We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Comment & Response |

Confirmatory Testing for Onychomycosis

Apphia L. Wang, MD1; Boni E. Elewski, MD1; Craig A. Elmets, MD1
[+] Author Affiliations
1Department of Dermatology, University of Alabama at Birmingham School of Medicine, Birmingham
JAMA Dermatol. 2016;152(7):848. doi:10.1001/jamadermatol.2016.0786.
Text Size: A A A
Published online


To the Editor Mikailov and colleagues1 propose that the empirical treatment of onychomycosis with terbinafine without confirmatory testing is cost-effective. While the approach may be reasonable when disease prevalence is exceedingly high, prescribing medications with known adverse effects, some serious, leads to delay in correct treatment and unnecessary therapy for patients with dystrophic nails who do not have onychomycosis. In fact, only about half of dystrophic nails are caused by fungi2,3; the other half are manifestations of psoriasis, lichen planus, and trauma, among other causes. If empirical treatment is provided for clinically suspected onychomycosis in dystrophic nails, correct treatment is delivered only half the time, the same probability as a random coin flip. The calculations of cost savings using 75% disease prevalence by Mikailov et al1 overestimate savings. Fingernail dystrophy without toenail involvement is seldom caused by a dermatophyte; therefore, empirical treatment with terbinafine should be administered with caution. Furthermore, recent meta-analyses for the prevalence of onychomycosis in Europe and North America estimate it to be only 4%, with previous reports of 7% to 14% in North America.35


Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





July 1, 2016
Shari R. Lipner, MD, PhD; Richard K. Scher, MD
1Department of Dermatology, Weill Cornell Medicine, New York, New York
JAMA Dermatol. 2016;152(7):847. doi:10.1001/jamadermatol.2016.0785.
July 1, 2016
Anar Mikailov, MD; Cara Joyce, PhD; Arash Mostaghimi, MD, MPA, MPH
1Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
2Walgreen Co, Deerfield, Illinois
JAMA Dermatol. 2016;152(7):848-849. doi:10.1001/jamadermatol.2016.0784.
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...