- Adam O Goldstein, MD, MPH
Adam O Goldstein, MD, MPH
- Department of Family Medicine
- University of North Carolina at Chapel Hill
- Neal Bhatia, MD
Neal Bhatia, MD
- Associate Clinical Professor
- Department of Dermatology, Harbor-UCLA Medical Center
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — Dermatology
- Professor of Dermatology and Public Health
- Denver VA Medical Center, University of Colorado School of Medicine and Colorado School of Public Health
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Professor of Pediatrics and Medicine (Dermatology)
- Dell Medical School, University of Texas, Austin
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
- Ted Rosen, MD
Ted Rosen, MD
- Section Editor — Infections and Infestations
- Professor, Department of Dermatology
- Baylor College of Medicine
Onychomycosis, fungal infection of the nail, can cause disfigurement of the nail, pain, and may increase risk for soft tissue bacterial infection in immunocompromised patients. Dermatophytes, particularly Trichophyton rubrum, are the most common causes of onychomycosis. Yeast (eg, Candida albicans) and nondermatophyte molds can also cause onychomycosis. (See "Onychomycosis: Epidemiology, clinical features, and diagnosis".)
Therapeutic options for onychomycosis include oral antifungal medications, topical antifungal medications, and physical interventions. Factors such as the causative organism, severity of nail involvement, treatment side effects, and patient preference influence treatment selection.
The management of onychomycosis will be reviewed here. The clinical features and diagnosis of onychomycosis are reviewed separately. (See "Onychomycosis: Epidemiology, clinical features, and diagnosis".)
APPROACH TO TREATMENT
Patient selection — Treatment of onychomycosis is not mandatory in all patients. We suggest treating onychomycosis in:
●Patients with a history of cellulitis of the lower extremity, especially if repeated, who have ipsilateral toenail onychomycosis
- Roujeau JC, Sigurgeirsson B, Korting HC, et al. Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study. Dermatology 2004; 209:301.
- Lubeck DP, Gause D, Schein JR, et al. A health-related quality of life measure for use in patients with onychomycosis: a validation study. Qual Life Res 1999; 8:121.
- Elewski BE. The effect of toenail onychomycosis on patient quality of life. Int J Dermatol 1997; 36:754.
- Drake LA, Patrick DL, Fleckman P, et al. The impact of onychomycosis on quality of life: development of an international onychomycosis-specific questionnaire to measure patient quality of life. J Am Acad Dermatol 1999; 41:189.
- Mikailov A, Cohen J, Joyce C, Mostaghimi A. Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis. JAMA Dermatol 2016; 152:276.
- Friedlander SF, Chan YC, Chan YH, Eichenfield LF. Onychomycosis does not always require systemic treatment for cure: a trial using topical therapy. Pediatr Dermatol 2013; 30:316.
- de Berker D. Clinical practice. Fungal nail disease. N Engl J Med 2009; 360:2108.
- Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia 2008; 166:353.
- Murdan S. Drug delivery to the nail following topical application. Int J Pharm 2002; 236:1.
- Elewski BE, Rich P, Pollak R, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: Two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol 2013; 68:600.
- Welsh O, Vera-Cabrera L, Welsh E. Onychomycosis. Clin Dermatol 2010; 28:151.
- Lauharanta J. Comparative efficacy and safety of amorolfine nail lacquer 2% versus 5% once weekly. Clin Exp Dermatol 1992; 17 Suppl 1:41.
- Reinel D, Clarke C. Comparative efficacy and safety of amorolfine nail lacquer 5% in onychomycosis, once-weekly versus twice-weekly. Clin Exp Dermatol 1992; 17 Suppl 1:44.
- Baran R, Kaoukhov A. Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy. J Eur Acad Dermatol Venereol 2005; 19:21.
- Baran R, Sigurgeirsson B, de Berker D, et al. A multicentre, randomized, controlled study of the efficacy, safety and cost-effectiveness of a combination therapy with amorolfine nail lacquer and oral terbinafine compared with oral terbinafine alone for the treatment of onychomycosis with matrix involvement. Br J Dermatol 2007; 157:149.
- Elewski BE, Aly R, Baldwin SL, et al. Efficacy and safety of tavaborole topical solution, 5%, a novel boron-based antifungal agent, for the treatment of toenail onychomycosis: Results from 2 randomized phase-III studies. J Am Acad Dermatol 2015; 73:62.
