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

Abstract

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).

Fig. 1.

Summary of video screening.

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.

Results

The hashtags “#onychomycosis” and “#nailfungus” generated 129.2 M views and 240 M views on TikTok, respectively. The mean DISCERN rating for the top 100 onychomycosis-related videos was 1.77. Dermatologists posted 40% (16/40) of physician-created videos and 16% (16/100) of all posts (Table 1). The average onychomycosis-related video posted by dermatologists was similar for likes (48,747) and comments (544) compared to all other physician groups (podiatrists 13,843 and 360, plastic surgeons 37,081 and 210, and other specialists 2,210 and 63) (p > 0.05). Posts by physicians versus nonphysicians had higher DISCERN scores (2.28 vs. 1.44, p < 0.001) and a greater number of views (1,209,953 vs. 343,993, p < 0.05). There was no difference in number of comments and likes between physicians and nonphysicians (p > 0.05).

Table 1.

Top 100 TikTok videos with #onychomycosis or #nailfungus

	Videos, n (%)	Mean n of views	Mean n of likes	Mean n of comments	Mean DISCERN score
Total	100 (100)	736,221	20,097	298	1.77
Content creator
Physician	40 (40)	1,209,953	28,675	413	2.28
Nonphysician	56 (56)	343,993	15,142	205	1.44
Private company	4 (4)	1,490,100	3,682	443	1.25
Gender
Male	34 (34)	841,152	26,089	372	2.12
Female	55 (55)	491,440	18,774	210	1.58
NA/unknown	11 (11)	1,569,575	9,678	497	1.96
Physician pecialties
Dermatology	16 (40)	1,369,650	48,747	544	2.56
Podiatry	18 (45)	1,364,067	13,843	360	2.06
Plastic surgery	3 (7.5)	560,167	37,081	376	2.00
Other	3 (7.5)	83,333	2,210	63	2.33
Video type
Educational	72 (72)	801,764	21,703	292	1.93
Advertisement	7 (7)	875,871	3,742	259	1.43
Promotional	4 (4)	1,076,050	43,073	370	1.50
Entertainment	17 (17)	321,165	14,623	324	1.18
Video content
Treatment	69 (69)	738,838	15,632	265	1.86
Information about  onychomycosis	19 (19)	969,884	36,473	401	1.79
Personal experience	12 (12)	351,208	19,841	323	1.25

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 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.

Table 2.

Top ten most recommended onychomycosis treatments on TikTok

Recommended therapy	N	Is it in accordance with the current onychomycosis treatment guidelines? [6]
Nail removal procedure	17	Noa
Tea tree oil	13	No
Vinegar	11	No
Laser therapy	9	Nob
Topical cough suppressant	6	No
Listerine	5	No
Oral terbinafine	4	Yes
Hydrogen peroxide	4	No
Topical efinaconazole	4	Yes
Oregano oil	3	No

^aAtraumatic nail removal procedures, such as milling, may be used as adjunct therapy but surgical extraction of fungus-infected nails is not currently recommended.

^bLaser therapy can be considered for use in combination with antifungal topical or systemic therapy, but it is not currently recommended as monotherapy.

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 TikTok 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 (129.2 M). 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 evidence-based health education regarding onychomycosis and 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.

Conflict of Interest Statement

Kelita Waterton has no conflicts of interest. Dr. Lipner has served as a consultant for Hoth Therapeutics, Ortho-Dermatologics, Moberg Pharmaceuticals, and BelleTorus Corporation.

Funding Sources

This article has no funding source.

Author Contributions

Kelita Waterton and Dr. Lipner contributed to the data collection and interpretation. Kelita Waterton contributed to the drafting, editing, and revision of the final manuscript. Dr. Lipner edited and revised the manuscript.

Funding Statement

This article has no funding source.

Data Availability Statement

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.