Treatment of onychomycosis

Article information

J Korean Med Assoc. 2019;62(7):385-391

Publication date (electronic) : 2019 July 17

doi : https://doi.org/10.5124/jkma.2019.62.7.385

Yang Won Lee, MD

Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea

Corresponding author: Yang Won Lee E-mail: 20050078@kuh.ac.kr

Received 2019 June 27; Accepted 2019 June 29.

Abstract

Onychomycosis is a fungal nail infection caused by various fungal species, including dermatophytes, non-dermatophytes, and yeast. It is one of most bothersome nail problems, because it may cause permanent deformity of the nail, local pain, paresthesia, and difficulties performing activities of daily living and engaging in social interactions. Additionally, the treatment of onychomycosis is considered to be challenging because of the long duration of treatment, high recurrence and treatment failure rates, and drug interactions. In this article, we review the prognostic factors for onychomycosis treatment, the treatment options that have been approved, and off-label therapies and devices. Furthermore, we describe preventive therapy for recurrence and emerging methods to achieve a high cure rate. For successful treatment of onychomycosis, the risk factors should be clarified according to the patient's status and the clinical characteristics of onychomycosis. Recently, combinations of various treatment options, such as systemic therapy with simultaneous topical antifungal agents and boost therapy, have been reported as effective treatments of onychomycosis. In addition, laser therapy, photodynamic therapy, and plasma therapy have been proposed as emerging curative options. Providing patient-specific treatment based on an understanding of these treatments plays a pivotal role in achieving better treatment results. This article suggested the updated treatment options for onychomycosis to help clinicians make proper plans and achieve better results.

Keywords: Onychomycosis; Antifungal agents; Laser therapy; Therapeutics

References

1. Elewski BE, Hay RJ. Novel treatment strategies for superficial mycoses: introduction. J Am Acad Dermatol 1999;40(6 Pt 2):S1–S2.

2. English MP. Trichophyton rubrum infection in families. Br Med J 1957;1:744–746.

3. Piraccini BM, Alessandrini A. Onychomycosis: a review. J Fungi (Basel) 2015;1:30–43.

4. Gupta AK. Onychomycosis in the elderly. Drugs Aging 2000;16:397–407.

5. Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol 2012;66:494–502.

6. Baran R, Faergemann J, Hay RJ. Superficial white onychomycosis: a syndrome with different fungal causes and paths of infection. J Am Acad Dermatol 2007;57:879–882.

7. Hay RJ, Baran R. Onychomycosis: a proposed revision of the clinical classification. J Am Acad Dermatol 2011;65:1219–1227.

8. Carney C, Tosti A, Daniel R, Scher R, Rich P, DeCoster J, Elewski B. A new classification system for grading the severity of onychomycosis: Onychomycosis Severity Index. Arch Dermatol 2011;147:1277–1282.

9. Scher RK, Tavakkol A, Sigurgeirsson B, Hay RJ, Joseph WS, Tosti A, Fleckman P, Ghannoum M, Armstrong DG, Markin-son BC, Elewski BE. Onychomycosis: diagnosis and definition of cure. J Am Acad Dermatol 2007;56:939–944.

10. Roberts DT. Onychomycosis: current treatment and future challenges. Br J Dermatol 1999;141(Suppl 56):1–4.

11. Tosti A, Piraccini BM, Stinchi C, Colombo MD. Relapses of onychomycosis after successful treatment with systemic antifungals: a three-year followup. Dermatology 1998;197:162–166.

12. Gupta AK, Studholme C. How do we measure efficacy of therapy in onychomycosis: patient, physician, and regulatory perspectives. J Dermatolog Treat 2016;27:498–504.

13. Del Rosso JQ. The role of topical antifungal therapy for onychomycosis and the emergence of newer agents. J Clin Aesthet Dermatol 2014;7:10–18.

14. Gupta AK, Ryder JE, Baran R. The use of topical therapies to treat onychomycosis. Dermatol Clin 2003;21:481–489.

15. Tabara K, Szewczyk AE, Bienias W, Wojciechowska A, Pastus-zka M, Oszukowska M, Kaszuba A. Amorolfine vs. ciclopirox: lacquers for the treatment of onychomycosis. Postepy Dermatol Alergol 2015;32:40–45.

16. Elewski BE, Ghannoum MA, Mayser P, Gupta AK, Korting HC, Shouey RJ, Baker DR, Rich PA, Ling M, Hugot S, Damaj B, Nyirady J, Thangavelu K, Notter M, Parneix-Spake A, Sigurgeirsson B. Efficacy, safety and tolerability of topical terbinafine nail solution in patients with mild-to-moderate toenail onychomycosis: results from three randomized studies using double-blind vehicle-controlled and open-label active-controlled designs. J Eur Acad Dermatol Venereol 2013;27:287–294.

