Onycholysis Medication

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.

Class Summary

Treat superinfection of the onycholytic nail by dermatophytic molds and/or candidal yeasts.

Clotrimazole (Mycelex, Lotrimin)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.

Econazole (Spectazole)

Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell wall membrane permeability, causing fungal cell death.

Ketoconazole topical (Nizoral)

Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P450 and sterol C-14 alpha-demethylation.

Itraconazole (Sporanox)

Fungistatic activity. 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 (Lamisil)

First oral allylamine antimycotic agent to be released, having a different mode of action than the azoles. Considered to be fungicidal, rather than fungistatic. Inhibits the enzyme squalene epoxidase in the sterol synthesis pathway.

Class Summary

Treat noninfectious causes of onycholysis. Have anti-inflammatory properties and cause profound and varied metabolic effects. 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 (Aristocort)

For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Clobetasol (Temovate)

Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.

Class Summary

Inhibit cell growth and proliferation. Mechanism is unknown for treating onycholysis. Reported to be effective in the treatment of nail pitting and onycholysis associated with psoriasis.

Fluorouracil topical (Fluoroplex)

Fluorinated pyrimidine analog used in topical form to treat actinic keratoses. Has unknown mechanism in treating onycholysis.

Use 1% solution.