Onachomycoses combination therapy

Onychomycoses are difficult to treat infections of the nail organ with a high recurrence rate. Risk groups include older people, diabetics and patients with immunodeficiency. Pre-existing nail injuries, especially trauma and a warm and humid environment (athletes) also favor infection. The following combination therapy has proven to be an optimized treatment regime.

Onychomycoses, combination therapy

• Take medical history: duration of nail changes, evidence of fungus, previous therapy, risk factors
• Clarify differential diagnosis: exclude post-traumatic changes, trophic disorders, psoriatic nail affections
• Prepare native preparation, remove material after proper cleaning. Samples should be taken from 2 places, if possible at the border of the infestation. Milling for mycologically younger material. Acidification with KOH or tetraammonium hydroxide (TEAH). Calcofluor and Blankophor preparations offer a higher sensitivity.
• Create a fungal culture or PCR:
• Mandatory, especially before systemic therapy.
• Classify infestation pattern morphologically (SWO=superficial white onychomycosis; DLSO=distolateral subungual onychomycosis; PSO=proximal subungual onychomycosis; TDO=total dystrophic onychomycosis)
• Remove fungus-contaminated nail material as subtly as possible. Grind nail plate thinly, if necessary by a podiatrist, possibly atraumatic detachment with 40% urea.
• Hygienic measures: Remove artificial nails; disinfect nail tools, change stockings daily, disinfect shoes regularly, wash contaminated textiles at 600 C.
• Topical local therapy: If there is sufficient clinical suspicion, start topical local therapy with nasal nail polish. File the surface of the nail before the first application.
• Choice of antifungal topical: Amorolfin nail polish (not water soluble) once a week. Alternatively Cicloprox solution (water-soluble) 1x/day. Topical monotherapy possible with infestation area <80% of the nail.
• Use of antimycotic systemic therapy: Not for SWO, not for small non-proximal infestation area, not for contraindications to systemic antimycotics. Use with infestation area >80% and/or matrix involvement: topical/systemic combination therapy (systemic monotherapy not advisable).
• Choice of antimycotic systemic therapy: First choice: Terbinafine 250mg/day; second choice: Itraconazole 200mg/day, Fluconazole 150-300mg/week (continuous therapy is preferable to pulse therapy)
• Schedule laboratory checks: Liver and blood lipid values after 4-6 weeks of systemic therapy. Check again after 6 months.
• Check-ups: After 6 weeks, then quarterly. Appropriate visual inspection of findings, ensure equal spacing. If necessary, re-milling of the nail plate / possibly by a podiatrist. Check adherence.
• Duration of therapy: 12-18 months, in any case until clinical freedom from symptoms. Negative culture under therapy not meaningful (!)
• Secondary prophylaxis: Unlimited long-term therapy; preferably with water-insoluble nail varnish (Amorolfin 1x/week or every 2 weeks); alternatively Ciclopirox 1-2x/week (Sigurgeirsson B et al. 2010).

1. Effendi I et al. (2020) Combination therapy of severe onchomycosis - recommendations of an expert panel. Act Dermatol 46: 311-318
2. Sigurgeirssohn B et al. (2010) Efficacy of amorolfine nail lacquer formmprophylaxis of onychomycosis over 3 years. J Eur Acad Dermatol Venereol 24: 910-915