17. Ruiz-Lopez P, Moreno-Coutino G, Fernandez-Martinez R, Espinoza-Hernandez J, Rodriguez-Zulueta P, Reyes-Teran G. Evaluation of improvement of onychomycosis in HIV-infected patients after initiation of combined antiretroviral therapy without antifungal treatment. Mycoses 2015;58:516–521.

18. Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8% in the treatment of toenail onychomycosis. J Am Acad Dermatol 2000;43(4 Suppl):S70–S80.

19. Elewski BE, Rich P, Pollak R, Pariser DM, Watanabe S, Senda H, Ieda C, Smith K, Pillai R, Ramakrishna T, Olin JT. Efinaconazole 10% solution in the treatment of toenail onychomycosis: two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol 2013;68:600–608.

20. Scher RK, Nakamura N, Tavakkol A. Luliconazole: a review of a new antifungal agent for the topical treatment of onychomycosis. Mycoses 2014;57:389–393.

21. Watanabe S, Kishida H, Okubo A. Efficacy and safety of luliconazole 5% nail solution for the treatment of onychomycosis: A multicenter, double-blind, randomized phase III study. J Dermatol 2017;44:753–759.

22. Elewski BE, Aly R, Baldwin SL, Gonzalez Soto RF, Rich P, Weisfeld M, Wiltz H, Zane LT, Pollak R. Efficacy and safety of tavaborole topical solution, 5%, a novel boron-based antifungal agent, for the treatment of toenail onychomycosis: results from 2 randomized phase-III studies. J Am Acad Dermatol 2015;73:62–69.

23. Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part II. J Am Acad Dermatol 1994;30:911–933.

24. Breckenridge A. Clinical significance of interactions with antifungal agents. Br J Dermatol 1992;126(Suppl 39):19–22.

25. Van Cauteren H. The toxicological properties of itraconazole. Recent Trends Discov Dev Eval Antifung Agents 1987. 263–271.

26. Munoz P, Moreno S, Berenguer J, Bernaldo de Quiros JC, Bouza E. Fluconazole-related hepatotoxicity in patients with acquired immunodeficiency syndrome. Arch Intern Med 1991;151:1020–1021.

27. Sigurgeirsson B, Paul C, Curran D, Evans EG. Prognostic factors of mycological cure following treatment of onychomycosis with oral antifungal agents. Br J Dermatol 2002;147:1241–1243.

28. Sigurgeirsson B, van Rossem K, Malahias S, Raterink K. A phase II, randomized, double-blind, placebo-controlled, parallel group, dose-ranging study to investigate the efficacy and safety of 4 dose regimens of oral albaconazole in patients with distal subungual onychomycosis. J Am Acad Dermatol 2013;69:416–425.

29. Moore JN, Healy JR, Kraft WK. Pharmacologic and clinical evaluation of posaconazole. Expert Rev Clin Pharmacol 2015;8:321–334.

30. Watanabe S, Tsubouchi I, Okubo A. Efficacy and safety of fosravuconazole L-lysine ethanolate, a novel oral triazole antifungal agent, for the treatment of onychomycosis: a multicenter, double-blind, randomized phase III study. J Dermatol 2018;45:1151–1159.

31. Gupta AK, Versteeg SG. A critical review of improvement rates for laser therapy used to treat toenail onychomycosis. J Eur Acad Dermatol Venereol 2017;31:1111–1118.

32. Hashimoto T, Blumenthal HJ. Survival and resistance of Trichophyton mentagrophytes arthrospores. Appl Environ Microbiol 1978;35:274–277.

33. Gupta AK, Ahmad I, Borst I, Summerbell RC. Detection of xanthomegnin in epidermal materials infected with Trichophyton rubrum. J Invest Dermatol 2000;115:901–905.

34. Sotiriou E, Koussidou-Eremonti T, Chaidemenos G, Apalla Z, Ioannides D. Photodynamic therapy for distal and lateral subungual toenail onychomycosis caused by Trichophyton rubrum: preliminary results of a single-centre open trial. Acta Derm Venereol 2010;90:216–217.

35. Heinlin J, Maisch T, Zimmermann JL, Shimizu T, Holzmann T, Simon M, Heider J, Landthaler M, Morfill G, Karrer S. Contact-free inactivation of Trichophyton rubrum and Microsporum canis by cold atmospheric plasma treatment. Future Microbiol 2013;8:1097–1106.

36. Arrese JE, Pierard GE. Treatment failures and relapses in onychomycosis: a stubborn clinical problem. Dermatology 2003;207:255–260.

37. Pierard GE, Pierard-Franchimont C, Arrese JE. The boosted oral antifungal treatment for onychomycosis beyond the regular itraconazole pulse dosing regimen. Dermatology 2000;200:185–187.

38. Lipner SR, Scher RK. Onychomycosis: treatment and prevention of recurrence. J Am Acad Dermatol 2019;80:853–867.

Article information Continued

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.