Onychomycosis: What We Miss, What Works, and Setting Realistic Expectations 

Onychomycosis is common, but often misdiagnosed, mistreated, and misunderstood. In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by podiatric physician and nail expert Tracey Vlahovic, DPM, for a pearl-packed discussion on how to correctly evaluate dystrophic nails, confirm the diagnosis, and set realistic expectations for patients. 

A key takeaway: not every dystrophic nail is fungal. Trauma, biomechanics, gait changes, and footwear can all shape nail morphology in ways that mimic infection. Looking globally at the foot, considering structural deformities, and using tools like dermoscopy can help clinicians avoid reflexively reaching for antifungals when the underlying issue is mechanical. 

The conversation also covers diagnostic confirmation and why proper nail sampling matters. Because fungal infection originates in the nail bed, distal nail plate alone may not provide a useful specimen, a mistake that can lead to false negatives and misdirected treatment.  

From treatment expectations to oral therapy pearls, Dr Vlahovic emphasizes a central principle—nails tell a story. Taking the time to read it carefully can change both the diagnosis and the outcome.