面试官: They're ugly, and, for some, nail fungus can be painful and 也 very tough to get rid of. 皮肤科医生, Dr. 克里斯托弗·赫尔, what's the 第一个 thing you do when a patient comes in with nail fungus?
Dr. 船体: 好吧, 第一个, 我想确定它确实是指甲真菌, because there are other nail conditions that can look very similar to and mimic nail fungus. 首先通常要对指甲进行评估. Sometimes we'll do some confirmatory testing with clippings and cultures and scrapings. 然后, once we're comfortable that it's a fungal infection and not another condition of the nail that looks like nail fungus, then we talk about how it's affecting them and what they're hoping to achieve as far as treatment.
面试官: 明白了吗. 所以如果是其他原因，治疗方案会有所不同. 这就是为什么你真的想知道 . . . 是真菌，对吧?
Dr. 船体: 正确的. And treating nail fungus is notoriously very challenging, often with failures along the way. And so it's important to be sure that before you start going down the path of treatment, 你的诊断是正确的.
面试官: 而且它可能需要很长时间才能治疗. 所以你不会想要走这条治疗之路，然后 . . . 是的.
Dr. 船体: 正确的. And some of the treatments require monitoring and have some risks associated with them.
指甲真菌的治疗选择
面试官: 明白了吗. 所以你发现这是一种指甲真菌. 在这一点上，有什么治疗选择?
Dr. 船体: 治疗方法有很多. 你知道，有很多东西可以在柜台上买到. You go to the internet and Google "nail fungus treatment," you'll come up with 10,000 hits, I bet.
面试官: 是的，药片，抛光剂，面霜?
Dr. 船体: 正确的.
面试官: 是的，各种各样的事情. 你喜欢用什么?
Dr. 船体: Most of those have not been investigated with really good clinical trials. But I think there's things that people have used and have found to be helpful. 最常见的是含有薄荷醇的产品. Vicks VapoRub是一种常见的治疗指甲真菌的药物. 这可能不会有大发娱乐. 但它也不会伤害任何东西.
我的大部分谈话通常都是在讨论药物治疗, 这些东西只能凭处方买到. 这些主要有两种形式, 哪些是局部抗真菌药物, 然后是口服抗真菌药物. 还有其他的 手术或程序选择，所以你也可以去除指甲. 然后 there's starting to be more interest in technologies like lasers for nail fungus.
面试官: So you would said at one point that you have a conversation with the patient, 你想要完成的是什么. 我知道对有些人来说这是非常痛苦的. 所以这可能是为了减轻指甲的厚度和疼痛.
Dr. 船体: 正确的. And it gets difficult to clip, trim, and groom nails when they get very thick. 它可能与指甲内生引起的疼痛有关. And in some cases, it can 也 predispose people to infection, so cellulitis and so forth. 所以有医学上重要的原因来治疗它们. 有些人就是不喜欢指甲的样子.
面试官: 是的. 因为穿你的人字拖不好看，对吧?
Dr. 船体: 正确的. 夏天穿凉鞋的时候带厚, yellow nails is something that a lot of people would like to not have to do.
面试官: 如果不是很痛，你会建议治疗吗? 你真的要让病人自己决定吗?
Dr. 船体: 是的. 我的个人哲学是让病人自己决定. 所以我给了他们不同的选择, 谈谈治疗的时间长短, 监控, 成功的可能性, and then have a conversation with them about whether they want to move forward with those treatments. And a lot of people like not to do anything and many people are very motivated to treat their nails.
口腔治疗的利弊
面试官: 确定. 那口服药物呢? I understand that some people are concerned about the side effects those can cause. 一般来说，口服药物比外用或 . . .
Dr. 船体: 是的. 口服药物比局部治疗更有效.
面试官: 确定.
Dr. 船体: The good news though is that the safety of most of these oral medications is very good. 而且治疗也便宜得多. So there's quite a bit of cost benefit from using the oral medications.
面试官: 口服药物的副作用有哪些?
潜在的肝毒性
Dr. 船体: The primary concern is liver toxicity, because these medications are metabolized by the liver. 看看口服药物和局部药物的成本效益, I'm really sort of arguing for the oral medication because it's so much less expensive. 但后来, 也, looking at a lot of the safety information about the medication and the risk of serious liver adverse event is very low in that medication. 尽管如此，我还是会建议进行适当的监控. And that's laboratory testing, usually a baseline and then midway through the treatment.
面试官: 是基于抗生素的吗？?
Dr. 船体: 它们是抗真菌的，所以它们对真菌有特异性. 所以它们对细菌没有像抗生素那样的作用.
面试官: So people that are afraid of antibiotics for whatever stomach reasons they might have.
Dr. 船体: 是的. 它不会对肠道菌群产生任何影响. 实际上，有趣的是，他们没有 . . . 这个特别的, terbinafine, doesn't have an effect on the natural yeast that we see in the intestine called candida. 所以应该不会有任何影响. Some people can get rashes, and there's, 你知道, other less common side effects. 但在大多数情况下，我发现他们是可以容忍的.
指甲真菌的家庭疗法
面试官: Some of the home remedies that I saw, you mentioned Vicks VapoRub, snake root extract, tea tree oil . . .
Dr. 船体: 我还没见过蛇根提取物. 但听起来它可能会把指甲吃掉.
面试官: 确定.
Dr. 船体: 是的. 外面有很多这样的东西. 很多人用醋，茶树油. The hard part with any of these topical medicines is they don't penetrate the nail unit very well. So getting them, actually, to the fungus in the nail unit is very difficult. And that's why a lot of the prescription topical medicines have such limited effects.
面试官: What about do-it-yourself at home trying to thin that nail out like, 你知道, by coating it with . . . 人们给它涂上什么?
Dr. 船体: 我觉得在家里做清创其实很有大发娱乐. 所以很多时候, 我会让人把指甲锉平, 把钉子夹回去, because that helps to kind of trim away some of the infected nail as well.
口腔治疗的最佳候选者
面试官: 你有什么建议吗？, 一般, be for somebody to use the oral pills if possible just because it's such a shorter treatment time?
Dr. 船体: 嗯，我认为这取决于个人. 有些人还有其他的危险因素, who have a history of liver disease or something where I wouldn't be comfortable putting them on that medication. 所以我使用两种药物，有时我使用它们的组合. So I'll have them do a 第一个 course with an oral antifungal and then follow up with a topical. 这也可能有助于防止再次感染.
面试官: 这在我的理解中很常见.
Dr. 船体: 是的. 所以这很常见. 你可以把指甲弄干净, 然后人们就暴露在环境中的真菌中, 站在他们的立场上，等等, 而且他们很容易再次感染.
面试官: 听起来好像有人得了甲真菌, 在很大程度上, 因为它很丑，所以让你烦恼吗? If there's pain involved, then for sure, you would recommend some treatment. 对一些人来说，可能还有其他医学原因需要治疗.
Dr. 船体: 对,是的. 有人用, 你知道, 例如, 有患足部溃疡风险的糖尿病患者, 蜂窝织炎感染, 他们是可能的人 . . . they may be more proactive about treating to help reduce their risk of infections.
面试官: 但在大多数情况下, 听起来好像你没有什么症状, 这只是一种个人选择?
Dr. 船体: 这是真的.
更新日期：2020年8月26日
最初发布日期：2017年7月19日
