Background Information

Causative Agent

85-95% are caused by dermatophyte infections

• Most common: Trichophyton rubrum

5-10% are caused by Candida species

2-5% of toenail onychomycosis are caused by non-dermatophyte moulds (e.g. Scopulariopsis, Scytalidium, Aspergillus, Fusarium, and Acremonium species)

Guidelines

Investigation and Diagnosis

Clinical diagnosis.

If antifungal treatments are being considered → arrange nail clippings and/or scrapings for fungal microscopy and culture

Management

General Management / Self-Care Advice

Self management:

• Keep nails trimmed short and filed down
• Wear well-fitting non-occlusive shoes, without high heels or narrow toes
• Wear cotton, absorbent socks
• Maintain good foot hygiene, including prompt treatment of any associated tinea pedis
• Wear protective footwear when using communal bathing places, locker rooms, and gymnasiums, to avoid re-exposure.
• Avoid prolonged or frequent exposure to warm, damp conditions if possible
• Avoid trauma to the nails if possible

Measures to prevent spread and transmission:

• Avoid sharing toenail clippers
• Replace old footwear that could be contaminated with fungal spores

Antifungal Treatment

DO NOT routinely offer antifungal to all patients, treatment is only indicated if:

• Symptomatic (walking is uncomfortable)
• Psychological distress due to cosmetic appearance

Choice of Antifungal

For early distal and superficial nail involvement: amorolfine 5% nail lacquer
 

If self-care measures alone and/or topical treatment not successful or appropriate: oral antifungal

• If dermatophyte nail infection confirmed
  • 1st line: oral terbinafine
  • 2nd line: oral itraconazole

• If non-dermatophyte nail infection (including Candida) confirmed
  • 1st line: oral itraconazole
  • 2nd line: oral terbinafine

References

Original Guideline