from their patients fears. I'm now looking for another dermatologist to see if we can find another type of treatment, like removing the affected nail and applying directly on the nail bed a topical antimycotic agent.
---------- Post added at 17:55 ---------- Previous post was at 17:52 ----------
Why even go to the doctor if you're not going to take the prescribed meds? :doh:
Positive thoughts
Because they prescribe meds without taking into account potential side effects, interactions, etc. They prescribe them and if anything happens it's as if it's not their fault... It's our body's fault. I think I should not be given oral itraconazole.
Thanks for reassuring me. Yes, those people had underlying conditions I guess. But how do I know that I haven't any of that? I suffer from anxiety, panic and now it seems that I have ectopic heart beats as well (5 supraventricular and 1 ventricular in the last holter I did last month). According to the cardiologista they're normal and benign, but according to me that's too much. Moreover, I'm taking a beta-blocker that is extensively metabolized in the liver, just as itraconazole is. The pernicious effects on the liver might add up, just as the inotropic effects on the heart (despite itraconazole being a drug to treat infections by fungus, it also affects the heart)... At the moment I'm not taking any antidepressant, and I hope I don't have to resume any of those "assassin" pills, but one never knows. Additionally I take one to several benzodiazepines almost daily to calm me down. So you see this is sort of a cocktail of drugs. That's why I'm afraid. I think dermatologists take this too lightly. It's like they're telling us to take the drug and if we day they're sorry but they couldn't have done any better... They're just cold and detached from their patients fears. I'm now looking for another dermatologist to see if we can find another type of treatment, like removing the affected nail and applying directly on the nail bed a topical antimycotic agent.
---------- Post added at 17:55 ---------- Previous post was at 17:52 ----------
Because they prescribe meds without taking into account potential side effects, interactions, etc. They prescribe them and if anything happens it's as if it's not their fault... It's our body's fault. I think I should not be given oral itraconazole.
Well then... based on your responses, I think you have a bit of a conundrum on your hands. Hope you find something that works for you.
Positive thoughts
Not to frighten you even more, Junot, but have you taken into account that if this infection proceeds to your bloodstream, then you can very well die from that? I used to send women directly to their doctors from my spa when I would see it. My esthetics training took this very seriously, and if it is recognized by pedicurists or podiatrists, they won't touch it with a barge pole. The spores become airborne when the nail is cut and it is highly contagious to others. As you have found out, the spores are highly resistant to topical medication. Once a doctor determines the infection is at the stage where it must be treated orally, it is at a stage where it will only respond to oral treatment. Like many infections, untreated it will likely get into the bloodstream and once that happens, you will be very, very sick, and at risk of cardiac complications and death. Perhaps this wasn't explained because the doctor didn't know you would simply decide to not take treatment.
No doctor is going to prescribe a treatment when the risks of side effects is greater than leaving it untreated. If you believe that your doctors will, then you need to find new ones, and report these seriously lacking medics to the authorities. Your actual health is in your own hands ...
Not to frighten you even more, Junot, but have you taken into account that if this infection proceeds to your bloodstream, then you can very well die from that? I used to send women directly to their doctors from my spa when I would see it. My esthetics training took this very seriously, and if it is recognized by pedicurists or podiatrists, they won't touch it with a barge pole. The spores become airborne when the nail is cut and it is highly contagious to others. As you have found out, the spores are highly resistant to topical medication. Once a doctor determines the infection is at the stage where it must be treated orally, it is at a stage where it will only respond to oral treatment. Like many infections, untreated it will likely get into the bloodstream and once that happens, you will be very, very sick, and at risk of cardiac complications and death. Perhaps this wasn't explained because the doctor didn't know you would simply decide to not take treatment.
No doctor is going to prescribe a treatment when the risks of side effects is greater than leaving it untreated. If you believe that your doctors will, then you need to find new ones, and report these seriously lacking medics to the authorities. Your actual health is in your own hands ...
Thanks. Yes I know all that, but generally the risk of spreading to other parts of the body, or into the bloodstream, is limited to eldery patients or to those patients with comorbidities (such as diabetes or AIDS). There are millions of people who live with this left untreated until they die (of other causes). Of course I want to get this treated for the sake of my health and aesthetics, I'm just looking for another dermatologist because the one I went to didn't make me feel very confident. And of course I would prefer a non-systemic treatment if possible. That's why this time I'm going to see a dermatologist in a dermatology-only center where they have all the equipment and methods for dermatological care, including laser therapy (if necessary I would prefer it over oral medications).
generally the risk of spreading to other parts of the body, or into the bloodstream, is limited to eldery patients or to those patients with comorbidities (such as diabetes or AIDS).
Can you not apply this same logic to the risks of medication? The risks of side effects, no matter how rare, are required to be reported and written with the medication. Even over the counter medicines carry side effects that can prove to be detrimental. Having been on SSRIs for an extended period of time, you've obviously overcome the detrimental risks associated with them. Why allow a rare side effect stop you from taking something that will alleviate the issue. It's only for a short period of time and the benefit far outweighs the negative.
