Onychomycosis:

new updates and

management challenge
Dr. Fitriani, Sp.KK, FINSDV
Dermatology and Venereology Department
Dr. Moh. Hoesin General Hospital / Medical Faculty of Sriwijaya University
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 ONYCHOMYCOSIS

• Toe nails 7-10 x

• The most frequent more frequent
nail disorders, 40- than fingernails
• Increasing with
50% nail diseases
age
• 5% of the world’s • Affected by
population predisposition
factors
Classified

Pathogens Entry of the fungi

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Classification
Onychomycosis
according to pathogens
Dermatophytes
(most common)

Yeasts

Non-Dermatophytes molds

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 Classification…
Onychomycosis
according to the entry the fungi
Distal-lateral subungual
onychomycosis

Proximal white subungual

onychomycosis

Superficial white onychomycosis

Endonyx onychomycosis

Total dystrophic onychomycosis

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 Distal-lateral subungual onychomycosis

• The vast majority of onychomycosis

• Beginning  fungi reach hyponychium, spreading
proximally
• Yellow-white discoloration nail plate, distal subungual
hyperkeratosis, onycholysis
• Mild and inconspicuous desquamation around the nail 
tinea pedis
• After months or years  no more progression but the
subungual hyperkeratosis may continue to thicken 5
 Proximal white subungual onychomycosis

• Rare infection
• First infects the undersurface of the proximal nail fold
via cuticle, then grows toward the matrix
• White to yellowish discoloration of the nail that grows
out from under the proximal nail fold
• Onycholysis
• Etiology: non-dermatophyte molds
T. rubrum  HIV infection
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 Superficial white onychomycosis

• Invade the dorsal nail plate

• Mostly on toenails: chalky-white patches with
no shine of the nail surface

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• HIV infection: the white discoloration is
inhomogeneous and more cloudy, but the nail
surface remains shiny on the fingernails

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 Endonyx onychomycosis

• Very rare infection

• Massive nail plate invasion without nail bed involvement
• No subungual hyperkeratosis or onycholysis
• Lamellar splitting and milky white discoloration
• Mainly caused by T. soundanense or T. violaceum

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 Total dystrophic onychomycosis

• The most severe stage

• Secondary to any of the other forms
• Primary in chronic mucocutaneous candidiasis due
to immune deffect
• The nail completely destroyed and substituted by
irregular keratotic debris
• Nail plate: diffusely thickened, friable, yellowish
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Diagnosis

Clinically Microscopy

Onychomycosis

Culture Histopathology

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 Diagnosis…

New diagnostic tools:

• Onychoscopy
• Confocal laser-scanning microscopy
(CLSM)
• PCR
• Dermatophyte test strip

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Disease Associations

• Tinea of the hand and/or feet

• Immunosuppression
• Arterial and venous insufficiency
• Diabetes mellitus

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 Management
of Onychomycosis

• Management is still challenging

• Very high recurrence due to :
• persisting risk factors
• environmental factors
• The treatment relies on the type and
severity of onychomycosis and the patient’s
comorbidities
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 Management
of Onychomycosis

Goal of therapy:
• Eliminate the infecting fungal organism
• Restore the nail to its normal state as it
grows

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 Management
of Onychomycosis
(Topical)

Modalities Indication Dose Mycologic

cure
Ciclopirox 8% T. Rubrum OM Once daily for 12 months 29-36%
lacquer superficial and distal
Efinaconazole 5% Dermatophyte OM Once daily for 12 months 53-55%
solution mild to moderate
Tavaborole 8% Dermatophyte OM Once daily for 12 months 31-36%
solution mild to moderate
Tioconazole 28% Dermatophyte OM Twice daily for 6-12 months <50%
solution superficial and distal
Amorolfin 5% Dermatophyte OM Once or twice daily for 6-12 <50%
lacquer superficial and distal months
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 Management
of onychomycosis
(Systemic)
Modalities Indication Dose Mycologic
cure
Itraconazole First line 200 mg daily for 12 weeks or 63-66%
dermatophyte OM Pulse therapy 400 mg daily for one
week a month (2 pulse on finger and 3
pulse on toe)
Terbinafine First line 250 mg daily for 6 weeks (finger) and 60%
dermatophyte OM 12-16 weeks (toe) or pulse therapy
500 mg daily for one week a month
(4 pulse both)
Fluconazole Alternate 150-450 mg a week for 3 months 42-48%
dermatophyte OM (finger) and 6 months (toe)
Griseofulvin Alternate 500-1000 mg daily for 6-9 months High
dermatophyte OM (finger) and 12-18 months (toe) recurrence
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 Management
of onychomycosis

COMBINATION THERAPY
• Topical + oral therapy
• Can reduce failure treatment

SURGICAL TREATMENT
• Must be combine with topical and oral therapy
• Removal of the affected nail plate, nail avulsion,
debridement

ANOTHER MODALITIES
• Laser treatment (Nd:YAG)
• Photodynamic treatment  still in experimental phase 18
 Management
of onychomycosis

NATURAL THERAPY
• Need further research for formal recommendations
• Including:
• Tea tree oil
• Ozonized sunflower oil
• Propolis

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 Failure to treatment

• Total onychomycosis, very thick subungual

hyperkeratosis, and dystrophic onychomycosis
• Etiological agents  several non-
dermatophytes do not respond to systemic
antifungals (Neoscytalidium, Scopulariopsis
and Fusarium sp.)
• Patients comorbidities  Immunodepressed
patients have a poor prognosis and several
drugs may modify antifungal blood levels
(HIV or Diabetes)
• Patient’s compliance

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 Management Strategy
• Drug choice relies on the OM type and
severity
• Knowing the patient’s comorbidities
• Combination therapy if needed
• Avoid drug interaction if there is
contraindication  Itrakonazole with
rifampisin
• Education to the patient
– patient’s compliance is necessary to
avoid drop out
– Maintain nail hygiene
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 Conclusion

• Onychomycosis is a very common

fungal infection, which needs a targeted
treatment
• Therapy requires several months, as the
nail grows very slowly, especially in
elderly
• Drug choice relies on the type and
severity of onychomycosis and the
patient’s comorbidities
• Combination therapy are needed if
required
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THANK YOU

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