Onychomycosis Follow-up

  • Author: Antonella Tosti, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 27, 2012
 

Further Outpatient Care

Although hepatotoxic reactions are unlikely, periodic monitoring of patients undergoing oral antifungal therapy should include a CBC count and measurements of liver enzyme levels approximately every 4-6 weeks.

Treatment may be discontinued after standard dosing with terbinafine or itraconazole when no evidence of fungal infection (by microscopy or culture) is present. Nails may continue to look dystrophic after a cure is achieved in the laboratory.

After antifungal therapy, disease-free nail growth should be measured at every visit. Nails should grow at a rate of 1.5-2 mm per month and may take up to 1 year to look normal. A clinician may consider an additional dose of antifungal medication if the outgrowth distance slows or stops after discontinuing therapy.

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Complications

Skin injury adjacent to the nail may allow organisms to colonize, thereby increasing the risk of infectious complications. Reports of complications in elderly persons and persons with diabetes include cellulitis, osteomyelitis, sepsis, and tissue necrosis.

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Prognosis

The goals for antifungal therapy are mycological cure and a normal looking nail. Mycological cure can be evaluated at the end of treatment, while clinical cure requires several more months owing to slow nail growth.[27]

  • Clinical trials have repeatedly demonstrated higher efficacy for terbinafine compared with other antifungal treatments.[23, 28]
  • A meta-analysis of 18 studies on terbinafine, 6 studies on pulse itraconazole, and 3 studies on fluconazole for onychomycosis showed a mycological cure rate of 76%, 63 %, and 48 % respectively.[29]
  • Yellow streaks along the lateral margin of the nail and/or presence of yellow onycholytic areas in the central portion of the nail (dermatophytoma) are associated with a poor response to treatment.
  • Residual nail changes persist in most patients as a result of the frequent association of onychomycosis with traumatic toenail dystrophies.
  • Onychomycosis caused by molds, particularly Fusarium species, are often not responsive to systemic therapy.
  • Recurrence (relapse or reinfection) of onychomycosis is not uncommon, with reported rates ranging from 10-53%.[30]
  • Fungal infections of the fingernails have a much more favorable prognosis than toenail infections.
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Patient Education

Patients should be educated about the use of appropriate footwear, especially in high-exposure areas such as communal bathing facilities and health clubs.

Following treatment, patients must be advised that nails may not appear normal for up to 1 year, and prophylactic antifungal therapy may be required to prevent reinfection of the skin and the nails. Patients may use topical terbinafine cream twice daily for 1-2 weeks for early tinea pedis or a 1-week pulse of itraconazole (200 mg PO bid) at the first signs of onychomycosis.[26]

For patient education resources, see the Psoriasis Center and Yeast and Fungal Infections Center, as well as Nail Psoriasis and Onychomycosis.

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Contributor Information and Disclosures
Author

Antonella Tosti, MD  Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Antonella Tosti, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, Canadian Dermatology Association, European Academy of Dermatology and Venereology, International Society of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard K Scher, MD  Adjunct Professor of Dermatology, University of North Carolina; Professor Emeritus of Dermatology, Columbia University

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Referencegratefully acknowledge the contributions of previous authors, Mark Blumberg, MD, MS, Gary R. Kantor, MD, and John Ratz, MD, MBA, to the development and writing of this article.

References

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Distal subungual onychomycosis. Onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Distal subungual onychomycosis. Subungual hyperkeratosis onycholysis and yellow streak. Image courtesy of Dr Antonella Tosti.
Proximal subungual onychomycosis. Proximal leukonychia. Image courtesy of Dr Antonella Tosti.
White superficial onychomycosis. Image courtesy of Dr Antonella Tosti.
Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.
Dermoscopy of distal subungual onychomycosis showing irregular margin of the onycholytic area with spikes projecting into the proximal nail plate, reported as the "aurora borealis" pattern. Handyscope at 20X.
 
 
 
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