At the Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference in Los Angeles, CA, Lipner et al presented therapeutic recommendations for treating onychomycosis.

Fungal infection of the nail bed or plate can be challenging, as nail growth can take months, drug penetration is difficult, and recurrence is common. Therefore, diagnosis should be careful to include laboratory testing to identify the infecting organism, such as fungal culture, periodic acid-Schiff stain, potassium hydroxide testing, or polymerase chain reaction. Differential diagnoses (eg, nail psoriasis, chronic paronychia, lichen planus) should be ruled out as well with examination and testing.

Once onychomycosis is confirmed, Lipner et al created a decision tree of therapeutic recommendations. They agreed that treatment should be individualized based on nail involvement, fungus, patient characteristics and medications, biomechanics, cost and affordability, and patient preference.

For pediatric patients, they recommended using topical efinaconazole. For adults with confirmed onychomycosis, the tree splits into two branches; in one branch, patients aged 64 years or younger who are relatively healthy should be treated based on clinical presentation, vs the other branch being treated based on patient characteristics (ie, patients aged 65 years or older or with concomitant medications or comorbidities). For cases that fall within the “clinical presentation” treatment branch, topical efinaconazole (mild to moderate disease or dermatophytoma) or oral terbinafine alone (moderate) or with topical treatment (severe) are first-line therapies. For patients aged 65 years or older or who have diabetes or peripheral vascular disease or are immunocompromised, fisrt-line treatment should be topical treatment plus oral terbinafine or oral fluconazole. Patients on concomitant medication should receive topical treatment but may also receive oral terbinafine or oral fluconazole. Persons with liver or kidney comorbidities should receive topical treatment only, and patients with concurrent nail psoriasis should be treated for onychomycosis first based on the clinical presentation.

The expert group also recommended patient education. Patients should understand that onychomycosis may sometimes take more than a year to see clinical result and the nail appearance may not return to normal. They also need to be educated on recurrence rate and extrapharmacologic care, including personal hygiene, laundry habits, footwear selection, and more.

Reference
Lipner SR, Joseph WS, Vlahovic TC, et al. Therapeutic recommendations for the treatment of toenail onychomycosis in the US. Presented at: r; November 4-7, 2021; Los Angeles, CA.