- Gupta AK, Daigle D, Foley KA. Topical therapy for toenail onychomycosis: an evidence-based review. Am J Clin Dermatol 2014; 15:489.
- Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8% in the treatment of toenail onychomycosis. J Am Acad Dermatol 2000; 43:S70.
- Gupta AK, Onychomycosis Combination Therapy Study Group. Ciclopirox topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized, evaluator-blinded study. J Drugs Dermatol 2005; 4:481.
- Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatolog Treat 2005; 16:327.
- Gupta AK. Treatment of dermatophyte toenail onychomycosis in the United States. A pharmacoeconomic analysis. J Am Podiatr Med Assoc 2002; 92:272.
- Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol 2004; 150:537.
- Crawford F, Young P, Godfrey C, et al. Oral treatments for toenail onychomycosis: a systematic review. Arch Dermatol 2002; 138:811.
- Sigurgeirsson B, Olafsson JH, Steinsson JB, et al. Long-term effectiveness of treatment with terbinafine vs itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol 2002; 138:353.
- De Cuyper C, Hindryckx PH. Long-term outcomes in the treatment of toenail onychomycosis. Br J Dermatol 1999; 141 Suppl 56:15.
- Piraccini BM, Sisti A, Tosti A. Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. J Am Acad Dermatol 2010; 62:411.
- Warshaw EM, Fett DD, Bloomfield HE, et al. Pulse versus continuous terbinafine for onychomycosis: a randomized, double-blind, controlled trial. J Am Acad Dermatol 2005; 53:578.
- Gupta AK, Sibbald RG, Lynde CW, et al. Onychomycosis in children: prevalence and treatment strategies. J Am Acad Dermatol 1997; 36:395.
- Baran R, Faergemann J, Hay RJ. Superficial white onychomycosis--a syndrome with different fungal causes and paths of infection. J Am Acad Dermatol 2007; 57:879.
- Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol 2004; 140:696.
- Gupta AK, Gregurek-Novak T, Konnikov N, et al. Itraconazole and terbinafine treatment of some nondermatophyte molds causing onychomycosis of the toes and a review of the literature. J Cutan Med Surg 2001; 5:206.
- De Doncker PR, Scher RK, Baran RL, et al. Itraconazole therapy is effective for pedal onychomycosis caused by some nondermatophyte molds and in mixed infection with dermatophytes and molds: a multicenter study with 36 patients. J Am Acad Dermatol 1997; 36:173.
- Rigopoulos D, Katoulis AC, Ioannides D, et al. A randomized trial of amorolfine 5% solution nail lacquer in association with itraconazole pulse therapy compared with itraconazole alone in the treatment of Candida fingernail onychomycosis. Br J Dermatol 2003; 149:151.
- Gupta AK, De Doncker P, Haneke E. Itraconazole pulse therapy for the treatment of Candida onychomycosis. J Eur Acad Dermatol Venereol 2001; 15:112.
- Lebwohl MG, Daniel CR, Leyden J, et al. Efficacy and safety of terbinafine for nondermatophyte and mixed nondermatophyte and dermatophyte toenail onychomycosis. Int J Dermatol 2001; 40:358.
- Segal R, Kritzman A, Cividalli L, et al. Treatment of Candida nail infection with terbinafine. J Am Acad Dermatol 1996; 35:958.
- Jo Siu WJ, Tatsumi Y, Senda H, et al. Comparison of in vitro antifungal activities of efinaconazole and currently available antifungal agents against a variety of pathogenic fungi associated with onychomycosis. Antimicrob Agents Chemother 2013; 57:1610.
- Coronado D, Merchant T, Chanda S, Zane LT. In Vitro Nail Penetration and Antifungal Activity of Tavaborole, a Boron-Based Pharmaceutical. J Drugs Dermatol 2015; 14:609.
- Montgomery BJ. Urea plasters alternative to surgery for nail removal. JAMA 1979; 241:1559, 1563.
- Averill RW, Scher RK. Simplified nail taping with urea ointment for nonsurgical nail avulsion. Cutis 1986; 38:231.
- Scher RK, Breneman D, Rich P, et al. Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the toenail. J Am Acad Dermatol 1998; 38:S77.
- Gupta AK. Pharmacoeconomic analysis of oral antifungal therapies used to treat dermatophyte onychomycosis of the toenails. A US analysis. Pharmacoeconomics 1998; 13:243.
