Truth or Trend – Misinformation Spreading Fast on TikTok: A Cross-Sectional Analysis of Onychomycosis Content

Background: Onychomycosis is the most frequently diagnosed nail condition in clinical practice. With the growing popularity of TikTok and online health information-seeking behavior, it is imperative to understand onychomycosis-related content on this platform. Objective: Our objective was to assess content and quality of the most popular onychomycosis-related content on TikTok. Methods: We queried TikTok for videos using the search terms “onychomycosis” and “nail fungus” for the top 100 videos by view count, with DISCERN scoring used to rate videos for quality. Results: Average DISCERN score was 1.77 and dermatologists posted videos with the highest mean score (2.56). Most of the videos were educational (72%) and/or related to treatment (69%). Home remedies were recommended more often (58%) than FDA-approved therapies (7%). Physician versus nonphysician posted videos had higher mean DISCERN score (2.28 vs. 1.44) (p < 0.001), greater view number (1,209,953 vs. 343,993) (p < 0.05), and more often discussed medical therapy (p < 0.05). Conclusion: While social media is a valuable resource for providing medical information to an interminable audience, there are significant shortcomings. Therefore, we recommend that dermatologists advise patients against relying on social media for medical information and consider using social media to provide accessible evidence-based health education on onychomycosis.


Introduction
Social media has become increasingly popular for modern-day communication, with utilization among the adult USA population increasing from 6% in 2006 to 72% in 2021 [1].TikTok has quickly become one of the fastest-growing social media platforms with over 1 billion monthly active users as of September 2021.Compared to other social media platforms, TikTok has the highest monthly usage and was the most downloaded app of 2022 [2].In a study evaluating the reliability of TikTok's most viewed dermatologic content, among 200 top videos, educational videos posted by board-certified dermatologists had 50.1% greater probability of being reliable than those posted by other sources (p < 0.00001) [3].Therefore, dermatologists may utilize TikTok and other popular social media platforms as tools to educate the public, and combat misinformation and unreliable data.Since onychomycosis is the most common nail disorder seen in clinical practice and patients may search for health-related information on social media, we sought to examine onychomycosis content on TikTok [4].

Materials and Methods
TikTok was queried using the search terms "onychomycosis" and "nail fungus" on January 31, 2023, to collect the top 100 onychomycosis videos, determined by the greatest number of likes and view count.To reach 100, 164 videos were screened.Videos that did not include content relevant to onychomycosis and/or onychomycosis treatment, did not contain English text or spoken audio, were duplicates, or had fewer views than another video posted by an already included user were excluded (Fig. 1).
Content creator type and gender were collected and subdivided into physicians, nonphysicians, and private companies.The number of likes, views, and comments was recorded to measure engagement.Video type was classified as an advertisement if it promoted a particular brand or product, promotional if it promoted the creator's own page, products, or services, educational if it provided information without promotion or advertisement, and entertainment if it did not provide information and did not attempt to advertise or promote any products or services.
Video content quality was assessed using DISCERN.DISCERN is a validated instrument (1-5 scale) that evaluates the quality of published material that contains health information.Scores 2 or less have serious shortcomings and are not useful or reliable sources of information about health or treatment choices.Materials with a DISCERN score of approximately 3 are considered good sources, though with several limitations, while those 4 and higher are considered high-quality sources of information [5].
We performed two-tailed t tests to measure the difference between physicians and nonphysicians as well as dermatologists and non-dermatologist specialists.An ANOVA test was used to measure the differences between video types and video content.p < 0.05 was considered statistically significant.
While most of the video content was educational (72%) and/or related to onychomycosis treatment (69%), only seven posts recommended an FDA-approved systemic or local treatment for onychomycosis and only two videos each provided a reference.The educational and treatment-related videos had higher DISCERN scores, 1.93 and 1.86, respectively, than other video types (advertisement 1.43, promotional 1.5, entertainment 1.18) (p < 0.01) and other video content (information about onychomycosis 1.79, personal experience 1.25) (p < 0.05), with no differences in the number of views, likes, or comments (p > 0.05).
The most frequently recommended or featured treatments on TikTok were nail removal (17, 22%), tea tree oil (13, 17%), vinegar (11, 14%), and laser therapy (9, 12%) (Table 2), and only two of the top ten most frequently recommended treatments were in adherence with the most recently published onychomycosis guidelines.The 61 videos containing the top ten most frequently recommended treatments for onychomycosis on TikTok had an average of 777,631 views, 16,397 likes, and 240 comments.Nonphysicians uploaded 58% of the videos containing the most frequently recommended home remedies for onychomycosis on TikTok.However, there was no significant difference between the average number Atraumatic nail removal procedures, such as milling, may be used as adjunct therapy but surgical extraction of fungus-infected nails is not currently recommended.b Laser therapy can be considered for use in combination with antifungal topical or systemic therapy, but it is not currently recommended as monotherapy.
of views, likes, or comments between the physician and nonphysician creators of these videos (p > 0.05).Videos posted by podiatrists made up the majority (10, 59%) of posts that featured nail removal procedures.There was no difference between the frequencies of videos posted by dermatologists compared to non-dermatologist physicians recommending medical therapy (p > 0.05).Physicians, however, were more likely to post videos discussing medical therapies when compared to nonphysicians (p < 0.05).Of the 69 videos with content primarily related to onychomycosis treatment, 40 (58%) videos recommended a home remedy.

