- Author: Melanie S Hecker, MD, MBA; Chief Editor: William D James, MD more...
In onycholysis, apply a topical antifungal imidazole or allylamine twice daily to avoid superinfection of the nail. An oral broad-spectrum antifungal agent (ie, fluconazole, itraconazole, terbinafine) may be used for cases with concomitant onychomycosis.
Midstrength topical corticosteroids are suitable for isolated onycholysis. High-potency topical steroids (eg, clobetasol ointment) under occlusion have been used with less than ideal results for patients with severe nail dystrophy unwilling to undergo intralesional injection of corticosteroids. Patients follow this regimen for 2 weeks and then discontinue use of topical steroids for 2 weeks to avoid the other local adverse effects of topical steroids.
Massaging 5-fluorouracil 1% solution twice a day into the proximal nail fold for 4 months has been effective for patients with nail pitting and hyperkeratosis from psoriasis. Application to the free end of the nail should be avoided, as this will cause onycholysis. Localized PUVA, oral etretinate, hydroxyurea, and isotretinoin are other agents that have had some success in treating onycholysis resulting from psoriasis.
Treatment is not without adverse effects. They may include subungual hematoma secondary to intralesional steroid injections and photo hemolysis secondary to PUVA treatment. Explain risks to patients before initiating therapy.
Antifungals treat superinfection of the onycholytic nail by dermatophytic molds and/or candidal yeasts.
Clotrimazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells.
Econazole is effective in cutaneous infections. It interferes with RNA and protein synthesis and metabolism. Econazole disrupts fungal cell wall membrane permeability, causing fungal cell death.
Ketoconazole is an imidazole broad-spectrum antifungal agent; it inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Fluconazole is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P450 and sterol C-14 alpha-demethylation.
Itraconazole has fungistatic activity. It is a synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450-dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Terbinafine was the first oral allylamine antimycotic agent to be released, having a different mode of action than the azoles. It is considered to be fungicidal, rather than fungistatic. It inhibits the enzyme squalene epoxidase in the sterol synthesis pathway.
Corticosteroids treat noninfectious causes of onycholysis. They have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. Intralesional and topical corticosteroids are designed to treat any noninfectious inflammatory condition associated with onycholysis with minimal risk for systemic absorption.
Triamcinolone is used for inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Clobetasol is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Pyrimidine antagonists, topical
Topical pyrimidine antagonists inhibit cell growth and proliferation. Their mechanism is unknown for treating onycholysis. They are reported to be effective in the treatment of nail pitting and onycholysis associated with psoriasis.
Fluorouracil is a fluorinated pyrimidine analog used in topical form to treat actinic keratoses. It has an unknown mechanism in treating onycholysis. Use 1% solution.
Rabar D, Combemale P, Peyron F. Doxycycline-induced photo-onycholysis. J Travel Med. 2004 Nov-Dec. 11(6):386-7. [Medline].
Hanneken S, Wessendorf U, Neumann NJ. Photodynamic onycholysis: first report of photo-onycholysis after photodynamic therapy. Clin Exp Dermatol. 2008 Aug. 33(5):659-60. [Medline].
Gregoriou S, Karagiorga T, Stratigos A, Volonakis K, Kontochristopoulos G, Rigopoulos D. Photo-onycholysis caused by olanzapine and aripiprazole. J Clin Psychopharmacol. 2008 Apr. 28(2):219-20. [Medline].
Bentabet Dorbani I, Badri T, Benmously R, Fenniche S, Mokhtar I. Griseofulvin-induced photo-onycholysis. Presse Med. 2012 Jan 12. [Medline].
Horio T. Spontaneous photo-onycholysis. J Dermatol. 1988 Dec. 15(6):540-2. [Medline].
Makris A, Mortimer P, Powles TJ. Chemotherapy-induced onycholysis. Eur J Cancer. 1996 Feb. 32A(2):374-5. [Medline].
Hogeling M, Howard J, Kanigsberg N, Finkelstein H. Onycholysis associated with capecitabine in patients with breast cancer. J Cutan Med Surg. 2008 Mar-Apr. 12(2):93-5. [Medline].
Paravar T, Hymes SR. Longitudinal melanonychia induced by capecitabine. Dermatol Online J. 2009 Oct 15. 15(10):11. [Medline].
Robert C, Sibaud V, Mateus C, Verschoore M, Charles C, Lanoy E, et al. Nail toxicities induced by systemic anticancer treatments. Lancet Oncol. 2015 Apr. 16(4):e181-e189. [Medline].
Tinio P, Bershad S, Levitt JO. Medical Pearl: Docetaxel-induced onycholysis. J Am Acad Dermatol. 2005 Feb. 52(2):350-1. [Medline].
Bazex J, Baran R, Monbrun F, Grigorieff-Larrue N, Marguery MC. Hereditary distal onycholysis--a case report. Clin Exp Dermatol. 1990 Mar. 15(2):146-8. [Medline].
Oram Y, Karincaoglu Y, Koyuncu E, Kaharaman F. Pulsed Dye Laser in the Treatment of Nail Psoriasis. Dermatol Surg. 2010 Jan 19. [Medline].
Edwards F, de Berker D. Nail psoriasis: clinical presentation and best practice recommendations. Drugs. 2009. 69(17):2351-61. [Medline].
Scotte F, Banu E, Medioni J, et al. Matched case-control phase 2 study to evaluate the use of a frozen sock to prevent docetaxel-induced onycholysis and cutaneous toxicity of the foot. Cancer. 2008 Apr 1. 112(7):1625-31. [Medline].
Scotte F, Tourani JM, Banu E, et al. Multicenter study of a frozen glove to prevent docetaxel-induced onycholysis and cutaneous toxicity of the hand. J Clin Oncol. 2005 Jul 1. 23(19):4424-9. [Medline].