- Havu V, Heikkilä H, Kuokkanen K, et al. A double-blind, randomized study to compare the efficacy and safety of terbinafine (Lamisil) with fluconazole (Diflucan) in the treatment of onychomycosis. Br J Dermatol 2000; 142:97.
- Salo H, Pekurinen M. Cost effectiveness of oral terbinafine (Lamisil) compared with oral fluconazole (Diflucan) in the treatment of patients with toenail onychomycosis. Pharmacoeconomics 2002; 20:319.
- Arenas R, Fernández G, Domínguez L. Onychomycosis treated with itraconazole or griseofulvin alone with and without a topical antimycotic or keratolytic agent. Int J Dermatol 1991; 30:586.
- Faergemann J, Anderson C, Hersle K, et al. Double-blind, parallel-group comparison of terbinafine and griseofulvin in the treatment of toenail onychomycosis. J Am Acad Dermatol 1995; 32:750.
- Hofmann H, Bräutigam M, Weidinger G, Zaun H. Treatment of toenail onychomycosis. A randomized, double-blind study with terbinafine and griseofulvin. LAGOS II Study Group. Arch Dermatol 1995; 131:919.
- Scher RK. Onychomycosis: therapeutic update. J Am Acad Dermatol 1999; 40:S21.
- Elewski B, Pollak R, Ashton S, et al. A randomized, placebo- and active-controlled, parallel-group, multicentre, investigator-blinded study of four treatment regimens of posaconazole in adults with toenail onychomycosis. Br J Dermatol 2012; 166:389.
- Sigurgeirsson B, van Rossem K, Malahias S, Raterink K. A phase II, randomized, double-blind, placebo-controlled, parallel group, dose-ranging study to investigate the efficacy and safety of 4 dose regimens of oral albaconazole in patients with distal subungual onychomycosis. J Am Acad Dermatol 2013; 69:416.
- www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm502073.htm (Accessed on May 23, 2016).
- Ortiz AE, Avram MM, Wanner MA. A review of lasers and light for the treatment of onychomycosis. Lasers Surg Med 2014; 46:117.
- Ledon JA, Savas J, Franca K, et al. Laser and light therapy for onychomycosis: a systematic review. Lasers Med Sci 2014; 29:823.
- Liddell LT, Rosen T. Laser therapy for onychomycosis: Fact or fiction? J Fungi 2015; 1:44.
- Carney C, Cantrell W, Warner J, Elewski B. Treatment of onychomycosis using a submillisecond 1064-nm neodymium:yttrium-aluminum-garnet laser. J Am Acad Dermatol 2013; 69:578.
- Kimura U, Takeuchi K, Kinoshita A, et al. Treating onychomycoses of the toenail: clinical efficacy of the sub-millisecond 1,064 nm Nd: YAG laser using a 5 mm spot diameter. J Drugs Dermatol 2012; 11:496.
- Hochman LG. Laser treatment of onychomycosis using a novel 0.65-millisecond pulsed Nd:YAG 1064-nm laser. J Cosmet Laser Ther 2011; 13:2.
- Noguchi H, Miyata K, Sugita T, et al. Treatment of onychomycosis using a 1064nm Nd:YAG laser. Med Mycol J 2013; 54:333.
- Waibel J, Wulkan AJ, Rudnick A. Prospective efficacy and safety evaluation of laser treatments with real-time temperature feedback for fungal onychomycosis. J Drugs Dermatol 2013; 12:1237.
- Zhang RN, Wang DK, Zhuo FL, et al. Long-pulse Nd:YAG 1064-nm laser treatment for onychomycosis. Chin Med J (Engl) 2012; 125:3288.
- Landsman AS, Robbins AH, Angelini PF, et al. Treatment of mild, moderate, and severe onychomycosis using 870- and 930-nm light exposure. J Am Podiatr Med Assoc 2010; 100:166.
- Hollmig ST, Rahman Z, Henderson MT, et al. Lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet laser for the treatment of onychomycosis: a randomized, controlled trial. J Am Acad Dermatol 2014; 70:911.
- Karsai S, Jäger M, Oesterhelt A, et al. Treating onychomycosis with the short-pulsed 1064-nm-Nd:YAG laser: results of a prospective randomized controlled trial. J Eur Acad Dermatol Venereol 2016.
- Gupta A, Simpson F. Device-based therapies for onychomycosis treatment. Skin Therapy Lett 2012; 17:4.