Positive thoughts
Can you not apply this same logic to the risks of medication? The risks of side effects, no matter how rare, are required to be reported and written with the medication. Even over the counter medicines carry side effects that can prove to be detrimental. Having been on SSRIs for an extended period of time, you've obviously overcome the detrimental risks associated with them. Why allow a rare side effect stop you from taking something that will alleviate the issue. It's only for a short period of time and the benefit far outweighs the negative.
Positive thoughts
You're right. I'll do it, but first I will see this new dermatologist to have a second opinion. If he tells me there's no other way to treat this I'll take those pills even though I know I'll feel anxious the first days, wondering whether this or that symptom might be due to them.
Well, I had an appointment with another dermatologist today. He told me that the first-line therapy to treat onychomycosis is oral terbinafine (at the moment this is the drug with the best risk/benefit ratio). Non-pharmacological treatments or topical agents aren't effective. He also told me that despite this fact, the chance of cure is not 100% but about 80%. He is aware that there is an interaction between the beta-blocker I'm taking and terbinafine. Terbinafine inhibits the liver cytochrome that metabolizes the beta-blocker, hence whislt on terbinafine I'll most likely have higher levels of beta-blocker running through my blood, which in turn increases the chance of adverse effects due to the beta-blocker (such as severe hypotension and/or bradycardia, heart block, among others).
Pharmaceutical companies always tell us to IMMEDIATELY contact OUR doctor as soon as we experience one out of an endless list of adverse effects. Thing is, how am I supposed to immediately contact MY doctors? They don't give me their telephone number so that I can contact them immediately. They're not at the medical centers I go to every single day of the week waiting for me to come in. They have other patients and their own life as well. So, if I happen to feel any adverse effect I can do nothing but schedule an appoitment (and that means that I'll have to wait several days) or visit an urgent care center or hospital ER (and there it won't even be MY doctor that will assess my situation).
So, in the end, I'm still reluctant to take these sort of drugs lightly... Should I visit my cardiologist first? I actually have an appointment with him scheduled for September, no less! - he happens to be a very busy man and has loads of patients... Perhaps he would tell me to reduce my beta-blocker daily dose to a quarter pill, or not, I don't know. My last ECG (done last week) is normal but accuses a sinus bradycardia (59 bpm). In addition my blood pressure usually oscillates from 90 to 110 mmHg (systolic) and 60 to 80 mmHg (diastolic), so I'm afraid that terbinafine helps to lower this even further to such a point that I faint or that I have a heart block or any other sort of hemodynamic instability.
The dermatologist told me to take this terbinafine once daily for three months and to stop it only if I happen to experience any adverse effect. But what if it's too late? Moreover, I've been experiencing lately such a level of anxiety that I guess that it would be difficult for me to know whether any given symptom is due to anxiety or to a new medication. What would you do? Should I wait for the cardiologist appointment considering there is a beta-blocker-terbinafine interaction?
Do you have a heart condition?
Do you have a heart condition?
No, the cardiologist gave me a beta-blocker just to counterbalance/block the effects of anxiety on the heart due to noradrenaline (I used to have a fast heart beat very easily and when I got very anxious or panicky my heart rate would go over 100 bpm). However now it seems IMO that the beta-blocker is lowering it a bit too much along with the blood pressure. But I have no heart condition according to all the heart tests I've done so far.
Well, that's good! But maybe checking with your cardiologist will finally put your mind at ease about taking the antifungal drug? All round, unless there is something serious to contraindicate it, it is clear that you must take it to heal up. ...
Let me ask you a question. If you had cancer, would you worry about the side effects of the treatment? I don't think so! The side effects of radiation and chemo are 100X worse than what could possibly happen with the prescribed medication. I know first hand as I deal with them every day but it sure beats the hell out of the alternative!
Albert Einstein said:
"Insanity is doing the same thing over and over again and expecting different results."
Prove to yourself you're sane. Look this irrational fear straight in the eyes and say "FU" and take care of this! You asked how you deal with Onychomycosis. You've had two medical professionals tell you. Now you have a choice, plain and simple. What's it going to be?
Positive thoughts and rational decisions
Has either your GP or the dermatologist given you an idea of how much longer they feel you have before you must make the decision to start the anti-fungal? If there is time, then you may feel better about the whole thing if you have the cardiologist's input. You may as well consult one of them meanwhile, as they will naturally assume you have followed through by now, and if there is more urgency as the weeks go by, you will need to weigh that into your decision. In consideration of your health, heart and otherwise. ...
Good luck!
Marie
Thanks both of you for your answers.
Fishmanpa, I don't know how I would react if I had cancer and I had to do radio a chemotherapy. But probably I wouldn't overthink it so much since the other option would be (most likely) death.
