Recommendations for universal confirmatory testing of toe nail fungus before systemic therapy should be replaced with therapy-specific recommendations, according to a study published Dec. 23, 2015 in JAMA Dermatology. The cost effectiveness of testing, the authors say, should be reconsidered in light of new drug pricing. The new study found that empirical treatment with terbinafine for all patients with suspected onychomycosis is more cost-effective than confirmatory testing across all prevalence of disease, with "minimal" effect on patient safety. However, confirmatory testing before treatment with the new drug efinaconazole, is associated with cost savings, given the drug’s high price tag. Standard confirmatory testing was established in international guidelines based on cost-effectiveness studies from the 1990s. But since that time, the cost of treatment has changed dramatically. A full 12-week course of terbinafine dropped in cost from $547 in 1999 to $10 today, the authors say, while the novel topical solution efinaconazole, 10%, costs $2,307 for full treatment of one nail. The researchers evaluated three approaches to onychomycosis evaluation before treatment with oral terbinafine or efinaconazole, 10%: empirical therapy without confirmatory testing; pretreatment confirmatory testing with potassium hydroxide (KOH) stain followed by periodic acid–Schiff (PAS) evaluation if KOH testing is negative; and […]