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Prior to initiating treatment with antifungal therapy for onchomycosis, it is important that a differential diagnosis is made to eliminate other possible conditions. This is because there are certain side effects associated with pharmacological treatment, such that it is best reserved for when it will be effective.
As the infection is usually embedded underneath the nail, it is particularly difficult to reach. This can cause significant treatment difficulty and, as a result of this, it may take a year or even longer for the infection to disappear entirely. Another reason for this extended recovery time is that new nail growth is required to replace the old and infected nail, which is a slow process.
Both oral and topical treatments can be utilized in the treatment of onychomycosis, as outlined below.
Medications that are administered orally include terbinafine, itraconazole and fluconazole. All of these treatments are effective given certain characteristics that they possess such as adequate penetration of the nail and durability to stay within the area of the infection, even after therapy has been discontinued.
Terbinafine is the most effective, clearing the infection in 76% of cases and is the best tolerated treatment. This is closely followed by itraconazole, which is 60% effective. Fluconazole, on the other hand, works for approximately half of all cases at 48%.
For some specific types of onychomycosis, such as the white superficial type, oral treatments that have a systemic effect are recommended. For individuals affected by this type of infection, the topical treatments offer limited benefits.
Some treatments are available as a nail paint to be applied directly to the affected area on a daily basis. These include ciclopirox, amorolfine and efinaconazole.
These are less effective that the oral treatments, with ciclopirox curing the condition in up to 10% of individual, while amorolfine may be more effective. The combination of ciclopirox and terbinafine is seen to be more beneficial than using either as a stand-alone treatment.
Topical and oral treatments are often recommended to be taken simultaneously, as this can help to increase the efficacy of treatment. The combination of both types of medication may provide additional benefit and improve the chance of health new nail growth.
Where possible, it is preferable to remove the affected part of the nail during treatment. This is believed to increase access to the heart of the infection, improving the response to medication. As a result, keeping nails well trimmed and removing affected parts of the nail as early as possible will help to promote new, healthy nail growth.
There has also been some interest in using oil as a natural remedy to fight onychomychosis. However, current research has failed to show a benefit of using this approach and it is not a recommendation widely used in evidence-based practice.
There is some research that suggests fungi are sensitive to heat, particularly in the 40-60°C (104 – 140°F) range. Based on this concept, laser therapy with the aim to manipulate the temperature around the nail infection to this temperature and disrupt the fungal growth is being developed.
This procedure is still being researched at this point in time, particularly in terms of the efficacy and safety of treatment. However, this is a promising option for the future that may be able to provide a more effective form of treatment.