Chemical Peeling as an Innovative Treatment Alternative to Oral Antifungals for Onychomycosis in Special Circumstances.

Toe nail onychomycosis (ONM) is a common problem in elderly patients. Treatment in diabetic patients with associated comorbidities such as congestive heart failure becomes a challenge. Oral antifungals are best avoided owing to most of them being contraindicated or unsafe due to comorbidities and/or risk of drug interactions stemming from polypharmacy. Topical agents alone are not effective. Unlike isolated ONM in healthy and younger patients, ONM involving multiple nails in geriatric and diabetic patients warrants treatment as it serves as a source of recurrent tinea of the feet and other sites, and even contributes to formation of diabetic foot ulcers. Long-pulsed Nd:YAG and fractional CO>sub<2>/sub< laser (in addition to antifungals) have been reported to provide gratifying results in toe nail ONM. But high treatment cost is a major limitation. Nail peeling with glycolic acid (GA) and low-concentration croton-oil free phenol (CFP) peels have been used in different nail conditions but not specifically for ONM. We report the successful use of Black peel (a superficial-to-medium depth peel used typically for anti-acne and cosmetic indications), a combination of 50% black acetic acid, 0.5% salicylic acid, 6% tetrahydrojasmonic acid, 10% bio sulphur, and 0.1% potassium iodide, in two difficult cases with ONM of multiple nails, the rationale of use being the additional anti-fungal effects of all the peel components.