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Fungal nail infection (onychomycosis) - Management
How should I treat non-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.
- If self-care measures are not appropriate, oral treatment is recommended.
- Before starting antifungal treatment, confirm the diagnosis (both microscopy and culture should be positive, and ideally, repeated at least once).
- Terbinafine and itraconazole are options for oral treatment, although neither is licensed for non-dermatophyte nail infection.
- Terbinafine has fewer potential interactions and has a better safety profile in the elderly than itraconazole.
- 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.
- Itraconazole can be given as pulse therapy, which may reduce the risk of adverse events.
- Prescribe as 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 and toenail infections require three pulsed courses.
- 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:
- Topical treatment with antifungals.
- 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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