Tinea pedis is probably the most common diagnosis observed in podiatry clinics today and in time, many patients go on to develop toenail infection as the disease progresses. For some, onychomycosis is the main reason for seeking professional advice, whilst for others, its diagnosis may come as a surprise during their appointment but what is the real impact of the disease on the patient?
Over the years, there have been a number of studies which have investigated what it's like to have a fungal nail infection from a patient’s perspective [1-3], using quality of life measures to quantify the effects. These are typically measured using a patient-reported outcome measure (or PROM for short). To be of any use, such tools need to be tested to ensure they are measuring the effect they say they are (a process known as “validation”).
In a forthcoming publication in the Journal of the American Academy of Dermatology, Stewart et al., have undertaken a systematic review of evidence to collate and evaluate the effects of onychomycosis and its treatment on the patients quality of life (QOL) [4]. From 1993 to 2020, the authors reviewed 30 papers on the subject which met their robust inclusion criteria. Interestingly, only half of the studies used previously validated tools to assess the effects of the disease on their patients, the rest used unvalidated, ad-hoc questionnaires to assess their patients. Validated tools identified in this study were:
International Onychomycosis-specific Questionnaire [5].
Quality of Life Questionnaire for Toenail Onychomycosis (OnyCOE-t) [6]
Dermatology Life Quality Index (DLQI) [7]
Bristol Foot Score [8]
NailQoL score [9]
So, what were the main findings? The review covered onychomycosis in a range of patients throughout adulthood (16-92). All the studies concluded that onychomycosis had an impact on the patients’ lives (many significantly), particularly in females who in many studies had worse QOL scores than men. Typical issues were concerns with the appearance of their nails, inconvenience of needing to seek treatment, embarrassment, pain and other symptoms. As expected, fingernail involvement in some studies was of greater concern than toenail although this was not a universal finding across all of the studies.
The second aspect reported by the study was the effect of treatment on those QOL scores and within these studies, it showed that treatment improved a patients QOL score whether it was oral or topical (or both). However, it was suggested in some that oral treatments such as terbinafine and itraconazole led to greater improvements in those QOL scores than topical treatments.
The findings from this work are probably no surprise to practitioners although I would add that all of these patients who were included in these studies were self-selecting in that they all originally were seeking treatment for their fungal nails. So, patients with onychomycosis who did not seek professional treatment were not included and ultimately this will skew the results. Nevertheless, this work highlights the effects of the disease on patients coming into our clinics seeking advice and we should certainly look to improve their nail appearance to help the patient have an improved quality of life. In addition, if practitioners are looking to audit their own success in treating onychomycosis from a patients point of view, it is perfectly feasible to use these measures in the clinic before and after treatment to quantify and demonstrate the positive benefit treatment for onychomycosis can achieve – perhaps there’s another blog article in that but certainly food for thought.
References
1. Lubeck D, Patrick D, McNulty P, Fifer K, Birnbaum J. Quality of life of persons with onychomycosis. Qual Life Res 1993, 2;341-348.
2. Elewski B. The effect of toenail onychomycosis on patient quality of life. Int J Dermatol 1997, 36;754-756.
3. Drake L, Scher R, Smith E, Hong J, Stiller M. Effect of onychomycosis on quality of life. Journal American Academy of Dermatology 1998, 38;702-704.
4. Stewart CR, Algu L, Kamran R, Leveille CF, Abid K, Rae C, Lipner SR. Impact of Onychomycosis and Treatment on Patient Reported Quality of Life Outcomes: A Systematic Review. J Am Acad Dermatol 2020.
5. Drake LA, Patrick DL, Fleckman P, Andr J, Baran R, Haneke E, Sapede C, Tosti A. The impact of onychomycosis on quality of life: development of an international onychomycosis-specific questionnaire to measure patient quality of life. J Am Acad Dermatol 1999, 41;189-196.
6. Potter LP, Mathias SD, Raut M, Kianifard F, Tavakkol A. The OnyCOE-t questionnaire: responsiveness and clinical meaningfulness of a patient-reported outcomes questionnaire for toenail onychomycosis. Health Qual Life Outcomes 2006, 4;50.
7. Dermatology Life Quality Index (DLQI) [http://www.dermatology.org.uk/quality/quality-dlqi.html]
8. Barnett S, Campbell R, Harvey I. The Bristol Foot Score: developing a patient-based foot-health measure. J Am Podiatr Med Assoc 2005, 95;264-272.
9. Warshaw EM, Foster JK, Cham PMH, Grill JP, Chen SC. NailQoL: a quality-of-life instrument for onychomycosis. Int J Dermatol 2007, 46;1279-1286.