Skip to main content

The Fungal Toenail: Topical, Oral, and Laser Treatments

  • Chapter
  • First Online:
Evidence-Based Podiatry
  • 632 Accesses

Abstract

Onychomycosis remains a common, progressive, and difficult disease to manage successfully. Early diagnosis and treatment are important irrespective of risk factors or comorbidities. Confirming the diagnosis of onychomycosis is paramount, especially before starting a systemic medication. Choosing other modalities, such as topical antifungals or non-surgical options to treat the nail, whether as monotherapy or as a combination regimen, should be tailored to each patient. Clinicians have more options than ever to manage fungal nail disease and ultimately improve quality of life for affected patients.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Ghannoum MA, Hajjeh RA, Scher R, et al. A large-scale North American study of fungal isolates from nails: the frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns. J Am Acad Dermatol. 2000;43:641–8.

    CAS  PubMed  Google Scholar 

  2. Thomas J, Jacobson GA, Narkowicz CK, et al. Toenail onychomycosis: an important global disease burden. J Clin Pharm Ther. 2010;35(5):497–519.

    CAS  PubMed  Google Scholar 

  3. Borman AM, Campbell CK, Fraser M, et al. Analysis of the dermatophyte species isolated in the British Isles between 1980 and 2005 and review of worldwide dermatophyte trends over the last three decades. Med Mycol. 2007;45:131–41.

    PubMed  Google Scholar 

  4. Saunte DM, Svejgaard EL, Haedersdal M, et al. Laboratory-based survey of dermatophyte infections in Denmark over a 10-year period. Acta Derm Venereol. 2008;88:614–6.

    PubMed  Google Scholar 

  5. Zaias N. Onychomycosis. Dermatol Clin. 1985;3(3):445–60.

    CAS  PubMed  Google Scholar 

  6. Westerberg DP, Yoyack MJ. Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11):762–70.

    PubMed  Google Scholar 

  7. Gupta AK, Skinner AR, Baran R. Onychomycosis in children: an overview. J Drugs Dermatol. 2003;2:31–4.

    PubMed  Google Scholar 

  8. Hay RJ, Baran R. Onychomycosis: a proposed revision of the clinical classification. J Am Acad Dermatol. 2011;65:1219–27.

    PubMed  Google Scholar 

  9. Faergemann J, Baran R. Epidemiology, clinical presentation and diagnosis of onychomycosis. Br J Dermatol. 2003;149(Suppl 65):1–4.

    PubMed  Google Scholar 

  10. Murphy F, Jiaravuthisan MM, Sasseville D, et al. Psoriasis of the nail: anatomy, pathology, clinical presentation, and review of the literature on therapy. J Am Acad Dermatol. 2007;57(1):1–27.

    PubMed  Google Scholar 

  11. Rich P, Elewski B, Scher RK, et al. Diagnosis, clinical implications, and complications of onychomycosis. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S5–8.

    PubMed  Google Scholar 

  12. Moll JM. Seronegative arthropathies in the foot. Baillieres Clin Rheumatol. 1987;1(2):289–314.

    CAS  PubMed  Google Scholar 

  13. Fletcher CL, Hay RJ, Smeeton NC. Onychomycosis: the development of a clinical diagnostic aid for toenail disease. Part I. Establishing discriminating historical and clinical features. Br J Dermatol. 2004;150:701–5.

    CAS  PubMed  Google Scholar 

  14. Weinberg JM, Koestenblatt EK, Tutrone WD, et al. Comparison of diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol. 2003;49(2):193–7.

    PubMed  Google Scholar 

  15. Reisberger EM, Abels C, Landthaler M, et al. Histopathological diagnosis of onychomycosis by periodic acid-Schiff-stained nail clippings. Br J Dermatol. 2003;148(4):749–54.

