Experts make new recommendations for toenail onychomycosis diagnosis, treatment
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Toenail onychomycosis should be confirmed with laboratory testing and treated with an individualized plan for each patient that can include a range of treatment options, according to new recommendations from a panel of experts.
“Onychomycosis — a fungal infection of the nail bed or plate caused by dermatophytes, non-dermatophyte molds or yeasts — affects up to 14% of individuals in North America,” Shari R. Lipner, MD, PhD, of Weill Cornell Medicine in New York City, and colleagues wrote. “It is undertreated, and treatment is challenging as toenail growth can take up to 12 months or more, the infection is frequently located under the keratinized nail plate and disease recurrence is common.”
Previous recommendations for treatment were published in Great Britain in 2014 and Canada in 2015.
A roundtable discussion with dermatologists, podiatrists and a microbiologist, all authors on the paper, was conducted on March 15. The participants analyzed diagnosis, current treatment options and best practices.
The authors recommend “careful assessment and testing” to rule out other causes of nail dystrophy that can have similar clinical appearances. Laboratory testing should also be conducted to rule out non-fungal conditions.
Treatment options include surgery, devices, oral medications, topical medications or a combination of multiple treatments. Individualized treatment plans for each patient were recommended unanimously by all participating panelists. Nail involvement, infecting organism, patient characteristic and comorbidities, current medications, biomechanics and cost and accessibility should all be taken into consideration.
Terbinafine, which is the most commonly used oral medication, and fluconazole are recommended as first-line oral treatments, with itraconazole and griseofulvin generally avoided for black box warnings and inferior efficacy, respectively.
Efinaconazole was recommended as the first-line topical treatment for pediatric patients and those with less severe disease.
Topical medications combined with terbinafine or fluconazole was suggested for older, immunocompromised or diabetic patients, as well as those with severe disease.
“Onychomycosis should be assessed clinically and confirmed with microscopy, histology and/or culture,” the authors wrote. “For optimal outcomes, patients should be counseled regarding treatment expectations as well as follow-up care and maintenance post-treatment.”
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