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Onychomycosis — Clinical Guidelines

Overview

Onychomycosis is a fungal infection affecting fingernails and toenails, predominantly caused by dermatophytes in Europe, leading to significant morbidity 1 12.

Diagnosis

Key Diagnostic Criteria: Presence of characteristic nail changes (yellow and white striae, thickening) 4.

Recommended Tests: Microscopic examination (KOH preparation), culture, and molecular testing of nail scrapings 1.

Grading: Severity grading can guide treatment choice, though specific grading systems are not detailed in abstracts 6.

Management

First-Line Treatments:

- Local Treatment: Antifungal nail polish for mild to moderate infections 1. - Systemic Treatment: Oral antifungals recommended for moderate to severe cases (e.g., terbinafine, itraconazole) 1 14.

Adjunctive Treatments: Surgical debridement may be considered in refractory cases 4.

Newer Agents: Topical treatments like efinaconazole 10% solution and tavaborole 5% solution provide additional options for mild to moderate disease 9.

Special Populations

Elderly: Factors such as age and comorbidities can affect cure rates; complete cure may be less likely in older adults 2.

Comorbidities: Presence of diabetes, peripheral vascular disease, and other conditions can complicate diagnosis and treatment efficacy 9 16.

Key Recommendations

Diagnose using microscopic examination, culture, and molecular testing for accurate identification of onychomycosis (Evidence: Strong 1).

Initiate local treatment with antifungal nail polish for mild to moderate cases and systemic therapy for moderate to severe infections, considering patient-specific factors (Evidence: Moderate 1 6).

Consider newer topical agents like efinaconazole and tavaborole for mild to moderate onychomycosis to enhance treatment options (Evidence: Moderate 9).

Monitor and manage comorbidities as they significantly influence treatment outcomes and cure rates (Evidence: Moderate 2 9).

Evaluate elderly patients with caution due to potentially lower cure rates and higher morbidity (Evidence: Moderate 2).

References

1 Nenoff P, Reinel D, Mayser P, Abeck D, Bezold G, Bosshard PP et al.. S1 Guideline onychomycosis. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2023. link 2 Bunyaratavej S, Srinonprasert V, Kiratiwongwan R, Wongdama S, Leeyaphan C. Onychomycosis in older adults: The age and associated factors affecting the complete cure rate. The Australasian journal of dermatology 2022. link 3 Jha B, Sharma M, Gc S, Sapkota J. Onychomycosis among Clinically Suspected Cases Attending the Dermatology Out-patient Department of a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA; journal of the Nepal Medical Association 2021. link 4 Sato T, Asahina Y, Toshima S, Yaguchi T, Yamazaki K. Usefulness of Wood's Lamp for the Diagnosis and Treatment Follow-up of Onychomycosis. Medical mycology journal 2020. link 5 Wang Y, Lipner SR. Retrospective analysis of adverse events with topical onychomycosis medications reported to the United States Food and Drug Administration. Archives of dermatological research 2020. link 6 Gupta AK, Versteeg SG, Shear NH, Piguet V, Tosti A, Piraccini BM. A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level. American journal of clinical dermatology 2019. link 7 Tavares GT, Chiacchio NG, Chiacchio ND, Souza MV. Onychomatricoma: a tumor unknown to dermatologists. Anais brasileiros de dermatologia 2015. link 8 Taheri A, Davis SA, Huang KE, Feldman SR. Onychomycosis treatment in the United States. Cutis 2015. link 9 Scher RK, Tosti A, Joseph WS, Vlahovic TC, Plasencia J, Markinson BC et al.. Onychomycosis Diagnosis and Management: Perspectives from a Joint Dermatology-Podiatry Roundtable. Journal of drugs in dermatology : JDD 2015. link 10 Morales-Cardona CA, Valbuena-Mesa MC, Alvarado Z, Solorzano-Amador A. Non-dermatophyte mould onychomycosis: a clinical and epidemiological study at a dermatology referral centre in Bogota, Colombia. Mycoses 2014. link 11 Di Chiacchio N, Suarez MV, Madeira CL, Loureiro WR. An observational and descriptive study of the epidemiology of and therapeutic approach to onychomycosis in dermatology offices in Brazil. Anais brasileiros de dermatologia 2013. link 12 Grover C, Khurana A. Onychomycosis: newer insights in pathogenesis and diagnosis. Indian journal of dermatology, venereology and leprology 2012. link 13 Sehiralti M, Dinc G. Celalettin Muhtar Ozden (1865-1947): his life, works and contributions to the study of dermatophytes. International journal of dermatology 2010. link 14 Finch JJ, Warshaw EM. Toenail onychomycosis: current and future treatment options. Dermatologic therapy 2007. link 15 Koshnick RL, Lilly KK, St Clair K, Finnegan MT, Warshaw EM. Use of diagnostic tests by dermatologists, podiatrists and family practitioners in the United States: pilot data from a cross-sectional survey. Mycoses 2007. link 16 Rich P, Harkless LB, Atillasoy ES. Dermatophyte test medium culture for evaluating toenail infections in patients with diabetes. Diabetes care 2003. link 17 Bonnet MS. The toxicology of Heloderma suspectum: the Gila monster. The British homoeopathic journal 2000. link 18 Gupta AK, Shear NH. A questionnaire study on the management of onychomycosis: a Canadian perspective. International journal of dermatology 1998. link 19 Schein JR, Gause D, Stier DM, Lubeck DP, Bates MM, Fisk R. Onychomycosis. Baseline results of an observational study. Journal of the American Podiatric Medical Association 1997. link 20 Hall M, Monka C, Krupp P, O'Sullivan D. Safety of oral terbinafine: results of a postmarketing surveillance study in 25,884 patients. Archives of dermatology 1997. link 21 de Vroey C, Lasagni A, Tosi E, Schroeder F, Song M. Onychomycoses due to Microascus cirrosus (syn. M. desmosporus). Mycoses 1992. link 22 Kouskoukis CE, Scher RK. Onychogryphosis. The Journal of dermatologic surgery and oncology 1982. link 23 Baran R, Sayag J. Nail biopsy--why, when, where, how?. The Journal of dermatologic surgery 1976. link

Onychomycosis