American Journal of Clinical Dermatology

, Volume 10, Issue 4, pp 211–220 | Cite as

Toenail Onychomycosis in Diabetic Patients

Issues and Management
  • Peter Mayser
  • Viviane Freund
  • Debby Budihardja
Therapy in Practice


Diabetes mellitus may be associated with serious sequelae, such as renal disease, retinopathy, and diabetic foot. A recent large prospective study has shown that onychomycosis is among the most significant predictors of foot ulcer. As the severity of onychomycosis may be associated with the length of time the individual has had the infection, early intervention is advisable owing to the progressive nature of the fungal infection. If left untreated, toenails can become thick, causing pressure and irritation, and thus act as a trigger for more severe complications.

In the treatment of onychomycosis, compliance and drug interactions are important considerations, as diabetic patients frequently take concomitant medications. Terbinafine and itraconazole have been investigated for the treatment of onychomycosis in diabetic patients and have been shown to have efficacy and safety profiles comparable to those in the nondiabetic population. Data from clinical trials and postmarketing surveillance suggest that drug interactions resulting in hypoglycemia may not be an important issue when itraconazole and terbinafine are used to treat diabetic patients receiving concomitant hypoglycemic medications. Patient advice and education in improved foot care are an integral part of onychomycosis management, and help achieve long-term cure and reduce the complications of diabetic foot.


Diabetic Patient Fluconazole Itraconazole Terbinafine Glipizide 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this review. Prof. Mayser has spoken at symposia sponsored by sanofi aventis, Novartis and Janssen-Cilag. Drs Freund and Budihardja have no conflicts of interest that are directly relevant to the content of this review.


