Onychomycosis
A fungal or yeast infection which results in Onychomycosis can invade through a tear in the proximal and lateral nail folds as well as the eponychium. This type of infection is characterized by onycholysis (nail plate separation) with evident debris under the nail plate. It normally appears white or yellowish in color, and may also change the texture and shape of the nail. The fungus digests the keratin protein of which the nail plate is comprised. As the infection progresses, organic debris accumulates under the nail plate, often discoloring it. Other infectious organisms may be involved, and if left untreated, the nail plate may separate from the nail bed and crumble off.
Medical Care
Treatment of onychomycosis depends on the clinical type of the onychomycosis, the number of affected nails, and the severity of nail involvement. A systemic treatment is always required in proximal subungual onychomycosis and in distal lateral subungual onychomycosis involving the lunula region. White superficial onychomycosis and distal lateral subungual onychomycosis limited to the distal nail can be treated with a topical agent. A combination of systemic and topical treatment increases the cure rate. Because the rate of recurrence remains high, even with newer agents, the decision to treat should be made with a clear understanding of the cost and risks involved, as well as the risk of recurrence. Photodynamic therapy and lasers may represent future treatment options.
Topical antifungals
The use of topical agents should be limited to cases involving less than half of the distal nail plate or for patients unable to tolerate systemic treatment. Agents include amorolfine (approved in other countries), ciclopirox olamine 8% nail lacquer solution, and bifonazole/urea (available outside the United States).
Topical treatments alone are generally unable to cure onychomycosis because of insufficient nail plate penetration. Ciclopirox and amorolfine solutions have been reported to penetrate through all nail layers but have low efficacy when used as monotherapy.15 They may be useful as adjunctive therapy in combination with oral therapy or as prophylaxis to prevent recurrence in patients cured with systemic agents.
Oral therapy
The newer generation of oral antifungal agents (itraconazole and terbinafine) has replaced older therapies in the treatment of onychomycosis.16,17,18 They offer shorter treatment regimens, higher cure rates, and fewer adverse effects. Fluconazole (not approved by the US Food and Drug Administration [FDA] for treatment of onychomycosis) offers an alternative to itraconazole and terbinafine. Derivatives of fluconazole may also be available soon. The efficacy of the newer antifungal agents lies in their ability to penetrate the nail plate within days of starting therapy. Evidence shows better efficacy with terbinafine than with other oral agents.
To decrease the adverse effects and duration of oral therapy, topical treatments and nail avulsion may be combined with oral antifungal management.20
Surgical Care
Surgical approaches to onychomycosis treatment include mechanical, chemical, or surgical nail avulsion.
Chemical removal by using a 40-50% urea compound is painless and useful in patients with very thick nails
Removal of the nail plate should be considered an adjunctive treatment in patients undergoing oral therapy.
A combination of oral, topical, and surgical therapy can increase efficacy and reduce cost.
Activity
Activity does not need to be limited during treatment, but patients should be educated about avoiding direct contact with high-risk areas in public places.
Medication
The goals of pharmacotherapy for onychomycosis are to reduce morbidity and to prevent complications.
Antifungals
The goals of pharmacotherapy for onychomycosis are to reduce morbidity and to prevent complications..