Tinea%20unguium Treatment
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
Pharmacotherapy
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
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
- 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