SADnomore, fortunately this is not a very urgent issue. The infection progresses very slowly, it's usually self-limited to the toenails and many times remains stationary. The dermatologist told me: "you can keep on applying topical agents for years and most likely the fungi will stay in your toenails with the risk of spreading to the healthy ones or you can take the pills and you have 80% of chances to be cured in three months even though you'll only see the results when a new nail has totally grown, which takes about 6 to 12 months".
By the way, I got my blood tests results today and unfortunately my liver enzymes levels (which doctors use as markers of hepatotoxicity) are a bit higher than they should be. I can tell you that my AST is 95 U/I (normal range is 12-78) and my ALT is 37 U/I (normal range is 15-37). This can be due to many things, I would go for exertion (I've been exercising everyday as you may be aware of) or an occasional variation, but I want to know what the doctors have to say first. I have an appointment with my GP/family doctor on August 20th and then in September with the cardiologist, so I'll wait until I get their opinions, in the light of this new data, since these oral anti-fungal drugs are, among other things, very prone to cause hepatotoxicity as well.
Thanks again for your time!
Fishmanpa, I don't know how I would react if I had cancer and I had to do radio a chemotherapy. But probably I wouldn't overthink it so much since the other option would be (most likely) death.
The dermatologist told me: "you can keep on applying topical agents for years and most likely the fungi will stay in your toenails with the risk of spreading to the healthy ones or you can take the pills and you have 80% of chances to be cured in three months even though you'll only see the results when a new nail has totally grown, which takes about 6 to 12 months".
Don't take the pills and there's a 0% chance of a cure and a probable risk of spreading the fungus. From what I know, the condition isn't painful, just unsightly. So, if you don't mind having green toe nails....... ;)
Positive thoughts
Dear Junot,
I took Itraconazole 200 mg 2x per day for five days-I couldn't finish the first week. I broke out in a rash, gained over five lbs of water weight and have been extremely anxious since taking the meds. I took them twenty years ago, and had no issues, but this time it has been really bad. It has been three weeks and I am still feeling the side effects. I would love to get rid of the fungus in my toe nails, but I will not take oral antifungals again. Your fears with these meds are very real. Sometimes the side effects of meds are worse than the issue one is taking them for. I wish you the best.
Dear Junot,
I took Itraconazole 200 mg 2x per day for five days-I couldn't finish the first week. I broke out in a rash, gained over five lbs of water weight and have been extremely anxious since taking the meds. I took them twenty years ago, and had no issues, but this time it has been really bad. It has been three weeks and I am still feeling the side effects. I would love to get rid of the fungus in my toe nails, but I will not take oral antifungals again. Your fears with these meds are very real. Sometimes the side effects of meds are worse than the issue one is taking them for. I wish you the best.
Thank you so much for sharing.
Yes, oral anti-fungals are amongst the drugs with the most side effects and one must ponder very well whether the benefits are higher than the risks. Sometimes doctors don't know how to be doctors and, in my case, they think that if you are 29 years old you can stand almost anything.
I've been told by one dermatologist to take 400 mg of itraconazole per day for 4 weeks, each week spaced by an interval of 22 days, and I've been told by my GP and other dermatologist (with whom I've had an appointment to have a second opinion) to take 250 mg of terbinafine per day for 3 months. Both of these agents have very similar side effects, but itraconazole is slightly worse in that respect. Of course, I didn't take any of them and I guess I've made the right decision.
By chance, I had several tests done this month, requested by a cardiologist I use to see due to my heart-related anxiety symptoms, and they showed that my liver enzymes and urine albumin are a bit over their normal range (as you might know, these are used as liver and kidney function markers, respectively) and apparently one my heart valves (the one between the right atrium and ventricle) is allowing a tiny reflux of blood from the ventricle back into the atrium. The (not so) funny thing is that itraconazole and terbinafine have not only toxic effects on the liver, but they also have direct effects on the heart (they decrease the heart contractility). I'm wondering what could have happened had I taken those pills, especially because I'm on a beta-blocker as well and the doctors are very aware of the potential interactions between these and oral anti-fungals. However, NONE of the doctors (GP and two dermatologists) referred me for tests to assess my general health status nor my liver function before prescribing these medicines. It is recommended to assess liver function before starting a treatment with itrazonazole or terbinafine, and in my case I think that caution should be seriously taken. Besides, only two of them have told me to check my liver enzymes a month after starting the treatment (this is a standard procedure, or should be, because some seem to forget it). In my view all this I've been through is totally irresponsible, given my history of anxiety, panic disorder and the medication I'm currently on.
Anyway, at the moment I am just applying topical amorolfine (this drug isn't available in the U.S.) and it's kind of working. I can see some improvements now. I managed to cut the part of the toenail that was infected, because it was cracking by itself, so I am able to apply it directly over the nail bed, which might be helping. The treatment might take a year but I prefer it over the risks of taking oral itraconazole or terbinafine.
Keep trying topical treatments on your toenails. It might take as long as a year to get rid of the fungi, but I think it's worth the waiting in comparison to those oral drugs.
Best regards!
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