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Onychomycosis and Diabetes: Patient Case Challenges

  • Authors: Warren S. Joseph, DPM
  • CME / ABIM MOC / CE Released: 6/27/2017
  • Valid for credit through: 6/27/2018
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Target Audience and Goal Statement

This activity is intended for dermatologists, primary care physicians, podiatrists, nurses and other clinicians who manage patients with onychomycosis.

The goal of this activity is to utilize case-based examples to address diagnosis, assessment of comorbidities, and individualizing treatment selection for patients with onychomycosis.

Upon completion of this activity, participants will:

  • have increased knowledge regarding the
    • Risks of untreated onychomycosis in the diabetic population
  • have greater competence related to
    • The selection of appropriate diagnostic tests for onychomycosis
    • Treatment individualization in patients with diabetes and onychomycosis


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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Warren S. Joseph, DPM


    Disclosure: Warren S Joseph, DPM, has disclosed the following relevant financial relationships
    Served as an advisor or consultant for: PharmaDerm; Valeant
    Served as a speaker or a member of a speakers bureau for: Valeant

    Dr Joseph does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Joseph does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Megan M. Stephan, PhD

    Freelance Writer, Somerville, MA


    Disclosure: Megan M. Stephan, PhD, has disclosed no relevant financial relationships.

  • Shari J. Dermer, PhD

    Scientific Director, Medscape, LLC


    Disclosure: Shari J. Dermer, PhD, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

CE Reviewer

  • Robert Eckles, DPM

    Associate Dean, New York College of Podiatric Medicine


    Disclosure: Robert Eckles, DPM, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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    For Nurses

  • Awarded 1.0 contact hour(s) of continuing nursing education for RNs and APNs; 0.75 contact hours are in the area of pharmacology.

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  • For Podiatrists

    Continuing Education Credits for this Education Event are awarded by the New York College Of Podiatric Medicine, which is an approved provider of CE in Podiatric Medicine and Surgery by the Council on Podiatric Medical Education. This completed event is awarded 1.0 credit hours.

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Onychomycosis and Diabetes: Patient Case Challenges

Authors: Warren S. Joseph, DPMFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/27/2017

Valid for credit through: 6/27/2018


The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Onychomycosis is a common infection that can lead to potentially severe complications in patients who have impaired circulation, peripheral neuropathy, or are immunocompromised. This infection is particularly common in patients with diabetes, many of whom have one or more of these conditions. Onychomycosis treatment reduces risks, but is complicated by the potential for drug-drug interactions between systemic antifungals and the large number of medications often taken by these patients. Several topical therapies are available, including two newer agents that became available in 2014, increasing the potential for individualized treatment selection. The following case-based activity will test your ability to select appropriate therapies in 2 patients with type 2 diabetes and onychomycosis, while bringing you up to date on risks and management of toenail infections in this vulnerable patient population.

Case 1: Albert

Albert is a 55-year-old man with type 2 diabetes who presents to your office with 10 thickened, elongated, yellowed toenails (Figure 1). He reports that he first noticed the changes in his toenails about 3 months ago, at which time most of his nails were already involved. Albert was diagnosed with type 2 diabetes 4 years ago, and his blood sugar is currently poorly controlled on metformin alone. He has elevated triglyceride levels for which he is taking a low dose of simvastatin. He is clinically obese, which may have contributed to the fact that he did not notice his toenail infection until it was well entrenched.

On clinical examination, you observe that all of Albert’s toenails are yellow in color and 6 have white lateral streaks. Two nails show involvement extending proximally to the lunula. Several nails, including both great toenails, show subungual hyperkeratosis that is greater than 2 mm thick and two are onycholytic. You estimate that at least 75% of the overall area of Albert’s toenails is infected, with involvement seen in all 10 toenails.

Figure 1. Onychomycosis of the toenails.

Photo courtesy of Warren Joseph, DPM.
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