Medscape is available in 5 Language Editions – Choose your Edition here.


Onychomycosis Treatment & Management

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

Medical Care

Treatment of onychomycosis depends on the clinical type of the onychomycosis, the number of affected nails, and the severity of nail involvement. A systemic treatment is always required in proximal subungual onychomycosis and in distal lateral subungual onychomycosis involving the lunula region. White superficial onychomycosis and distal lateral subungual onychomycosis limited to the distal nail can be treated with a topical agent. A combination of systemic and topical treatment increases the cure rate. Because the rate of recurrence remains high, even with newer agents, the decision to treat should be made with a clear understanding of the cost and risks involved, as well as the risk of recurrence. Photodynamic therapy and lasers may represent future treatment options.[25, 26]

Topical antifungals

The use of topical agents should be limited to cases involving less than half of the distal nail plate or for patients unable to tolerate systemic treatment. Agents available in the United States include ciclopirox olamine 8% and efinaconazole 10% nail solutions. Amorolfine and bifonazole/urea are available outside of the United States.

Topical treatments alone are generally unable to cure onychomycosis because of insufficient nail plate penetration. Ciclopirox and amorolfine solutions have been reported to penetrate through all nail layers but have low efficacy when used as monotherapy.[27] They may be useful as adjunctive therapy in combination with oral therapy or as prophylaxis to prevent recurrence in patients cured with systemic agents. Daily application and a long duration of treatment (48 wk) are required for efinaconazole and ciclopirox.

Efinaconazole is indicated for toenail onychomycosis. Its approval was based on 2 phase III multicenter, randomized trials (N = 1,655). Complete cure was seen in 17.8% and 15.2% of patients receiving the drug, versus 3.3% and 5.5% of subjects receiving the vehicle. Mycologic cure rates were significantly greater with efinaconazole (53.4-55.2%) compared with the drug vehicle (P < .001).[28, 29, 30]

Tavaborole, a topical oxaborole antifungal (boron-containing compound) is indicated for onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes. Its approval was based on 2 multicenter, double-blind, randomized trials involving 1194 subjects. After 48 weeks of treatment, complete cure was found in 6.5% and 9.1% in patients receiving tavaborole compared with 0.5% and 1.5%, respectively, of patients applying the vehicle alone.[31]  Mycological cure was obtained in 31.1% and 35.9% for active treatment versus 7.2% and 12.2% for the vehicle.

Oral therapy

The newer generation of oral antifungal agents (itraconazole and terbinafine) has replaced older therapies in the treatment of onychomycosis.[32, 33, 34] They offer shorter treatment regimens, higher cure rates, and fewer adverse effects. Fluconazole and the new triazole posaconazole[3] (both not approved by the US Food and Drug Administration [FDA] for treatment of onychomycosis) offer an alternative to itraconazole and terbinafine. The efficacy of the newer antifungal agents lies in their ability to penetrate the nail plate within days of starting therapy. Evidence shows better efficacy with terbinafine than with other oral agents (see Prognosis).[11]

To decrease the adverse effects and duration of oral therapy, topical treatments and nail avulsion may be combined with oral antifungal management.[35]


Surgical Care

Several laser devices have been used to treat onychomycosis, including Nd:YAG lasers and diode lasers. Evidence-based data on efficacy of the different lasers are still poor.

Photodynamic therapy has been reported as effective in noncontrolled studies.[36]

Surgical approaches to onychomycosis treatment can also include mechanical, chemical, or surgical nail avulsion. Chemical removal by using a 40-50% urea compound is painless and useful in patients with very thick nails. Removal of the nail plate should be considered an adjunctive treatment in patients undergoing oral therapy. A combination of oral, topical, and surgical therapy can increase efficacy and reduce cost.



Activity does not need to be limited during treatment, but patients should be educated about avoiding direct contact with high-risk areas in public places.


Long-Term Monitoring

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.

