The prognosis of the patient determines referrals for the management of onychomycosis. Failure to respond to therapy in spite of the administration of maximal doses of the therapeutic agents necessitates a referral. The referral provides a window for reexamination and a second opinion which easily covers up for any omissions on the previous treatment plan. In cases where there is extensive systemic involvement of the disease, it is prudent to refer. This provides an opportunity for the handling of any emergencies that easily arise from sepsis (Anfilova, 2018) . The above patient has edema on the ankle which is a possible indicator of the disease's systemic progression. Patients with comorbidities that are not easily manageable within a given set up are also referred. Comorbidities must be managed concurrently for maximal recuperation. Besides the onychomycosis the above patient is diabetic and this condition may necessitate referral.
Various nonpharmacological approaches to managing onychomycosis exist. The use of laser treatment and photodynamic therapy is one of them (Batool, 2019) . Laser beams possess energy which, when directed on the fungal cultures, quickly eliminates them. Mechanical avulsion of the affected nails helps manage the condition especially in resistant fungal species. The nail plate can equally be removed. Most of these methods, however, are used together with the various oral medications.
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It is necessary that the patient is offered the best care for the toe owing to the diabetic history of the patient. Diabetes is known to cause diabetic sores on the legs and thus, the presence of onychomycosis is a risk factor for a possible septic wound. The patient needs to understand a public bathroom is a possible cause of fungal infection and thus should keep away from such (Singal & Khanna, 2011) . Adherence to medications and optimal foot hygiene must be observed to enable better treatment outcomes.
References
Anfilova, M. R. (2018). Therapy of onychomycosis: problematic issues and practical guidelines. Ukrainian Journal of Dermatology, Venerology, Cosmetology , 0 (3), 117–124. https://doi.org/10.30978/ujdvk2018-3-117
Batool, S. (2019). Perspective of Postgraduate Biology Students About Onychomycosis. Current Trends On Biotechnology & Microbiology: Open Access Publishers , 1 (2). https://doi.org/10.32474/ctbm.2019.01.000107
Singal, A., & Khanna, D. (2011). Onychomycosis: Diagnosis and management. Indian Journal of Dermatology, Venereology, and Leprology , 77 (6), 659. https://doi.org/10.4103/0378-6323.86475
