Onychomycosis is a fungal infection of the nail bed, nail plate or both. It is caused by dermatophytes, non-dermatophyte molds and yeast.
Tinea unguium or dermatophytic onychomycosis is a dermatophyte infection of the nail more commonly affecting the toenails than the fingernails.
It is usually asymptomatic and patients first consult for cosmetic reasons.
It is suspected if there are changes in the 3rd or 5th toenail, involvement of the 1st and 5th toenails on the same foot and unilateral nail changes.

Principles of Therapy

  • Treatment for onychomycosis is indicated when:
    • Patients experience pain or discomfort related to the infected nails
    • Patients have diabetes & other risk factors for cellulitis
    • Patients have a history of ipsilateral lower extremity cellulitis
    • For cosmetic reasons
  • Patients w/ confirmed onychomycosis but are refractory to treatment may benefit from switching to an alternative oral agent


Oral Antifungals


  • Active against common dermatophytes, Candida sp & some non-dermatophytic molds
    • Offers an alternative to Itraconazole & Terbinafine
    • Not approved in most countries for onychomycosis treatment
  • Effects: Fungistatic, high-dose pulse therapy for fingernail treatment has been shown to have up to 90% clinical cure rate w/ near-total mycologic elimination
    • Outcome data on toenail treatment shows clinical improvement in 72-89% of patients treated


  • First-line agent for treatment of mild to moderate dermatophyte onychomycosis; 2nd-line therapy for patients with severe dermatophyte onychomycosis who cannot tolerate oral Terbinafine 
  • Has broad antifungal coverage that includes dermatophytes, Candida sp & a number of non-dermatophyte molds
  • Effects: Fungistatic, mycologic cure rates range from 45-70% & clinical cure rates from 35-80%
    • Studies have shown that both continuous & pulse therapies are effective


  • First-line agent for treatment of mild, moderate to severe dermatophyte onychomycosis 
  • Active against dermatophytes which are the cause of the majority of onychomycosis infections
    • Not as active against Candida sp or non-dermatophyte molds
  • Effects: Fungicidal, mycotic cure rate for toenails is 71-82% & clinical cure rate 60-70%
    • Some comparative trials have shown Terbinafine to be more effective than other agents for onychomycosis treatment

Topical Antifungals

  • Limited to mild cases involving very distal nail plate & in those unable to tolerate systemic treatment
    • Low response rate because of poor nail plate penetration
  • Used as an adjunct to oral therapy for resistant infections
  • May combine w/ surgical nail avulsion


  • Active against dermatophytes, dimorphic fungi, yeasts, other filamentous & dematiaceous fungi
  • Effects: May be effective in patients w/ mild infection w/o nail matrix (lunula) involvement
  • Has been used in combination w/ oral Terbinafine or Itraconazole
    • Combination therapy may be useful for patients w/ severe onychomycosis


  • Indicated in mild-to-moderate distal superficial onychomycosis
  • Treatment may take 6 months-1 year & cure rates range from 29-47%


  • A triazole antifungal, developed for the treatment of mild-to-moderate distal & lateral subungual onychomycosis (DLSO)
  • Inhibits fungal lanosterol 14α-demethylase, involved in the biosynthesis of ergosterol
  • Indicated for onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes


  • An imidazole molecule w/ fungicidal & fungistatic activity
  • May be used as treatment for moderate-to-severe DLSO caused by Trichophyton rubrum or Epidermophyton floccosum


  • A light-weight, water-soluble oxaborole topical nail lacquer (boron-containing-compound)
  • Indicated for onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes


  • Treatment option for superficial & distal onychomycosis

Longer courses of antifungals may be needed in:

  • Patients whose nails grow slowly
  • Patients who have decreased blood supply to the nail as a result of conditions (eg peripheral vascular occlusion or DM)
  • Patients who have near-total or total nail plate involvement

Non-Pharmacological Therapy

Other Treatment Options

  • Further studies are needed to prove the safety & efficacy of the following management options for tinea unguium

Surgical Avulsion & Debridement

  • Surgical avulsion may be considered for patients w/ single-nail onychomycosis unresponsive to pharmacological agents alone, followed by topical antifungal therapy 
  • Debridement may be considered as an adjunct to topical or oral pharmacologic interventions

Laser Therapy

  • Neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) & dual-wavelength (870 & 930 nm) near-infrared diode lasers are newer treatment options that showed significant improvements in nail appearance in several studies when used together w/ topical antifungal agents 

Photodynamic Therapy (PDT)

  • Involves the use of photosensitizing agents & a light source to treat fungal infection
Alternative Therapies
  • Eg Ageratina pichinchensis (snakeroot) extract, Melaleuca alternifolia (tea tree) oil, menthol
  • May help w/ symptom relief but further studies are needed to establish the therapeutic benefit of these agents
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Infectious Diseases - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
01 Dec 2019
Macrolide antibiotics are derived from the Streptomycesspecies. These contain either 14-membered (erythromycin [ERM],clarithromycin [CAM], roxithromycin [RXM]), 15-membered(azithromycin [AZM]) or 16-membered (spiramycin, josamycin,midecamycin) macrocyclic lactone rings. They inhibit proteinsynthesis by reversibly binding to the 23S ribosomal RNA (rRNA)in the 50s subunit of the bacterial ribosome. Traditionally,macrolides are used as first-line agents in respiratory, skin,soft tissue, and urogenital infections, and they are also activeagainst gram-positive cocci and atypical pathogens.
19 Jun 2019
Acquired immunodeficiency syndrome (AIDS) remains as one of the world’s leading causes of mortality in global public health. Dr Charles Hicks shared his insights into the increasing role of dolutegravir (DTG; Tivicay, GSK) – an integrase strand transfer inhibitor (INSTI) – in HIV therapy during the 4th National AIDS Conference 2018 at Swiss Garden International Hotel and Residences, Kuala Lumpur.
21 Sep 2019
Cryptococcosis is more common in nonhuman immunodeficiency virus (HIV) nontransplant (NHNT) patients, and this population tends to have more localized pulmonary cryptococcosis and significantly higher 90-day mortality, reports a study.
Stephen Padilla, 07 May 2019
The risk of HIV transmission is “effectively zero” among gay couples who have condomless anal sex when the HIV viral load is suppressed, according to a new study.