Reason for attending the office: This patient attended complaining of a nail that had recently gone ‘funny’ on the right big toe.  Careful assessment revealed a fungal toenail infection.

Agreed treatment: After discussing treatment options which include taking pills, painting on medication and laser surgery for fungal nails, it was mutually agreed that ‘fenestration’ would the best initial treatment option.  A simple procedure is carried out with a sterile medical tool to make tiny little hollows in the fungal nail. The aim of this treatment is to allow a prescribed liquid antifungal to then wick through the hollows and reach the infection.  This procedure suited the patient due to the ease of treatment and minimal discomfort.

Alternative Treatment Discussed:  It was discussed that layered treatment may be needed which could include the use of other modalities such as fungal nail laser surgery and the use of pills.  A layered approach to treatment can help with aims of obtaining some cosmetic improvement and/or a reduction in fungus.

Outcome: At follow up a marked clinical improvement was noted.

Timeframe: The usual timescale for a large toenail to grow from bottom to top is usually about 12 months.  

Conclusion: This is a good example of how treatment can be layered for fungal nail infection.  Whilst this nail responded well to fenestration and topical treatment some infections may require the use of other modalities such as fungal nail laser surgery and / or the use of pills.

Please note that in most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the hierarchy, with single case studies, expert opinion and anecdotal experience at the bottom.

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