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Should I treat a fungal nail infection?
- Self care alone may be appropriate for people who are not bothered by the infected nail or who wish to avoid the possible adverse effects of drug treatment.
- Consider drug treatment if:
- Walking is uncomfortable.
- Abnormal-looking nails are causing significant psychological distress.
- The person has diabetes, vascular disease, or a connective tissue disorder (because of a higher risk for secondary bacterial infections and cellulitis).
- The nail infection is thought to be the source of fungal skin infection.
- The person is, or is likely to become, severely immunocompromised (for example with haematological malignancy or its treatment).
- Discuss the likely benefits and adverse effects of treatment so the person can make a fully informed choice.
- Treatment does not always cure the infection. Cure rates range between approximately 60–80%.
- Treatment that eradicates the infection sometimes does not restore the nail's appearance to normal.
- The drugs need to be taken for several months, or longer for resistant nails.
- Unpleasant adverse effects can occur. These include headache, itching, loss of the sense of taste, gastrointestinal symptoms, rash, and fatigue. Although abnormal liver function tests are not uncommon, liver failure and other serious adverse effects are rare.
Basis for recommendation
These recommendations reflect expert opinion in reviews and the British Association of Dermatology guidelines, which are based on the best available evidence [Roberts et al, 2003; DTB, 2008].
What should I advise about self care of fungal nail infection?
- Advise the person to avoid or minimize exposure to situations which predispose to, or aggravate, fungal nail infection, for example:
- Prolonged or frequent exposure to warm, damp conditions.
- Occlusive footwear.
- Damaging the nails.
- Keep nails trimmed short and filed down.
- For toenail onychomycosis, advise the person to:
- Wear well-fitting shoes, without high heels or narrow toes.
- Maintain good foot hygiene, including treating any athlete's foot (tinea pedis).
- Wear clean shower shoes when using a communal shower.
- Be meticulous with the hygiene of affected feet.
- Consider seeking treatment from a podiatrist if thickened toenails cause discomfort when walking.
- Consider a medicated nail paint or lacquer for mild or superficial infection of nails.
- Advise that other fungal infections should be treated if present.
- Herbal products are promoted for fungal nail infection, but there is no good evidence that they are safe or more effective than standard treatments.
Basis for recommendation
These recommendations reflect expert opinion in reviews and the British Association of Dermatology guidelines, which are based on the best available evidence [Roberts et al, 2003; DTB, 2008].
Advice on footcare
Advice on tea tree oil and Ageratina pichinchesis
- CKS recommends advising against using tea tree oil (which has weak indirect evidence of effectiveness) and Ageratina pichinchensis extract (which also has weak indirect evidence of effectiveness), because they appear to be not more effective than topical amorolfine, and topical amorolfine has been better studied.
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.
Basis for recommendation
These recommendations reflect expert opinion in reviews and the British Association of Dermatology guidelines, which are based on the best available evidence [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 may be considered as an option [Roberts et al, 2003; DTB, 2008].
Topical antifungals
- UK guidelines state that topical treatment for dermatophyte infection can only be recommended for the treatment of superficial white onychomycosis and very early cases of distal and lateral subungual onychomycosis where the infection is confined to the distal edge of the nail [Roberts et al, 2003]. This is because:
Confirming the diagnosis by mycological microscopy or culture before starting treatment is recommended [Roberts et al, 2003] because:
- It is not possible to make a confident diagnosis of dermatophyte nail infection solely on the basis of the clinical history and examination.
- 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.
Safety of oral antifungal treatments
- There is evidence from a systematic review that oral antifungal treatment for superficial dermatophytosis and onychomycosis is associated with a low incidence of serious adverse events in immunocompetent people. The systematic review included data from randomized controlled trials (RCTs) and observational studies.
Oral terbinafine
- There is moderate evidence from RCTs that oral terbinafine is effective.
- There is weak evidence from RCTs that oral terbinafine may be more effective than oral itraconazole.
- There are fewer drug interactions with oral terbinafine than with azole antifungals, and adverse effects are usually mild and transient although there are concerns about liver toxicity.
Oral itraconazole
- There is weak evidence from RCTs that oral itraconazole is effective.
- There is weak evidence from RCTs that oral itraconazole may be less effective than oral terbinafine.
- Pulsed therapy is recommended because there is no good evidence that it is less effective than continuous therapy, and it may reduce the risk of adverse effects.
Treatments that are not recommended
- Combined topical treatment and oral drug treatment are not recommended because there is only weak evidence for oral terbinafine combined with topical treatments, and weaker evidence for oral itraconazole combined with topical treatments.
- Ageratina pichinchensis plant extract is not recommended because, although there is weak evidence of effectiveness, it does not appear to be more effective than topical amorolfine, and there is no good evidence on its safety.
- Topical tea tree oil (from the Melaleuca alternifolia plant) is not recommended because, although there is weak evidence of effectiveness, it does not appear to be more effective than topical amorolfine, and there is no good evidence on its safety.
- Oral griseofulvin is not recommended because there is evidence from RCTs that it is less effective than oral terbinafine, and weak evidence from RCTs that it is less effective than oral itraconazole. Also, adverse effects are more of a concern with griseofulvin [Roberts et al, 2003].
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.
Basis for recommendation
These recommendations reflect expert opinion in reviews and the British Association of Dermatology guidelines, which are based on the best available evidence [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 guidelines published by the British Association of Dermatologists, and reviews) that self care alone be considered as an option [Roberts et al, 2003; DTB, 2008].