    PubMed  Google Scholar 

  16. Borkowski P, Williams M, Holewinski J, et al. Onychomycosis: an analysis of 50 cases and a comparison of diagnostic techniques. J Am Podiatr Med Assoc. 2001;91(7):351–5.

    CAS  PubMed  Google Scholar 

  17. Elewski BE. Diagnostic techniques for confirming onychomycosis. J Am Acad Dermatol. 1996;35:56–60.

    Google Scholar 

  18. Arca E, Saracli MA, Akar A, et al. Polymerase chain reaction in the diagnosis of onychomycosis. Eur J Dermatol. 2004;14:52–5.

    CAS  PubMed  Google Scholar 

  19. Pierard GE, Arrese-Estrada J, Pierard-Franchimont C. Treatment of onychomycosis: traditional approaches. J Am Acad Dermatol. 1993;29:S41–5.

    CAS  PubMed  Google Scholar 

  20. Spreadbury C, Holden D, Aufaurre-Brown A, et al. Detection of aspergillus fumigatus by polymerase chain reaction. J Clin Microbiol. 1993;31:615–21.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Miyakawa Y, Mabuchi T, Kagaya K, et al. Isolation and characterization of a species-specific DNA fragment for detection of Candida albicans by polymerase chain reaction. J Clin Microbiol. 1992;30:894–900.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Baharaeen S, Vishniac HS. 25S ribosomal RNA homologies of basidiomycetous yeasts: taxonomic and phylogenetic implications. Can J Microbiol. 1984;30:613–21.

    CAS  PubMed  Google Scholar 

  23. Walberg M, Mørk C, Sandven P, et al. 18S rDNA polymerase chain reaction and sequencing in onychomycosis diagnostics. Acta Derm Venereol. 2006;86:223–6.

    CAS  PubMed  Google Scholar 

  24. Ameen M, Lear JT, Madan V, et al. British Association of Dermatologists’ guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014;171:937–58.

    CAS  PubMed  Google Scholar 

  25. Thatai P, Sapra B. Transungual delivery: deliberations and creeds. Int J Cosmet Sci. 2014;36:398–411.

    CAS  PubMed  Google Scholar 

  26. Kobayashi Y, Miyamoto M, Sugibayashi K, et al. Drug permeation through the three layers of the human nail plate. J Pharm Pharmacol. 1999;51:271–8.

    CAS  PubMed  Google Scholar 

  27. Gupta AK, Joseph WS. Ciclopirox 8% nail lacquer in the treatment of onychomycosis of the toenails in the United States. J Am Podiatr Med Assoc. 2000;90:495–501.

    CAS  PubMed  Google Scholar 

  28. Bohn M, Kraemer K. The dermatopharmacologic profile of ciclopirox 8% nail lacquer. J Am Podiatr Med Assoc. 2000;90(10):491–4.

    CAS  PubMed  Google Scholar 

  29. Hamilton JB, Terada H, Mestler GE. Studies of growth throughout the lifespan in Japanese: growth and size of nails and their relationship to age, sex, heredity, and other factors. J Gerontol. 1955;10(4):401–15.

    CAS  PubMed  Google Scholar 

  30. Elewski BE, Rich P, Wiltz H, et al. Efficacy and safety of tavaborole topical solution, 5%, a novel boron-based antifungal agent for the treatment of onychomycosis: results from two randomized phase 3 studies. J Am Acad Dermatol. 2015;73(1):62–9.

    CAS  PubMed  Google Scholar 

  31. Elewski BE, Rich P, Pollak R, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: two phase 3 multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2013;68:600–8.

    CAS  PubMed  Google Scholar 

  32. Elewski BE, Pollak RA, Pillai R, et al. Access of efinaconazole topical solution, 10%, to the infection site by spreading through the subungual space. J Drugs Dermatol. 2014;13:1394–8.

    CAS  PubMed  Google Scholar 

  33. Gupta AK, Pillai RK. The presence of an air gap between the nail plate and nail bed in onychomycosis patients: treatment implications for topical therapy. J Drugs Dermatol. 2015;14(8):859–63.