  1. 1.
    Gupta AK, Humke S. The prevalence and management of onychomycosis in diabetic patients. Eur J Dermatol 2000; 10: 379–84PubMedGoogle Scholar
  2. 2.
    Farkas B, Paul C, Dobozy A, et al. Terbinafine (Lamisil) treatment of toenail onychomycosis in patients with insulin-dependent and non-insulindependent diabetes mellitus: a multicentre trial. Br J Dermatol 2002; 146: 254–60PubMedCrossRefGoogle Scholar
  3. 3.
    Joshi N, Caputo GM, Weitekamp MR, et al. Infections in patients with diabetes mellitus. N Engl J Med 1999; 341: 1906–12PubMedCrossRefGoogle Scholar
  4. 4.
    Rich P, Hare A. Onychomycosis in a special patient population: focus on the diabetic. Int J Dermatol 1999; 38: 17–9PubMedCrossRefGoogle Scholar
  5. 5.
    Boyko WL, Doyle JJ, Ryu S, et al. Onychomycosis and its impact on secondary infection development in the diabetic population. 4th Annual International Meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR); 1999 May 23-26; Arlington (VA)Google Scholar
  6. 6.
    Boyko EJ, Ahroni JH, Cohen V, et al. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care 2006; 6: 1202–7CrossRefGoogle Scholar
  7. 7.
    Effendy I, Lecha M, Feuilhade de Chauvin M, et al. Epidemiology and clinical classification of onychomycosis. J Eur Acad Dermatol Venereol 2005; 19 Suppl. 1: 8–12PubMedCrossRefGoogle Scholar
  8. 8.
    Scher RK, Tavakkol A, Sigurgeirsson B, et al. Onychomycosis: diagnosis and definition of cure. J Am Acad Dermatol 2007; 56: 939–44PubMedCrossRefGoogle Scholar
  9. 9.
    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: 21–9PubMedCrossRefGoogle Scholar
  10. 10.
    Seebacher C, Brasch J, Abeck D, et al. Onychomycosis. Mycoses 2007; 50: 321–7PubMedCrossRefGoogle Scholar
  11. 11.
    Cribier B, Bakshi R. Terbinafine in the treatment of onychomycosis: a review of its efficacy in the high-risk populations and in patients with nondermatophyte infections. Br J Dermatol 2004; 150: 414–20PubMedCrossRefGoogle Scholar
  12. 12.
    Gupta AK, Ryder JE, Lynch LE, et al. The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence. J Drugs Dermatol 2005; 4: 302–8PubMedGoogle Scholar
  13. 13.
    Lange M, Roszkiewicz J, Szczerkowska-Dobosz A, et al. Onychomycosis is no longer a rare finding in children. Mycoses 2006; 49: 55–9PubMedCrossRefGoogle Scholar
  14. 14.
    Mayser P, Hensel J, Thoma W, et al. Prevalence of fungal foot infections in patients with diabetes mellitus type 1: underestimation of moccasin-type tinea. Exp Clin Endocrinol Diabetes 2004; 112: 264–8PubMedCrossRefGoogle Scholar
  15. 15.
    Szepietowski JC, Reich A, Garlowska E. Factors influencing coexistence of toenail onychomycosis with tinea pedis and other dermatomycoses: a survey of 2761 patients. Arch Dermatol 2006; 142: 1279–84PubMedCrossRefGoogle Scholar
  16. 16.
    Alteras I, Saryt E. Prevalence of pathogenic fungi in the toenails of diabetic patients. Mycopathologica 1979; 67: 157–9CrossRefGoogle Scholar
  17. 17.
    Lugo-Somolinos A, Sanchez JL. Prevalence of dermatophytosis in patients with diabetes. J Am Acad Dermatol 1992; 26: 408–10PubMedCrossRefGoogle Scholar
  18. 18.
    Buxton PK, Milne LJ, Prescott RJ, et al. The prevalence of dermatophyte infection in well-controlled diabetics and the response to Trichophyton antigen. Br J Dermatol 1996; 134: 900–3PubMedCrossRefGoogle Scholar
  19. 19.
    Romano C, Massai L, Asta F, et al. Prevalence of dermatophytic skin and nail infections in diabetic patients. Mycoses 2001; 44: 83–6PubMedCrossRefGoogle Scholar
  20. 20.
    Dogra S, Kumar B, Bhansali A, et al. Epidemiology of onychomycosis in patients with diabetes mellitus in India. Int J Dermatol 2002; 41: 647–51PubMedCrossRefGoogle Scholar
  21. 21.
    Piérard GE, Piérard-Franchimont C. The nail under fungal siege in patients with type II diabetes mellitus. Mycoses 2005; 48: 339–42PubMedCrossRefGoogle Scholar
  22. 22.
    Gupta AK, Konnikov N, MacDonald P, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol 1998; 139: 665–71PubMedCrossRefGoogle Scholar
  23. 23.
    Saunte DM, Holgersen JB, Haedersdal M, et al. Prevalence of toe nail onychomycosis in diabetic patients. Acta Dermatol Venereol 2006; 86: 425–8CrossRefGoogle Scholar
  24. 24.
    Manzano-Gayosso P, Hernández-Hernández F, Méndez-Tovar LJ, et al. Onychomycosis incidence in type 2 diabetes mellitus patients. Mycopathologia 2008; 166: 41–5PubMedCrossRefGoogle Scholar
  25. 25.
    Chang SJ, Hsu SC, Tien KJ, et al. Metabolic syndrome associated with toenail onychomycosis in Taiwanese with diabetes mellitus. Int J Dermatol 2008; 47: 467–72PubMedCrossRefGoogle Scholar
  26. 26.
    Finch J, Warshaw E. Toenail onychomycosis: current and future treatment options. Dermatol Ther 2007; 20: 31–46PubMedCrossRefGoogle Scholar
  27. 27.