Discussion
Our study showed that onychomycosis-related TikTok videos reached a wide audience, garnering an average of 736,221 viewers, which is appreciably higher than the average number of views of onychomycosis content on YouTube (284,144 views) [7].Therefore, posts on the TikTok platform may have greater impact than other platforms displaying similar information.With the increase in social media usage in recent years, highly viewed social media posts may reach individuals with cultural or socioeconomic barriers to obtaining quality medical information and increasing opportunities for health literacy [8].
In a qualitative survey-based study of 17 physicians who used social media to distribute health information, time commitment, skill requirements, and lack of guidelines of acceptable social media use, were reported as challenges of using their social media for health communication.However, they still reported that the benefits of their participation in social media far outweighed any barriers [9].Furthermore, a prospective, two-center, cross-sectional survey of 460 dermatology patients, reported that patients desire more access to evidence-based medical information on the internet and greater online presence by dermatologists [10].Our analysis revealed that the TikTok videos uploaded by physicians had significantly greater viewership than videos uploaded by nonphysicians, indicating that physicians may have a greater influence than their counterparts as it pertains to onychomycosis-related content.In addition, physicians had greater content quality and were more likely to discuss medical therapy.Similarly, other reports have identified dermatologists as the Tik-Tok creators with greater reliability and a higher percentage of videos that follow the American Academy of Dermatology guidelines when compared to nonphysician posters.In a study analyzing TikTok's most viewed dermatological content, educational videos posted by board-certified dermatologists had 96.8% adherence to the American Academy of Dermatology (AAD) guidelines versus 48% of patient-posted videos [3].In another cross-sectional study analyzing TikTok's popular user content related to atopic dermatitis, 100% of the videos uploaded by dermatologists followed AAD guidelines, but overall, only 39% of the top 200 videos were in accordance [11].
There was a preponderance of home remedy recommendations, including tea tree oil, vinegar, topical cough suppressants, and Listerine ® , in the onychomycosis treatment-related videos, and very limited discussion of antifungals approved by the United States Food and Drug Administration for onychomycosis.Only two of the top ten most frequently recommended treatments on TikTok were in accordance with the most recently published guidelines for the treatment of onychomycosis [6].We found that physicians uploaded several of the TikTok videos which recommended home remedies and alternative treatments.Studies evaluating alternative remedies for onychomycosis are small, not well-controlled, and/or demonstrated poor efficacy [12,13].There is a need for larger, randomized, controlled clinical trials to provide further guidance on cure rates for these popularized methods.Therefore, physicians should aim to provide evidence-based data and recommendations that follow current guidelines.Referencing home remedies in social media content may delay appropriate treatment.
TikTok videos with the hashtag #nailfungus (240 M) had nearly twice as many views as videos with the hashtag #onychomycosis (129.2M).Therefore, using simplified language may increase accessibility to viewers that are not familiar with more complicated medical terminology.In a study evaluating onychomycosis content on the internet, only 33% of the 51 analyzed websites met the acceptable 7th-grade reading level for health information.Furthermore, while the AAD website ranked highly for its readability, it only appeared as a top hit for the search term "nail fungus" and not with the medical term "onychomycosis" [14].
TikTok videos that include health-related information are not reviewed and thus may spread misinformation to a broad audience.Therefore, we recommend that dermatologists advise patients to exercise caution when viewing onychomycosis-related content shared on social media and provide reliable patient education resources.We also suggest that physicians consider establishing social media platforms to provide evidencebased health education regarding onychomycosis and Onychomycosis on TikTok Skin Appendage Disord 2023;9:444-448 DOI: 10.1159/000533319 other dermatological diseases.While TikTok and other social media platforms have their shortcomings, our data on their viewership and engagement suggest that they can be instrumental in increasing health literacy and access to medical information.

Statement of Ethics
Ethics approval was not required because this study is based exclusively on published literature.

Table 2 .
Top ten most recommended onychomycosis treatments on TikTok