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Fungal nail infection (onychomycosis) - Management
How should I treat Candida nail infection?

  • If the person has few troublesome symptoms, or is at increased risk of developing adverse effects from treatment, consider recommending general self-care measures alone.
  • Before starting antifungal treatment, confirm the diagnosis (positive microscopy and positive culture).
  • If the infection is mild and superficial, consider topical treatment with amorolfine 5% nail lacquer.
    • For fingernails, continue for 6 months; for toenails, continue for 12 months. For more details see Prescribing information on amorolfine.
  • If self-care measures alone or topical treatment are not appropriate, oral treatment is recommended.
    • If oral antifungals are considered necessary for a child younger than 18 years of age, refer to a dermatologist.
    • Oral itraconazole is recommended first-line.
      • Prescribe pulsed therapy: 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days. For more details see Prescribing information on itraconazole.
      • Fingernail infections require two pulsed courses; toenail infections require three pulsed courses.
      • A pulsed regimen is preferred over the continuous regimen.
    • Oral terbinafine is an alternative.
      • Prescribe 250 mg once a day; for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails. For more details see Prescribing information on terbinafine.
  • Treat associated paronychia:
    • Advise self-care measures such as:
      • Soaking in warm water three to four times a day.
      • Keeping the affected area dry and clean.
      • Protecting the affected area (for example by wearing gloves when washing dishes, and the use of barrier creams).
      • Avoiding sucking the fingers, squeezing the lesions, and biting the nails.
    • Offer analgesia (paracetamol or ibuprofen) if needed.
    • If topical treatment of the nail infection is indicated, tell the person to apply treatment to the paronychia as well (this may need to be continued for 3–6 months).
    • If oral treatment of the nail infection is given, this would be expected to also treat any paronychia.
  • Monitor nail growth.
    • Consider filing a notch at the base of the most abnormal nail when starting treatment — this can help future comparisons of old with new nail growth.
    • When a normal area of nail appears near the proximal nail fold, it is likely that the nail is responding to the treatment. Consider discontinuing treatment about 4 weeks after this normal area appears.
  • After completing treatment, consider re-sampling the nail if its appearance still suggests infection, although nail appearance does not always return to normal after the infection has been cured.
  • Treatments that are not recommended include:
    • Combined topical treatment and oral drug treatment.
    • Griseofulvin.
    • Topical tea tree oil (from the Melaleuca alternifolia plant).
    • Topical extracts of Ageratina pichinchensis.

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