Onychomycosis: Current Trends in Diagnosis and Treatment



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Am Fam Physician. 2013 Dec 1;88(11):762-770.

This version of the article contains supplmental content.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on onychomycosis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Onychomycosis is a fungal infection of the nails that causes discoloration, thickening, and separation from the nail bed. Onychomycosis occurs in 10% of the general population, 20% of persons older than 60 years, and 50% of those older than 70 years. It is caused by a variety of organisms, but most cases are caused by dermatophytes. Accurate diagnosis involves physical and microscopic examination and culture. Histologic evaluation using periodic acid–Schiff staining increases sensitivity for detecting infection. Treatment is aimed at eradication of the causative organism and return to a normal appearance of the nail. Systemic antifungals are the most effective treatment, with meta-analyses showing mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole. Concomitant nail debridement further increases cure rates. Topical therapy with ciclopirox is less effective; it has a failure rate exceeding 60%. Several nonprescription treatments have also been evaluated. Laser and photodynamic therapies show promise based on in-vitro evaluation, but more clinical studies are needed. Despite treatment, the recurrence rate of onychomycosis is 10% to 50% as a result of reinfection or lack of mycotic cure.

Onychomycosis is a fungal infection of the fingernails or toenails that causes discoloration, thickening, and separation from the nail bed. Onychomycosis occurs in 10% of the general population but is more common in older adults; the prevalence is 20% in those older than 60 years and 50% in those older than 70 years.1 The increased prevalence in older adults is related to peripheral vascular disease, immunologic disorders, and diabetes mellitus. The risk of onychomycosis is 1.9 to 2.8 times higher in persons with diabetes compared with the general population.2 In patients with human immunodeficiency virus infection, the prevalence ranges from 15% to 40%.3

Onychomycosis affects toenails more often than fingernails because of their slower growth, reduced blood supply, and frequent confinement in dark, moist environments. It may occur in patients with distorted nails, a history of nail trauma, genetic predisposition, hyperhidrosis, concurrent fungal infections, and psoriasis. It is also more common in smokers and in those who use occlusive footwear and shared bathing facilities.1,4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

When preparing a nail specimen to test for onychomycosis, the nail should be cleaned with 70% isopropyl alcohol, then samples of the subungual debris and eight to 10 nail clippings should be obtained. The specimen should be placed on a microscope slide with a drop of potassium hydroxide 10% to 20% solution, then allowed to sit for at least five minutes before viewing under a microscope.

C

8, 11

Periodic acid–Schiff staining should be ordered to confirm infection in patients with suspected onychomycosis.

C

14

Systemic antifungal agents are the most effective treatment for onychomycosis, but cure rates are much less than 100%. Terbinafine (Lamisil) is the most effective systemic agent available.

C

23

When prescribing the topical agent ciclopirox, patients should be informed that it has some benefit in the treatment of onychomycosis, but also has a high failure rate.

C

28, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

When preparing a nail specimen to test for onychomycosis, the nail should be cleaned with 70% isopropyl alcohol, then samples of the subungual debris and eight to 10 nail clippings should be obtained. The specimen should be placed on a microscope slide with a drop of potassium hydroxide 10% to 20% solution, then allowed to sit for at least five minutes before viewing under a microscope.

C

8, 11

Periodic acid–Schiff staining should be ordered to confirm infection in patients with suspected onychomycosis.

C

14

Systemic antifungal agents are the most effective treatment for onychomycosis, but cure rates are much less than 100%. Terbinafine (Lamisil) is the most effective systemic agent available.

C

23

When prescribing the topical agent ciclopirox, patients should be informed that it has some benefit in the treatment of onychomycosis, but also has a high failure rate.

C

28, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case

The Authors

DYANNE P. WESTERBERG, DO, FAAFP, is the founding chair of Family and Community Medicine at Cooper Medical School of Rowan University, and chief of Family and Community Medicine at Cooper University Hospital, both in Camden, N.J. At the time this article was written, she was chief of Family and Community Medicine at Cooper University Hospital, and vice chair of Family Medicine and Community Health at Robert Wood Johnson Medical School in Camden.

MICHAEL J. VOYACK, DO, is an attending physician at Cooper University Hospital and a clinical instructor of family and community medicine at Cooper Medical School of Rowan University.

Address correspondence to Dyanne P. Westerberg, DO, FAAFP, Cooper University Hospital, 401 Haddon Ave., E&R Building, 2nd Floor, Camden, NJ 08103 (e-mail: westerberg-dyanne@cooperhealth.edu). Reprints are not available from the authors.


Figures 1 through 5 provided by Robert T. Brodell, MD.

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