Contributor Information and Disclosures

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, International Society of Dermatology, European Academy of Dermatology and Venereology, Women's Dermatologic Society, Canadian Dermatology Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PharmaDerm<br/>Received income in an amount equal to or greater than $250 from: Valeant; Pharmaderm.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate 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, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

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

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully 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.

  1. Andre J, Achten G. Onychomycosis. Int J Dermatol. 1987 Oct. 26(8):481-90. [Medline].

  2. Baran R, Hay RJ, Tosti A, Haneke E. A new classification of onychomycosis. Br J Dermatol. 1998 Oct. 139(4):567-71. [Medline].

  3. Bohn M, Kraemer K. The dermatopharmacologic profile of ciclopirox 8% nail lacquer. J Am Podiatr Med Assoc. 2000 Nov-Dec. 90(10):491-4. [Medline].

  4. Bristow IR, Spruce MC. Fungal foot infection, cellulitis and diabetes: a review. Diabet Med. 2009 May. 26(5):548-51. [Medline].

  5. Lubeck DP. Measuring health-related quality of life in onychomycosis. J Am Acad Dermatol. 1998 May. 38(5 Pt 3):S64-8. [Medline].

  6. Midgley G, Moore MK. Nail infections. Dermatol Clin. 1996 Jan. 14(1):41-49. [Medline].

  7. Carney C, Tosti A, Daniel R, et al. A new classification system for grading the severity of onychomycosis: Onychomycosis Severity Index. Arch Dermatol. 2011 Nov. 147(11):1277-82. [Medline].

  8. Cohen AD, Medvesovsky E, Shalev R, et al. An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis. J Dermatolog Treat. 2003 Dec. 14(4):237-42. [Medline].

  9. Crawford F, Young P, Godfrey C, et al. Oral treatments for toenail onychomycosis: a systematic review. Arch Dermatol. 2002 Jun. 138(6):811-6. [Medline].

  10. Iorizzo M, Piraccini BM, Tosti A. New fungal nail infections. Curr Opin Infect Dis. 2007 Apr. 20(2):142-5. [Medline].

  11. Gupta AK, Scher RK, De Doncker P, Sauder DN, Shear NH. Onychomycosis. New therapies for an old disease. West J Med. 1996 Dec. 165(6):349-51. [Medline].

  12. Jennings MB, Pollak R, Harkless LB, Kianifard F, Tavakkol A. Treatment of toenail onychomycosis with oral terbinafine plus aggressive debridement: IRON-CLAD, a large, randomized, open-label, multicenter trial. J Am Podiatr Med Assoc. 2006 Nov-Dec. 96(6):465-73. [Medline].

  13. Katz HI, Gupta AK. Oral antifungal drug interactions. Dermatol Clin. 1997 Jul. 15(3):535-44. [Medline].

  14. Kemna ME, Elewski BE. A U.S. epidemiologic survey of superficial fungal diseases. J Am Acad Dermatol. 1996 Oct. 35(4):539-42. [Medline].

  15. Hull PR. Onychomycosis--treatment, relapse and re-infection. Dermatology. 1997. 194 Suppl 1:7-9. [Medline].

  16. Cribier BJ, Paul C. Long-term efficacy of antifungals in toenail onychomycosis: a critical review. Br J Dermatol. 2001 Sep. 145(3):446-52. [Medline].

  17. Ebihara M, Makimura K, Sato K, Abe S, Tsuboi R. Molecular detection of dermatophytes and nondermatophytes in onychomycosis by nested polymerase chain reaction based on 28S ribosomal RNA gene sequences. Br J Dermatol. 2009 Nov. 161(5):1038-44. [Medline].

  18. Elewski B, Pollak R, Ashton S, Rich P, Schlessinger J, Tavakkol A. 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 Feb. 166(2):389-98. [Medline].

  19. Elewski BE. Clinical pearl: diagnosis of onychomycosis. J Am Acad Dermatol. 1995 Mar. 32(3):500-1. [Medline].

  20. Elewski BE. Diagnostic techniques for confirming onychomycosis. J Am Acad Dermatol. 1996 Sep. 35(3 Pt 2):S6-9. [Medline].

