Tinea%20unguium Treatment

• 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

Fluconazole

• 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

Itraconazole

• 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

Terbinafine

• 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

Amorolfine

• 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

Ciclopirox

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

Efinaconazole

• 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

Luliconazole

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

Tavaborole

• 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

Tioconazole

• 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

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

• 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