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A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level

  • Therapy in Practice
  • Published:
American Journal of Clinical Dermatology Aims and scope Submit manuscript

Abstract

Onychomycosis is a fungal nail infection caused by dermatophytes, non-dermatophyte molds, and yeasts. Treatment of this infection can be difficult, with relapse likely to occur within 2.5 years of cure. The objective of this article is to review factors that can impact cure and to suggest practical techniques that physicians can use to maximize cure rates. Co-morbidities, as well as disease severity and duration, are among the many patient factors that could influence the efficacy of antifungal therapies. Furthermore, organism, treatment, and environmental factors that may hinder cure include point mutations, biofilms, affinity for non-target enzymes, and exposure to fungal reservoirs. To address patient-related factors, physicians are encouraged to conduct confirmatory testing and treat co-morbidities such as tinea pedis early and completely. To combat organism-focused factors, it is recommended that disruption of biofilms is considered, and drugs with multiple routes of delivery and unique mechanisms of action are prescribed when traditional agents are not effective. Extending follow-up periods, using combination treatments, and considering pulse regimens may also be of benefit. Through these practical techniques, physicians can maximize cure and limit the risk of relapse and re-infection.

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Authors and Affiliations

  1. Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada

    Aditya K. Gupta, Neil H. Shear & Vincent Piguet

  2. Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X2P1, Canada

    Aditya K. Gupta & Sarah G. Versteeg

  3. Division of Dermatology, Women’s College Hospital, Toronto, ON, Canada

    Vincent Piguet

  4. Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA

    Antonella Tosti

  5. Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy

    Bianca Maria Piraccini

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  1. Aditya K. Gupta
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  3. Neil H. Shear
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  4. Vincent Piguet
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Correspondence to Aditya K. Gupta.

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Conflict of interest:

Dr. A.K. Gupta is a clinical trials investigator and speaker for Valeant Canada, and a clinical trials investigator for Moberg. S.G. Versteeg is employed by Mediprobe Research Inc., a site where clinical trials are run under supervision of Dr. A.K. Gupta. Dr. V. Piguet reports receiving educational grants in his role as Department Division Director, Dermatology, University of Toronto (on behalf of the Division of Dermatology Residency Program) from Abbvie, Celgene, Janssen, Naos, Lilly, Sanofi, and Valeant, and non-financial support from La Roche-Posay, outside the submitted work. Dr. B.M. Piraccini has received consulting fees and/or honoraria from Isdin, Pfizer, and Polichem. Dr. N.H. Shear and Dr. A. Tosti have no conflicts to declare.

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Gupta, A.K., Versteeg, S.G., Shear, N.H. et al. A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level. Am J Clin Dermatol 20, 123–133 (2019). https://doi.org/10.1007/s40257-018-0403-4

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