Onychomycosis: Rapid Evidence Review

 

Am Fam Physician. 2021 Oct ;104(4):359-367.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/nail-fungal-infections/.

Author disclosure: No relevant financial affiliations.

Onychomycosis is a chronic fungal infection of the fingernail or toenail bed leading to brittle, discolored, and thickened nails. Onychomycosis is not just a cosmetic problem. Untreated onychomycosis can cause pain, discomfort, and physical impairment, negatively impacting quality of life. Onychomycosis should be suspected in patients with discolored nails, nail plate thickening, nail separation, and foul-smelling nails. Accurate diagnosis is important before initiating treatment because therapy is lengthy and can cause adverse effects. A potassium hydroxide preparation with confirmatory fungal culture, periodic acid–Schiff stain, or polymerase chain reaction is the preferred diagnostic approach if confirmative testing is cost prohibitive or not available. Treatment decisions should be based on severity, comorbidities, and patient preference. Oral terbinafine is preferred over topical therapy because of better effectiveness and shorter treatment duration. Patients taking terbinafine in combination with tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antipsychotics, beta blockers, or tamoxifen should be monitored for drug-drug interactions. Topical therapy, including ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, is less effective than oral agents but can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions. Nail trimming and debridement used concurrently with pharmacologic therapy improve treatment response. Although photodynamic and plasma therapies are newer treatment options that have been explored for the treatment of onychomycosis, larger randomized trials are needed. Preventive measures such as avoiding walking barefoot in public places and disinfecting shoes and socks are thought to reduce the 25% relapse rate.

Onychomycosis, a chronic fungal infection of the fingernail or toenail bed, is commonly encountered in primary care. Onychomycosis is not just a cosmetic problem. If untreated, it can cause pain, discomfort, and physical impairment, negatively impacting quality of life. This article provides a summary of the best available patient-oriented evidence on the diagnosis and management of this condition.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Confirmatory testing using potassium hydroxide preparation with direct microscopy is recommended before initiating treatment for onychomycosis.12,15

C

Expert opinion and consensus guidelines

Terbinafine has the highest effectiveness of any available therapy and should be recommended as first-line therapy for most patients without contraindications.21,24,57

B

Consistent evidence from a Cochrane review and a large prospective follow-up study

Topical therapy can be used to treat patients with superficial onychomycosis or early distal lateral subungual onychomycosis.12,19,38

B

Expert opinion and one patient-oriented systematic review


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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Confirmatory testing using potassium hydroxide preparation with direct microscopy is recommended before initiating treatment for onychomycosis.12,15

C

Expert opinion and consensus guidelines

Terbinafine has the highest effectiveness of any available therapy and should be recommended as first-line therapy for most patients without contraindications.21,24,57

B

Consistent evidence from a Cochrane review and a large prospective follow-up study

Topical therapy can be used to treat patients with superficial onychomycosis or early distal lateral subungual onychomycosis.12,19,38

B

Expert opinion and one patient-oriented systematic review


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 https://www.aafp.org/afpsort.

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BEST PRACTICES IN DERMATOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection.

American Academy of Dermatology


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN DERMATOLOGY

The Authors

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WINFRED TAYLOR FRAZIER, MD, MPH, FAAFP, is medical director at the University of Pittsburgh (Pa.) Medical Center (UPMC) St. Margaret New Kensington Family Health Center and an associate program director at the UPMC St. Margaret Family Medicine Residency Program....

ZULEICA M. SANTIAGO-DELGADO, MD, is a core faculty member in the Department of Family Medicine at the University of Texas Medical Branch, Galveston.

KENNETH C. STUPKA II, MD, MPH, is a family medicine physician at The Clinics of North Texas, LLP, Wichita Falls. At the time this article was written, he was a resident in the Department of Family Medicine at the University of Texas Medical Branch.

Address correspondence to Winfred Taylor Frazier, MD, MPH, FAAFP, UPMC St. Margaret New Kensington Family Health Center, 1072 5th Ave., New Kensington, PA 15068 (email: frazierwt2@upmc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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