Updated Perspectives on the Diagnosis and Management of Onychomycosis

Abstract

Onychomycosis is the most common nail disease encountered in clinical practice and can cause pain, difficulty with ambulation, and psycho-social problems. A thorough history and physical examination, including dermoscopy, should be performed for each patient presenting with nail findings suggestive of onychomycosis. Several approaches are available for definitive diagnostic testing, including potassium hydroxide and microscopy, fungal culture, histopathology, polymerase chain reaction, or a combination of techniques. Confirmatory testing should be performed for each patient prior to initiating any antifungal therapies. There are several different therapeutic options available, including oral and topical medications as well as device-based treatments. Oral antifungals are generally recommended for moderate to severe onychomycosis and have higher cure rates, while topical antifungals are recommended for mild to moderate disease and have more favorable safety profiles. Oral terbinafine, itraconazole, and griseofulvin and topical ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the Food and Drug Administration for treatment of onychomycosis in the United States and amorolfine 5% nail lacquer is approved in Europe. Laser treatment is approved in the United States for temporary increases in clear nail, but clinical results are suboptimal. Oral fluconazole is not approved in the United States for onychomycosis treatment, but is frequently used off-label with good efficacy. Several novel oral, topical, and over-the-counter therapies are currently under investigation. Physicians should consider the disease severity, infecting pathogen, medication safety, efficacy and cost, and patient age, comorbidities, medication history, and likelihood of compliance when determining management plans. Onychomycosis is a chronic disease with high recurrence rates and patients should be counseled on an appropriate plan to minimize recurrence risk following effective antifungal therapy.

An Increase in Specialist Treatment for Onychomycosis: An Unexplained Tendency. A Retrospective Study of Patients Treated for Onychomycosis in Danish Hospitals from 1994 to 2018

“…Additionally, the well-known high relapse rate after medical treatment combined with a high demand for a normal-appearing nails may influence the referral pattern. As new promising treatment modalities of onychomycosis are in the pipeline [ 8 , 24 , 25 ], one may speculate as to whether this could further increase the number of referrals to specialist treatment.…”

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents

“…69,71 Treatment of a non-fungal disorder with an antifungal agent unnecessarily exposes the patient to adverse drug effects and may allow for worsening of their condition. 72 Moreover, unnecessary antifungal exposure may potentiate development of resistance in the patient's microbiota.…”

“…However, antifungal drugs are often prescribed empirically, without testing to confirm the presence and identity of a causative fungal organism, and treatment failure may be followed by additional empiric prescription of other antifungal drugs 69,71 . Treatment of a non‐fungal disorder with an antifungal agent unnecessarily exposes the patient to adverse drug effects and may allow for worsening of their condition 72 . Moreover, unnecessary antifungal exposure may potentiate development of resistance in the patient's microbiota.…”

Appraisal of selected ethnomedicinal plants as alternative therapies against onychomycosis: Evaluation of synergy and time-kill kinetics

“…Current therapy for onychomycosis comprises both oral (terbinafine, fluconazole, and itraconazole) and topical (terbinafine, efinaconazole, amorolfine, and ciclopirox) antifungals ( ShariLipnerMD, 2019 ). However, poor drug penetration owing to hyperkeratosis in case of topical application, resistance to contemporary antifungals, particularly of Trichophyton species against terbinafine, prolonged duration of therapy, drug–drug interactions, and adverse effects are some of the clinical challenges in treating the disease ( Thampi et al, 2022 ; Falotico and Lipner, 2022 ).…”