    PubMed  Google Scholar 

  34. Singh G, Haneef NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol Venereol Leprol. 2005;71(6):386–92.

    PubMed  Google Scholar 

  35. Baran R, Kaoukhov A. Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy. J Eur Acad Dermatol Venereol. 2005;19(1):21–9.

    CAS  PubMed  Google Scholar 

  36. Lecha M, Effendy I, Feuilhade de Chauvin M, et al. Treatment options—development of consensus guidelines. J Eur Acad Dermatol Venereol. 2005;19(Suppl 1):25–33.

    PubMed  Google Scholar 

  37. Jublia (efinaconazole topical solution, 10%) [package insert]. Bridgewater, NJ: Valeant Pharmaceuticals LLC; 2014.

    Google Scholar 

  38. Zeichner JA, Stein Gold L, Korotzer A. Penetration of (14C)-Efinaconazole solution does not appear to be influenced by nail polish. J Clin Aesthet Dermatol. 2014;7(9):45–8.

    Google Scholar 

  39. Vlahovic T, Merchant T, Chanda S, et al. In vitro nail penetration of tavaborole topical solution, 5% through nail polish on ex vivo human fingernails. J Drugs Dermatol. 2015;14(7):675–8.

    CAS  PubMed  Google Scholar 

  40. Del Rosso JQ. Advances in the treatment of superficial fungal infections: focus on onychomycosis and dry tinea pedis. J Am Osteopath Assoc. 1997;97:339–46.

    PubMed  Google Scholar 

  41. Sigurgeirsson B, Billstein S, Rantanen T, et al. L.I.ON. Study: efficacy and tolerability of continuous terbinafine compared to intermittent itraconazole in the treatment of toenail onychomycosis. Br J Dermatol. 1999;141(Supp 56):5–14.

    PubMed  Google Scholar 

  42. Baran R, Tosti A, Hartmane I, et al. An innovative water-soluble biopolymer improves efficacy of ciclopirox nail lacquer in the management of onychomycosis. J Eur Acad Dermatol Venereol. 2009;23:773–81.

    CAS  PubMed  Google Scholar 

  43. Baran R, Sigurgeirsson B, de Berker D, et al. A multicenter, randomized, controlled study of the efficacy, safety and cost-effectiveness of a combination therapy with amorolfine nail lacquer and oral terbinafine compared with oral terbinafine alone for the treatment of onychomycosis. Br J Dermatol. 2007;157:149–57.

    CAS  PubMed  Google Scholar 

  44. Hay RJ. The future of onychomycosis therapy may involve a combination of approaches. Br J Dermatol. 2001;145:3–8.

    PubMed  Google Scholar 

  45. Rosen T. Evaluation of gender as a clinically relevant outcome variable in the treatment of onychomycosis with efinaconazole topical solution 10%. Cutis. 2015;96(3):197–201.

    PubMed  Google Scholar 

  46. Rodriguez DA. Efinaconazole topical solution, 10% for the treatment of mild and moderate toenail onychomycosis. J Clin Aesthet Dermatol. 2015;8(6):24–9.

    PubMed  PubMed Central  Google Scholar 

  47. Markinson B, Caldwell B. Efinaconazole topical solution, 10%: efficacy in onychomycosis patients with co-existing tinea pedis. J Am Podiatr Med Assoc. 2015;105(5):407–11.

    PubMed  Google Scholar 

  48. Rich P. Efinaconazole topical solution, 10%: the benefits of treating onychomycosis early. J Drugs Dermatol. 2015;14(1):58–62.

    CAS  PubMed  Google Scholar 

  49. Gupta AK, et al. Cumulative meta-analysis of systemic antifungal agents for the treatment of onychomycosis. Br J Dermatol. 2004;150(3):537–44.

