Onychomycosis (cont.)

Medical Author:

John Ratz, MD, MBA

Coauthor:

Jessica B Johnson

Medical Editor:

Dirk M Elston, MD

Medical Editor:

Mary L Windle, PharmD

Medical Editor:

Ronald A Greenfield, MD

Introduction
Anatomy of the Nail
Subtypes of Onychomycosis
Symptoms of Onychomycosis
Causes of Onychomycosis
Diagnosis of Onychomycosis
Treatment of Onychomycosis
Summary of Common Types of Onychomycosis
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Synonyms and Keywords
Authors and Editors
Viewer Comments: Onychomycosis - Treatment

Treatment of Onychomycosis

Medications

In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible.

Topical antifungals are medicines applied to the skin and nail area that kill fungus.
- These topical agents should only be used if less than half the nail is involved or if the person with onychomycosis cannot take the oral medicines. Medicines include amorolfine (approved for use outside the United States), ciclopirox olamine (Penlac, which is applied like nail polish), sodium pyrithione, bifonazole/urea (available outside the United States), propylene glycol-urea-lactic acid, imidazoles, such as ketoconazole (Nizoral Cream), and allylamines, such as terbinafine (Lamisil Cream).
- Topical treatments are limited because they cannot penetrate the nail deeply enough, so they are generally unable to cure onychomycosis. Topical medicines may be useful as additional therapy in combination with oral medicines.
Newer oral medicines are available. These antifungal medicines are more effective because they go through the body to penetrate the nail plate within days of starting therapy.
- Newer oral antifungal drugs terbinafine (Lamisil Tablets) and itraconazole (Sporanox Capsules) have replaced older therapies, such as griseofulvin, in the treatment of onychomycosis. They offer shorter treatment periods (oral antifungal medications usually are administered over a 3-month period), higher cure rates, and fewer side effects. These medications are fairly safe, with few contraindications (conditions that make taking the medicine inadvisable), but they should not be taken by patients with liver disease or heart failure. Before prescribing one of these medications, doctors often order a blood test to make sure the liver is functioning properly. Common side effects include nausea and stomach pain.
- Fluconazole (Diflucan) is not approved by the Food and Drug Administration (FDA) for treatment of onychomycosis, but it may be an alternative to itraconazole and terbinafine.
To decrease the side effects and duration of oral therapy, topical and surgical treatments may be combined with oral antifungal management.

Surgery

Surgical approaches to onychomycosis treatment include surgically or chemically removing the nail (nail avulsion or matrixectomy).

Removing the nail plate (fingernail or toenail) is not effective treatment on its own. This procedure should be considered an adjunctive (additional) treatment combined with oral therapy.

A combination of oral, topical, and surgical therapy can increase the effectiveness of treatment and reduce the cost of ongoing treatments.

Summary of Common Types of Onychomycosis

Characteristics of Common Types of Onychomycosis (OM)

Characteristic	DLSO	PSO	WSO
Frequency	Most common	Generally uncommon but frequent in AIDS patients	Makes up 10% of cases of OM
Progress of infection	Infection begins with invasion of the space under the nail edge where the nail separates from the nail bed (called the hyponychium)	Infection begins at the nail fold (where the nail meets the finger or toe) and affects newly forming nail	Infection begins at the surface of the nail (nail plate) and progresses to deeper layers
Clinical appearance	Separation of the nail from the nail bed (onycholysis), thickening of the area under the nail (subungual hyperkeratosis)	Subungual hyperkeratosis, white discoloration (leukonychia), separation of the nail from the nail bed (onycholysis), and destruction of the nail unit	White areas on the nail surface, eventually involving the entire nail surface
Most common causative organism	Trichophyton rubrum	Trichophyton rubrum	Trichophyton mentagrophytes, Aspergillus terreus, Acremonium roseogriseum, Fusarium oxysporum
Affected nails	Toenails most commonly affected but may affect fingernails as well	Much more common on the toenails, rarely affects fingernails	Mainly affect toenails The term total dystrophic onychomycosis is not a subtype, but is, instead, the final stage of any of the previously described forms of onychomycosis, candidal onychomycosis, or both