These recommendations reflect expert opinion published in British Association of Dermatology guidelines, and in reviews [Roberts et al, 2003; DTB, 2008; HPA, 2009].

Referral of children requiring oral antifungal treatment

• This is recommended because fungal nail infection is rare in children and the preferred treatments are off-licence.

Self care alone

• Many people are not particularly troubled by their abnormal nails, but available treatments can have adverse effects. Experts therefore recommend (in UK guidelines and reviews) that self care alone be considered as an option [Roberts et al, 2003; DTB, 2008].

Confirming the diagnosis by mycological microscopy and culture before starting treatment

• It is not possible to make a confident diagnosis of non-dermatophyte nail infection solely on the basis of the clinical history and examination [Roberts et al, 2003].
• Non-dermatophyte nail infection progresses slowly and there is nothing to lose if treatment is delayed by a few weeks. However, treatments can have adverse effects [Roberts et al, 2003].
• Repeat microscopy and culture is recommended to conform non-dermatophyte nail infection, because the clinical significance of a single positive test is uncertain — the test may have detected a commensal or contaminant organism [Roberts et al, 2003].

Oral terbinafine and oral itraconazole

• Two randomized controlled trials (RCTs) provide limited evidence that oral terbinafine and oral itraconazole may be equally effective in non-dermatophyte nail infection.

Treatments that are not recommended

• CKS found no evidence from clinical trials (or supporting expert opinion), and therefore does not recommend the following for treating non-dermatophyte fungal nail infection:
• 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.