  21. Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data. Arch Dermatol. 1998 Dec. 134(12):1551-4. [Medline].

  22. Evans EG. Causative pathogens in onychomycosis and the possibility of treatment resistance: a review. J Am Acad Dermatol. 1998 May. 38(5 Pt 3):S32-36. [Medline].

  23. Faergemann J, Baran R. Epidemiology, clinical presentation and diagnosis of onychomycosis. Br J Dermatol. 2003 Sep. 149 Suppl 65:1-4. [Medline].

  24. Friedlander SF, Chan YC, Chan YH, Eichenfield LF. Onychomycosis Does Not Always Require Systemic Treatment for Cure: A Trial Using Topical Therapy. Pediatr Dermatol. 2012 Dec 28. [Medline].

  25. Manevitch Z, Lev D, Palhan M, Lewis A, Enk CD. Direct Antifungal Effect of Femtosecond Laser on Trichophyton rubrum Onychomycosis. Photochem Photobiol. 2009 Dec 7. [Medline].

  26. Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol. 2012 Mar. 66(3):494-502. [Medline].

  27. Gupta AK, Palese CS, Scher RK. How to treat special populations suffering from onychomycosis. Skin and Aging. 1999. 7:54-8.

  28. Brooks M. FDA OKs first topical triazole antifungal for onychomycosis (Jublia). Medscape Medical News. June 10, 2014. [Full Text].

  29. Valeant Pharmaceuticals International, Inc. Valeant Pharmaceuticals announces FDA approval of Jublia for the treatment of onychomycosis [press release]. Available at Accessed: June 16, 2014.

  30. Elewski BE, Rich P, Pollak R, Pariser DM, Watanabe S, Senda H, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: Two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2013 Apr. 68(4):600-8. [Medline].

  31. Elewski B, Zane L, Rich P, Aly R, Gonzalez Soto R, Leon N. Pivotal phase III safety and efficacy results of tavaborole (AN2690), a novel boron-based molecule for the topical treatment of toenail onychomycosis. Presented at the American Academy of Dermatology 72nd Annual Meeting. March 21-25, 2014. Denver, Colorado.

  32. Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol. 2004 Mar. 150(3):537-44. [Medline].

  33. Gupta AK, Scher RK. Oral antifungal agents for onychomycosis. Lancet. 1998 Feb 21. 351(9102):541-2. [Medline].

  34. Gupta AK, Scher RK, De Doncker P. Current management of onychomycosis. An overview. Dermatol Clin. 1997 Jan. 15(1):121-35. [Medline].

  35. Gupta AK, Zaman M, Singh J. Fast and sensitive detection of Trichophyton rubrum DNA from the nail samples of patients with onychomycosis by a double-round polymerase chain reaction-based assay. Br J Dermatol. 2007 Oct. 157(4):698-703. [Medline].

  36. Piraccini BM, Rech G, Tosti A. Photodynamic therapy of onychomycosis caused by Trichophyton rubrum. J Am Acad Dermatol. 2008 Nov. 59(5 Suppl):S75-6. [Medline].

  37. [Guideline] Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014 Nov. 171(5):937-58. [Medline].

  38. [Guideline] American Academy of Dermatology. Ten Things Physicians and Patients Should Question. Choosing Wisely. Available at October 29, 2013; Accessed: April 30, 2016.

  39. 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 Mar. 62(3):411-4. [Medline].

  40. Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol. 2004 Jun. 140(6):696-701. [Medline].

  41. Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. J Am Acad Dermatol. 2000 Feb. 42(2 Pt 1):217-24. [Medline].

  42. Tosti A, Piraccini BM, Lorenzi S, Iorizzo M. Treatment of nondermatophyte mold and Candida onychomycosis. Dermatol Clin. 2003 Jul. 21(3):491-7, vii. [Medline].

  43. 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(2):162-6. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.