Onychomycosis review

Classification of onychomycosis:Capture

Diagnosis

  • KOH prep, cultu or histology
  • For subungual infection, try to get the samepl from nail bed

Treatment

  • Oral griseofulvin is out (though still remains for tinea capitis)
  • Topical agents? Seldom effective, ciclopirox (FDA indicated) can be tried if no lunula involvement.
  • Oral antifungals
    – Terbinafine (lamisil)
    – Itraconazole (sporanox)
    – fluconazole

Capture

Which drug is better?

  • Comparative trials have shown terbinafine to be superior to itraconazole in treating dermatophytic onychomycosis.
  • Trials involving non-dermatophytic onychomycosis is limited.
  • To dates, fluconazole has not been included in direct comparison trials.

Cost

  • Terbinafine is cheapest.
  • Pulse itraconazole is cheapter than continuous therapy

Adjuvant therapy

  • Surgical/chemical nail avulsion maybe useful in severe onycholysis with extensive nail thickening or spikes in the nail. These nail changes can be caused by dermatophytoma and respond poorly to standard medications.

    Spikes projecting into the proximal nail plate

Onychomycosis in cildren:

  • Consider immunosuppression if it happens
  • Terbinafine is not yet FDA indicated but has been shown to be safe and effective. Griseofulvin still remains the mainstay although the efficacy is variable.

Reference:

PHILLIP RODGERS, M.D., and MARY BASSLER, M.D., University of Michigan Medical School, Ann Arbor, Michigan. Treating Onychomycosis. Am Fam Physician. 2001 Feb 15;63(4):663-673

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