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Re-evaluating guidelines for testing and treating toenail fungus

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Onychomycosis – a fungal infection of the toenails – is the most common nail disease in adults. The American Board of Internal Medicine's Choosing Wisely campaign recommends confirmatory testing before treatment begins, but this recommendation is based on data from 1999. Brigham and Women's Hospital researchers led by Arash Mostaghimi, MD, MPA, MPH, of BWH's Dermatology Department, set out to test whether such recommendations still make medical and economic sense.

The research team evaluated treatment with one of two therapies: an oral pill called terbinafine or a topical solution of efinaconazole, 10 percent (Jublia). The team found that treatment and monitoring for the oral pill cost an average of $53; a full course of treatment with the topical solution costs $2307 per nail. The team found that for the oral pill, the price of confirmatory testing exceeded the cost of treating all suspected cases. Researchers also note that cases of adverse effects from treatment are very rare–on average, it would cost between $18.2 and 90.2 million to avoid one case of liver injury. For the topical solution, however, confirmatory testing before treatment substantially reduced costs, suggesting that confirmatory testing should still be used before beginning treatment with efinaconazole.

"Blanket recommendations for confirmatory testing before systemic therapy should be reconsidered and replaced with recommendations tailored to specific therapies," the authors write.

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