Guidelines Summary

In 2014, the British Association of Dermatologists published updated evidence-based guidelines for the management of onychomycosis.^[50]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.^[51]

Medication

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Media Gallery

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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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, 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.

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, The Society of Federal Health Professionals (AMSUS), International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

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.

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