- Lim EH, Kim HR, Park YO, et al. Toenail onychomycosis treated with a fractional carbon-dioxide laser and topical antifungal cream. J Am Acad Dermatol 2014; 70:918.
- Watanabe D, Kawamura C, Masuda Y, et al. Successful treatment of toenail onychomycosis with photodynamic therapy. Arch Dermatol 2008; 144:19.
- Piraccini BM, Rech G, Tosti A. Photodynamic therapy of onychomycosis caused by Trichophyton rubrum. J Am Acad Dermatol 2008; 59:S75.
- Sotiriou E, Koussidou-Eremonti T, Chaidemenos G, et al. Photodynamic therapy for distal and lateral subungual toenail onychomycosis caused by Trichophyton rubrum: Preliminary results of a single-centre open trial. Acta Derm Venereol 2010; 90:216.
- Gilaberte Y, Aspiroz C, Martes MP, et al. Treatment of refractory fingernail onychomycosis caused by nondermatophyte molds with methylaminolevulinate photodynamic therapy. J Am Acad Dermatol 2011; 65:669.
- Gupta AK, Paquet M, Simpson FC. Therapies for the treatment of onychomycosis. Clin Dermatol 2013; 31:544.
- Grover C, Bansal S, Nanda S, et al. Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial. Br J Dermatol 2007; 157:364.
- Amichai B, Nitzan B, Mosckovitz R, Shemer A. Iontophoretic delivery of terbinafine in onychomycosis: a preliminary study. Br J Dermatol 2010; 162:46.
- Amichai B, Mosckovitz R, Trau H, et al. Iontophoretic terbinafine HCL 1.0% delivery across porcine and human nails. Mycopathologia 2010; 169:343.
- Nair AB, Kim HD, Chakraborty B, et al. Ungual and trans-ungual iontophoretic delivery of terbinafine for the treatment of onychomycosis. J Pharm Sci 2009; 98:4130.
- Derby R, Rohal P, Jackson C, et al. Novel treatment of onychomycosis using over-the-counter mentholated ointment: a clinical case series. J Am Board Fam Med 2011; 24:69.
- Ramsewak RS, Nair MG, Stommel M, Selanders L. In vitro antagonistic activity of monoterpenes and their mixtures against 'toe nail fungus' pathogens. Phytother Res 2003; 17:376.
- Auvinen T, Tiihonen R, Soini M, et al. Efficacy of topical resin lacquer, amorolfine and oral terbinafine for treating toenail onychomycosis: a prospective, randomized, controlled, investigator-blinded, parallel-group clinical trial. Br J Dermatol 2015; 173:940.
- Drake LA, Shear NH, Arlette JP, et al. Oral terbinafine in the treatment of toenail onychomycosis: North American multicenter trial. J Am Acad Dermatol 1997; 37:740.
- Tosti A, Piraccini BM, Stinchi C, Colombo MD. Relapses of onychomycosis after successful treatment with systemic antifungals: a three-year follow-up. Dermatology 1998; 197:162.
- Warshaw EM, St Clair KR. Prevention of onychomycosis reinfection for patients with complete cure of all 10 toenails: results of a double-blind, placebo-controlled, pilot study of prophylactic miconazole powder 2%. J Am Acad Dermatol 2005; 53:717.
- Sigurgeirsson B, Olafsson JH, Steinsson JT, et al. Efficacy of amorolfine nail lacquer for the prophylaxis of onychomycosis over 3 years. J Eur Acad Dermatol Venereol 2010; 24:910.
- Zeichner JA. Onychomycosis to Fungal Superinfection: Prevention Strategies and Considerations. J Drugs Dermatol 2015; 14:s32.
- APPROACH TO TREATMENT
- Patient selection
- Treatment options
- Pre-treatment diagnostic testing
- DERMATOPHYTE ONYCHOMYCOSIS
- Mild to moderate dermatophyte onychomycosis
- - Oral terbinafine
- - Topical therapy
- Moderate to severe dermatophyte onychomycosis
- - Oral terbinafine
- - Itraconazole
- White superficial onychomycosis
- YEAST AND NONDERMATOPHYTE MOLD ONYCHOMYCOSIS
- SYMPTOM RELIEF
- OTHER THERAPIES
- Alternative oral antifungal drugs
- Photodynamic therapy
- TREATMENT FAILURE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS