Therapy goals
- Improvement of the symptomatology
- Elimination of pathogens
Therapy recommendation
The foundation of any onychomycosis therapy is local (“topical”) therapy:
- In type 1 infection (nail covered), the infected nail mass must first be removed so that topical antifungals (local antifungals/antifungal agents) can find their way into the nail bed. This is not required for an atrophic nail already displaced by the fungus (type 2 infection).
- For painless and efficient removal of the infected nail (atraumatic nail extraction), treatment with 20-40% urea (with occlusion/covering of the nail) is required before specific therapy – usually for two weeks.
- After removal of the infected nail, local therapy with an antifungal agent (antifungal nail polish) is required (e.g., ciclopiroxolamine).
Systemic therapy
- Systemic therapy is required in addition to local treatment when a nail is affected more than 50% or more than three nails at a time or the nail matrix, or proximal subungual onychomycosis.
- Systemic therapy always requires thorough local therapy. The healing success of systemic therapy without local therapy is rather modest with a rate of 40-70%.
- Meta-analysis: terbinafine cut off in mycoses as oral therapy compared to azoles and griseofulvin as more effective and led to fewer side effects with a similar relapse rate (recurrence of the disease).
- Network meta-analysis: continuous oral antifungal therapies were superior to pulse therapies of one week of daily dosing followed by a three-week break) and topical applications. Terbinafine (250 mg) and itraconazole (200 mg) daily for 3 to 4 months proved to be the most effective therapy.
Notice:
- Onychomycosis due to molds usually do not respond to systemic antifungals.
- Onychomycosis is not confirmed in every second suspected nail. Nail diseases such as chronic nail dystrophies often have a similar appearance.
- Only a confirmed diagnosis ensures proper therapy and avoids drug side effects of antifungal therapy.
Further notes
- Oral antifungal therapy with terbinafine or griseofulvin has rarely been associated with transaminase elevation, anemia (anemia), lymphopenia (lack of lymphocytes in the blood), or neutropenia (decrease in neutrophil granulocytes in the blood) in liver-healthy children and adults; Laboratory values for aspartate aminotransferase (AST, ASAT; also called glutamate oxaloacetate transaminase (GOT)) and for parameters of anemia, lymphopenia, and neutropenia were similar to those before treatment.
- Highest clinical cure rate in children treated with itraconazole.
- Highest mycological cure rate in children receiving therapy with ciclopirox
