Brief Treatment Guide for Onychomycosis

Abstract

Most onychomycosis infections result from dermatophyte organisms and present as distal lateral subungual onychomycosis (DLSO). Mild to moderate infections may be effectively treated with topical lacquer medications; however, there is no general consensus on what constitutes mild infection. In general, mild infections involve relatively small areas of the nail plate without infection of the nail matrix or lunula. Characteristics such as nail thickness, the number of nails affected, and the degree of onycholysis will also be taken into account in the categorization of nail severity and may increase the severity to moderate or severe even where nail plate area involvement is low. Similarly, although an infection may be mild, for patients with underlying health issues such as diabetes or immunodeficiency, oral therapy may be recommended as it typically provides the higher treatment efficacy required by these conditions. Severe infections may be treated with oral antifungal agents or combinations of oral agents and oral antifungals or oral and topical lacquer antifungals. Débridement is a technique that may be used in nearly any degree of infection to aid treatment efficacy by reducing the burden of fungal infection. Other treatment issues discussed include superficial white onychomycosis, nondermatophyte mold infection, and infection prophylaxis. Treatment is discussed considering a dermatophyte infection of DLSO presentation, unless otherwise stated. Infections should be confirmed by laboratory culture to eliminate any other diagnosis. Therapy recommendations concentrate on those agents approved in Canada for onychomycosis: oral terbinafine, oral itraconazole, and ciclopirox 8% nail lacquer.