Confirming the diagnosis by mycological culture before starting treatment
- Experts and guidelines published by the British Association of Dermatologists recommend that, before treatment is started, the diagnosis of Candida onychomycosis be confirmed by microscopy and culture because [Roberts et al, 2003]:
- It is not possible to make a confident diagnosis of Candida nail infection solely on the basis of the clinical history and examination.
- Distal nail infection with Candida yeasts is uncommon and virtually all people have Raynaud's phenomenon or some other form of vascular insufficiency.
- Candida yeasts are frequently isolated from normal nails [Johnson, Personal Communication, 2009].
- Candida nail infection progresses slowly and there is nothing to lose if treatment is delayed by a few weeks. However, oral treatments can have adverse effects.
Topical antifungals
- Although there is only weak evidence that treatment with topical antifungals alone may be effective in the treatment of Candida nail infection, this is recommended by UK guidelines published by the British Association of Dermatologists, which take account of clinical experience and expert opinion [Roberts et al, 2003].
- CKS does not recommend topical tioconazole because it needs to be administered twice a day and is therefore less practical than topical amorolfine which is administered once or twice a week [ABPI Medicines Compendium, 2007a; ABPI Medicines Compendium, 2007c].
Safety of oral antifungal treatments
- There is evidence from a systematic review of the safety of oral treatments for superficial fungal infections that oral antifungal treatment for superficial dermatophytosis and onychomycosis was associated with a low incidence of serious adverse events in immunocompetent people. The systematic review included data from RCTs and observational studies.
Oral itraconazole
- There is evidence that oral itraconazole effectively treats Candida nail infection.
- No clinical trials have directly compared oral with topical itraconazole; the evidence that treatment with topical treatment alone may be effective in the treatment of Candida nail infection is limited.
- No clinical trials have directly compared oral itraconazole with oral terbinafine, but there is weak evidence that oral terbinafine may be effective in Candida nail infection.
Treatments that are not recommended
- There is no good evidence that combining oral itraconazole with topical antifungals offers any advantage in comparison with systemic treatment alone.
- Oral griseofulvin is seldom used because adverse effects are more of a concern [Roberts et al, 2003].
- Ageratina pichinchensis plant extract is not recommended because, although there is weak evidence of effectiveness, it does not appear to be more effective than topical amorolfine, and there is no good evidence on its safety.
- Topical tea tree oil (from the Melaleuca alternifolia plant) is not recommended because, although there is weak evidence of effectiveness, it does not appear to be more effective than topical amorolfine, and there is no good evidence on its safety.
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.
Basis for recommendation
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.
When should I refer?
- Children younger than 18 years of age who require oral antifungals should be referred to dermatology.
- Fungal nail infection is uncommon in this age group, and the treatments are not licensed.
- If the nails are traumatized by the person's footwear, or deformed toenails traumatize adjacent toes, refer to podiatry.
- If the diagnosis is uncertain, refer to dermatology.
- If treatment is unsuccessful, refer to dermatology.
- If the person is immunocompromised, refer to dermatology.
Basis for recommendation
In the absence of evidence, these recommendations are based on what is considered to be good practice.
How should I manage failure to respond to treatment?
- Assess and, if possible, manage likely causes of treatment failure, namely:
- Poor adherence to advice and prescriptions.
- Poor absorption of oral drugs (such as with inflammatory bowel disease).
- Immunocompromise.
- Resistance of the infecting organisms to the antifungal agent.
- Failure of the nail to grow.
- Consider referral to a dermatologist or podiatrist. Assessment and treatment options that they may consider include:
- Obtaining better specimens for culture.
- Changing to another drug.
- Mechanical debridement.
- Complete or partial removal of the affected nail — this may require a local anaesthetic.
Basis for recommendation
These recommendations reflect expert opinion in reviews and the British Association of Dermatology guidelines, which are based on the best available evidence [Roberts et al, 2003; DTB, 2008].
- CKS found no randomized controlled trials of the management of treatment failure.
What should I advise about prevention of further infections?
- Advise the person to:
- Treat other fungal infections, such as athlete's foot.
- Wear footwear in public environments such as communal bathing places, locker rooms, and gymnasiums.
- Consider replacing old footwear as this could be contaminated with fungal spores.
Basis for recommendation
In the absence of evidence, these recommendations are based on what is considered to be good practice.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Topical amorolfine (dermatophyte or candidal nail infection)
Age from 12 years onwards
Amorolfine 5% nail lacquer: apply once or twice a week
Amorolfine 5% paint
Apply to the affected nail(s) once or twice a WEEK.
Supply 5 mls.
Oral antifungal (dermatophyte nail infection)
Age from 18 years onwards
Terbinafine tablets: 250mg once a day
Terbinafine 250mg tablets
Take one tablet once a day.
Supply 28 tablets.
Itraconazole capsules: 200mg twice a day for 7 days
Itraconazole 100mg capsules
Take two capsules twice a day for 7 days. Repeat the course after a 21-day break.
Supply 28 capsules.
Oral antifungal (candidal nail infection)
Age from 18 years onwards
Itraconazole capsules: 200mg twice a day for 7 days
Itraconazole 100mg capsules
Take two capsules twice a day for 7 days. Repeat the course after a 21-day break.
Supply 28 capsules.
Terbinafine tablets: 250mg once a day
Terbinafine 250mg tablets
Take one tablet once a day.
Supply 28 tablets.
Oral antifungal (non-dermatophyte nail infection)
Age from 18 years onwards
Terbinafine tablets: 250mg once a day
Terbinafine 250mg tablets
Take one tablet once a day.
Supply 28 tablets.
Itraconazole capsules: 200mg twice a day for 7 days
Itraconazole 100mg capsules
Take two capsules twice a day for 7 days. Repeat the course after a 21-day break.
Supply 28 capsules.