Onychomycosis Guidelines

Updated: Jun 30, 2016
  • Author: Antonella Tosti, MD; Chief Editor: Dirk M Elston, MD  more...
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Guidelines

Guidelines Summary

In 2014, the British Association of Dermatologists published updated evidence-based guidelines for the management of onychomycosis. [37] Treatment recommendations are given for both adults and children (ages 1-12 y).

Adult systemic treatment recommendations are as follows:

  • Terbinafine as first line of treatment for dermatophyte onychomycosis and generally preferred over itraconazole; not recommended for patients with active or chronic liver disease (level A)
  • Itraconazole as first line of treatment for dermatophyte onychomycosis (level A)
  • Fluconazole may be a useful alternative in patients unable to tolerate terbinafine or itraconazole (level B)
  • Griseofulvin is no longer a treatment of choice owing to lower efficacy and higher relapse rates compared with terbinafine and itraconazole (level C)
  • Combination treatment recommended if response to topical monotherapy is likely to be poor (level D)

Adult topical treatment recommendations are as follows:

  • Amorolfine or tioconazole are useful for superficial and distal onychomycosis (level D)
  • Ciclopirox is useful for superficial and distal onychomycosis and for patients in whom systemic therapy is contraindicated (level D)

Adult other treatment recommendations are as follows:

  • Surgical avulsion, debridement alone, and photodynamic therapy (PDT) not recommended

Children systemic treatment recommendations are as follows:

  • Terbinafine as first line of treatment for dermatophyte onychomycosis and generally preferred over itraconazole (level A)
  • Itraconazole is first line of treatment for dermatophyte onychomycosis (level A)
  • Fluconazole considered as second line if itraconazole and terbinafine contraindicated or not tolerated (level B)
  • Griseofulvin considered as second line if itraconazole and terbinafine contraindicated or not tolerated (level C)

In 2013, as part of the Choosing Wisely® initiative from the American Board of Internal Medicine Foundation (ABIM), the American Academy of Dermatology (AAD) released recommendations regarding low-value care that cautioned against prescribing oral antifungal therapy for suspected nail fungus without confirmation of fungal infection. The AAD concluded that about half of suspected fungal infections are not fungal infections and starting patients on treatment before confirming diagnosis could unnecessarily expose them to the adverse effects of antifungal therapy. Although the diagnosis of onychomycosis can be made clinically, it is important to confirm this with a nail clipping and with a periodic acid-Schiff or a fungal culture. [38]