    Gupta AK, Ryder JE, Baran R, et al. Non-dermatophyte onychomycosis. Dermatol Clin 2003; 21: 257–68PubMedCrossRefGoogle Scholar
  28. 28.
    Iorizzo M, Piraccini BM, Tosti A. New fungal nail infections. Curr Opin Infect Dis 2007; 20: 142–5PubMedCrossRefGoogle Scholar
  29. 29.
    Winston JA, Miller JL. Treatment of onychomycosis in diabetic patients. Clin Diabetes 2006; 24: 160–6CrossRefGoogle Scholar
  30. 30.
    Seebacher C, Nietsch KH, Ulbricht HM. A multicenter, open-label study of the efficacy and safety of ciclopirox nail lacquer solution 8% for the treatment of onychomycosis in patients with diabetes. Cutis 2001; 68 (2 Suppl.): 17–22PubMedGoogle Scholar
  31. 31.
    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: 21–9PubMedCrossRefGoogle Scholar
  32. 32.
    Brenner MA, Harkless LB, Mendicino RW, et al. Ciclopirox 8% nail lacquer topical solution for the treatment of onychomycosis in patients with diabetes: a multicenter, open-label study. J Am Podiatr Med Assoc 2007; 97: 195–202PubMedGoogle Scholar
  33. 33.
    Watanabe D, Kawamura C, Masuda Y, et al. Successful treatment of toenail onychomycosis with photodynamic therapy. Arch Dermatol 2008; 144: 19–21PubMedCrossRefGoogle Scholar
  34. 34.
    Scher RK, Breneman D, Rich P, et al. Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the toenail. J Am Acad Dermatol 1998; 38: s87–94CrossRefGoogle Scholar
  35. 35.
    Gupta AK, Gover MD, Lynde CW. Pulse itraconazole vs. continuous terbinafine for the treatment of dermatophyte toenail onychomycosis in patients with diabetes mellitus. J Eur Acad Dermatol Venereol 2006; 20: 1188–93PubMedCrossRefGoogle Scholar
  36. 36.
    Kill J. Treatment options for onychomycosis [online]. Available from URL: [Accessed 2009 Apr 28]Google Scholar
  37. 37.
    Gupta AK, Ryder JE, Lynch LE, et al. The use of terbinafine in the treatment of onychomycosis in adults and special populations: a review of the evidence. J Drugs Dermatol 2005; 4: 302–8PubMedGoogle Scholar
  38. 38.
    Warshaw EM, Fett DD, Bloomfield HE, et al. Pulse versus continuous terbinafine for onychomycosis: a randomized, double-blind, controlled trial. J Am Acad Dermatol 2005; 53: 578–84PubMedCrossRefGoogle Scholar
  39. 39.
    Evans EG, Sigurgeirsson B. Double blind, randomised study of continuous terbinafine compared with intermittent itraconazole in treatment of toenail onychomycosis: the LION Study Group. BMJ 1999; 318: 1031–5PubMedCrossRefGoogle Scholar
  40. 40.
    Sigurgeirsson B, Olafsson JH, Steinsson JB, et al. Long-term effectiveness of treatment with terbinafine vs itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol 2002; 138: 353–7PubMedCrossRefGoogle Scholar
  41. 41.
    Rich F, Karchmer A, Atillasoy ES. The safety and efficacy of oral terbinafine in the treatment of onychomycosis in diabetic patients. J Eur Acad Dermatol Venereol 1999; 12 Suppl. 2: 229Google Scholar
  42. 42.
    Bohannon NJ, Streja L. Effectiveness of terbinafine therapy for toenail onychomycosis in persons with diabetes. Diabetes 2000; 49 Suppl. 1: A195Google Scholar
  43. 43.
    Baran R, Sigurgeirsson B, de Berker D, et al. A multicentre, 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 with matrix involvement. Br J Dermatol 2007; 157: 149–57PubMedCrossRefGoogle Scholar
  44. 44.
    Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatol Treat 2005; 16: 327–30CrossRefGoogle Scholar
  45. 45.
    Gupta AK, Katz I, Shear NH. Drug interactions with itraconazole, fluconazole, and terbinafine and their management. J Am Acad Dermatol 1999; 41: 237–49PubMedCrossRefGoogle Scholar
  46. 46.
    Verspeelt J, Marynissen G, Gupta AK, et al. Safety of itraconazole in diabetic patients. Dermatology 1999; 198: 382–4PubMedCrossRefGoogle Scholar
  47. 47.
    Albreski DA, Gross EG. The safety of itraconazole in the diabetic population. J Am Podiatr Med Assoc 1999; 89: 339–45PubMedGoogle Scholar
  48. 48.
    Pollak R, Billstein SA. Safety of oral terbinafine for toenail onychomycosis. J Am Podiatr Med Assoc 1987; 87: 565–70Google Scholar
  49. 49.
    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: 364–8PubMedCrossRefGoogle Scholar
  50. 50.
    Sumikawa M, Egawa T, Honda I, et al. Effects of foot care intervention including nail drilling combined with topical antifungal application in diabetic patients with onychomycosis. J Dermatol 2007; 34: 456–64PubMedCrossRefGoogle Scholar
  51. 51.
    Bild DE, Selby JV, Sinnock P, et al. Lower-extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Care 1989; 12: 24–31PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2009

Authors and Affiliations

  • Peter Mayser
    • 1
  • Viviane Freund
    • 1
  • Debby Budihardja
    • 1
  1. 1.Center of Dermatology and AndrologyJustus Liebig UniversityGiessenGermany

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