Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Fungal nail infection (onychomycosis) - Management
How should I treat dermatophyte 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 or positive culture).
  • If the infection is mild and superficial, consider topical treatment with amorolfine 5% nail lacquer.
    • Continue topical treatment for 6 months for fingernail infections and 9–12 months for toenail infections. For more details see Prescribing information on amorolfine.
    • Mild and superficial infection of the nail includes:
      • Superficial onychomycosis (small flaky white patches and pits on the top of the nail plate; the nail is roughened and crumbles easily).
      • Mild distal onychomycosis (the nail lifts up and the free edge erodes).
      • Lateral onychomycosis (white or yellow opaque streaks on one side of the nail), although this may be less likely to respond than distal or superficial onychomycosis.
  • 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 terbinafine is recommended first-line.
      • 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.
      • Visible improvement can be expected after the end of 2 months of treatment for fingernails and 3 months of treatment for toenails.
    • Oral itraconazole is an alternative.
      • Prescribe as pulsed therapy: 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.
      • Fingernail infections require two pulsed courses and toenail infections require at least three pulsed courses.
      • For more details see Prescribing information on itraconazole.
  • 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. The exception is that it can be considered for people unable to use terbinafine or itraconazole, for example because of liver disease.
    • Topical tea tree oil (from the Melaleuca alternifolia plant).
    • Topical extracts of Ageratina pichinchensis.

© NHS Institute for Innovation and Improvement