    CAS  PubMed  Google Scholar 

  50. Alley MR, Baker SJ, Beutner KR, Plattner J. Recent progress on the topical therapy of onychomycosis. Expert Opin Investig Drugs. 2007;16(2):157–67.

    CAS  PubMed  Google Scholar 

  51. Sporanox oral solution [package insert]. Raritan: Ortho Biotech Products, L.P; 2009.

    Google Scholar 

  52. Lamisil [package insert]. East Hanover: Novartis Pharmaceuticals Corporation; 2013.

    Google Scholar 

  53. Potter LP, Mathias SD, Raut M, et al. The impact of aggressive debridement used as an adjunct therapy with terbinafine on perceptions of patients undergoing treatment for toenail onychomycosis. J Dermatolog Treat. 2007;18:46–52.

    CAS  PubMed  Google Scholar 

  54. Malay DS, Yi S, Borowsky P, et al. Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial. J Foot Ankle Surg. 2009;48:294–308.

    PubMed  Google Scholar 

  55. Jennings MB, Pollak R, Harkless LB, et al. Treatment of toenail onychomycosis with oral terbinafine plus aggressive debridement: IRON-CLAD, a large, randomized, open-label, multicenter trial. J Am Podiatr Med Assoc. 2006;96:465–73.

    PubMed  Google Scholar 

  56. Markinson BC, Vlahovic TC, Joseph WS, et al. Diagnosis and management of onychomycosis: perspectives from a joint podiatry-dermatology roundtable. J Am Podiatr Med Assoc. 2015.

    Google Scholar 

  57. Gupta AK, Paquet M, Simpson FC. Therapies for the treatment of onychomycosis. Clin Dermatol. 2013;31(5):544–54.

    PubMed  Google Scholar 

  58. Grover C, Bansal S, Nanda S, et al. Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial. Br J Dermatol. 2007;157(2):364–8.

    CAS  PubMed  Google Scholar 

  59. Pandhi D, Verma P. Nail avulsion: indications and methods (surgical nail avulsion). Indian J Dermatol Venereol Leprol. 2012;78:299–308.

    PubMed  Google Scholar 

  60. Ortiz AE, Avram MM, Wanner MA. A review of lasers and light for the treatment of onychomycosis. Lasers Surg Med. 2014;46:117–24.

    PubMed  Google Scholar 

  61. Bristow IR. The effectiveness of lasers in the treatment of onychomycosis: a systematic review. J Foot Ankle Res. 2014;7:34.

    PubMed  PubMed Central  Google Scholar 

  62. Evans E. The rationale for combination therapy. Br J Dermatol. 2001;145:9–13.

    PubMed  Google Scholar 

  63. Olafsson JH, Sigurgeirsson B, Baran R. Combination therapy for onychomycosis. Br J Dermatol. 2003;149(Suppl 65):15–8.

    CAS  PubMed  Google Scholar 

  64. Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatolog Treat. 2005;16:327–30.

    CAS  PubMed  Google Scholar 

  65. Rigopoulos D, Katoulis AC, Ioannides D. A randomized trial of amorolfine 5% solution nail lacquer in association with itraconazole pulse therapy compared with itraconazole alone in the treatment of Candida fingernail onychomycosis. Br J Dermatol. 2003;149:151–6.

    CAS  PubMed  Google Scholar 

  66. Xu Y, Miao X, Zhou B, et al. Combined oral terbinafine and long-pulsed 1,064-nm Nd: YAG laser treatment is more effective for onychomycosis than either treatment alone. Dermatol Surg. 2014;40(11):1201–7.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Tracey C. Vlahovic .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Vlahovic, T.C. (2020). The Fungal Toenail: Topical, Oral, and Laser Treatments. In: Tower, D.E. (eds) Evidence-Based Podiatry. Springer, Cham. https://doi.org/10.1007/978-3-030-50853-1_2

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-50853-1_2

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-50852-4

  • Online ISBN: 978-3-030-50853-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics