Highlights & Basics
- Dermatophyte infections may be diagnosed clinically. However, speciation via fungal culture and proof of mycologic cure via serial fungal culture may aid patient care.
- Confirm diagnosis of onychomycosis (fungal nail disease) and tinea capitis (fungal scalp infection) prior to treatment if possible.
- Limited tinea corporis (body) infection can usually be managed with topical therapy alone. Systemic therapy is preferred for tinea capitis (scalp), tinea barbae (beard), tinea manuum (hands), and onychomycosis (nails).
- Most fungal infections of the skin are mild. However, in cases of immunocompromise, fungi can sometimes cause severe disease.
Quick Reference
History & Exam
Key Factors
scaling scalp lesions
patchy alopecia
erythematous, scaling skin lesions with central clearing
erythematous, scaling rash with follicular pustules in beard or mustache
erythematous, annular patches on face
vesicles and scaling of hands
fissuring, maceration, and scaling in the interdigital spaces of the fourth and fifth toes
chronically, scaly, hyperkeratotic plantar skin with erythema of the soles, heels, and sides of the feet
folliculitis with nodules
Other Factors
thickened nail with subungual hyperkeratosis, onycholysis, and white-yellow to brown discoloration
small, white speckled patches on the surface of the nail plate with crumbling nail
lymphadenopathy
black-dot alopecia
milky white nail plate
area of leukonychia in the proximal nail plate
Diagnostics Tests
1st Tests to Order
potassium hydroxide (KOH) microscopy
Other Tests to consider
dermoscopy
fungal culture
polymerase chain reaction (PCR)
Wood lamp exam (ultraviolet light)
Emerging Tests
reflectance confocal microscopy
Treatment Options
acute
tinea capitis
systemic antifungal therapy
topical antifungal shampoo
tinea barbae, tinea manuum, or Majocchi granuloma
systemic antifungal therapy
Definition
Classifications
Site of infection
- Dermatophyte infections of the hair and hair follicle and perifollicular skin: tinea capitis, tinea barbae, Majocchi (trichophytic) granuloma
- Dermatophyte infections of keratinized epidermal skin: tinea faciale or faciei, tinea corporis, tinea cruris, tinea manuum, tinea pedis
- Dermatophyte infections of the nail apparatus: tinea unguium (toenails, fingernails)
- Onychomycosis, a more inclusive term including nail infections caused by dermatophytes, as well as yeasts and molds
Source of infecting organism
- People (anthropophilic organisms)
- Animals (zoophilic organisms)
- Soil (geophilic organisms)
- Fomites
Taxonomy
- Microsporum species
- Trichophyton species
- Epidermophyton species
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
- Tinea pedis: the most common of the superficial fungal infections, occurring in up to 70% of adults.[4]
- Tinea corporis: common, with highest prevalence in preadolescents in hot, humid climates.
- Tinea cruris: most prevalent in adolescent and adult men.
- Tinea barbae: uncommon and most likely to be found in men who have been in direct contact with infected farm animals.
Etiology
- Directly from one person to another (anthropophilic organisms)
- Transmitted to humans from soil (geophilic organisms)
- Spread to humans from animal hosts (zoophilic organisms).
- Genetic susceptibility, including atopy
- Ethnicity
- Immunosuppressive illnesses or medications (e.g., HIV infection, corticosteroids)
- Presence of other skin diseases that disrupt the epidermis (e.g., atopic dermatitis)
- Other illnesses that predispose to skin infection, including diabetes mellitus and peripheral vascular disease.
- Sweating
- Occlusion
- Occupational exposure
- High humidity (tropical or semitropical climates)
- Exposure to infected pets or farm animals, infected fomites, skin contact with the floors of public bathing facilities
- Contact sports such as wrestling.
Pathophysiology
Images
Tinea corporis of the axilla. Central clearing with an active border of inflammation noted. Satellite lesion is present
Annular lesion on the elbow, with a silvery scale. No central clearing. Microscopic exam with potassium hydroxide revealed no fungal elements. Despite the resemblance to tinea corporis, there was a similar lesion on the extensor surface of both knees and a family history that together confirmed the diagnosis of psoriasis
Tinea capitis
Tinea capitis in a child with Fitzpatrick type VI skin with the typical appearance of fine scale and brown hair, which may be visualised as black dots
A kerion (abscess due to dermatophyte infection) in a child with Fitzpatrick type 1 skin
Tinea barbae. Note the pustules in the follicles, redness, and scaling
Tinea manuum. On the extensor surface of the hand there is extensive inflammation, scaling, hyperkeratosis, and erythema
Tinea manuum
Tinea pedis. Intense inflammation produces hyperpigmentation and vesicle formation. Vesiculobullous form of tinea pedis
Vesiculobullous form of tinea pedis and onychomycosis
Distal lateral subungual onychomycosis
Majocchi granuloma
Infant presenting with rash formerly known as moniliasis, now called candidiasis, caused by Candida spp.
Diagnostic Approach
History
- Diabetes
- Atopy
- Exposure to people, farm animals, or pets with skin infections
- Exposure to hot, humid weather
- Wearing occlusive clothing or footwear
- Hyperhidrosis
- Use of topical or systemic glucocorticoids or immunosuppressive medications
- Immunosuppressive disease, such as HIV.
General exam
Examination of the scalp
Examination of the face
Examination of the hand and foot
- Interdigital: signs of dermatophyte infection (erythema, scaling) are localized to web spaces
- Vesicular: if fungal infection spreads from the webs to the digit pulp and the palmoplantar regions vesicles may develop (which can appear similar to pompholyx seen in atopic dermatitis of the hands) with associated desquamation (peeling of skin). Itching intensifies subsequent to acute inflammation; rash associated with the id reaction can occur
- Hyperkeratotic: typified by minimal inflammation and prominent hyperkeratosis (thickening of skin) over the entire palmoplantar regions, with minimal or no itching. Hyperkeratosis of the feet may present with a moccasin-like distribution pattern; the plantar skin becomes chronically scaly and thickened, with hyperkeratosis and erythema of the soles, heels, and sides of the feet.
Examination of the groin
Examination of the nail
- White-yellow to orange-brown patches or streaks in the nail
- Onycholysis (nail plate separating from the nail bed)
- Subungual debris
- Hyperkeratosis (thickening) of the nail bed
- Dystrophy of normal nail architecture.
- Distal lateral subungual onychomycosis (DLSO): nails are thickened with subungual hyperkeratosis and onycholysis; discoloration ranges from white-yellow to brown
- White superficial onychomycosis: confined to the toenails and presents as small, white speckled patches on the surface of the nail plate
- Proximal subungual onychomycosis: presents as an area of leukonychia in the proximal nail; the nail plate surface is normal and there is no subungual hyperkeratosis
- Endonyx onychomycosis: nails have a milky white color of the nail plate, but, unlike DLSO, no evidence of subungual hyperkeratosis or onycholysis.
Laboratory confirmation
- Nail infection should be confirmed by pathology or mycology before starting treatment.[13]
- PAS staining of nail clippings is useful to confirm diagnosis of onychomycosis.[25]
- Fungal culture is useful for confirming diagnosis when long-term oral therapy is being considered, particularly after negative KOH microscopy when there is a high index of suspicion for tinea unguium. Take the sample from the undersurface of the nail, as proximally as possible.
- PCR rapidly confirms the diagnosis of fungal nail infection.[26]
- Dermoscopy is a noninvasive tool for the identification of hair and scalp disorders.[27] The presence of comma and corkscrew hairs suggests a diagnosis of tinea capitis.
- Fungal cultures are recommended in tinea capitis when KOH testing is nonconfirmatory.[23] Sample scalp lesions by scalpel scraping, hair pluck, brush, or swab as appropriate to the lesion.[23] Fungal culture of the scalp is best accomplished by running wet cotton buds through the scalp and plating on media.
- KOH testing on the hair often reveals hairs infected with sporae, whereas preparations of tinea from other sites show hyphae in the stratum corneum as common features.
Risk Factors
History & Exam
Tests
Differential Diagnosis
Atopic dermatitis
Differentiating Signs/Symptoms
- History of atopy and lack of lesions with active inflammatory border with central clearing. Lesions in flexural folds of neck, arms, and legs. Chronic and relapsing, often since childhood.
Differentiating Tests
- Diagnosis is clinical. Potassium hydroxide (KOH) microscopy is infrequently done, and rarely fungal culture or biopsy may be undertaken to exclude diagnosis of dermatophyte infection.
Dyshidrotic dermatitis
Differentiating Signs/Symptoms
- Sudden eruption of pruritic, small intradermal vesicles on hands and feet. There may be history of contact irritants: for example, nickel.
Differentiating Tests
- Diagnosis is clinical. KOH microscopy is infrequently done and rarely fungal culture or biopsy may be undertaken to exclude diagnosis of dermatophyte infection.
Lichen simplex chronicus
Differentiating Signs/Symptoms
- Leather-like, hyperpigmented patches that are pruritic and chronically rubbed, producing a leathery change in affected skin.
Differentiating Tests
- Diagnosis is clinical. KOH microscopy is infrequently done, and rarely fungal culture or biopsy may be undertaken to exclude diagnosis of dermatophyte infection.
Psoriasis
Differentiating Signs/Symptoms
- Family history of psoriasis, presence of characteristic silvery plaque and lesions located on extensor surface of elbows and knees will aid in diagnosis. Psoriasis limited to the nails can be difficult to distinguish, particularly if limited to toenails. In psoriasis, subungual hyperkeratosis is usually white silver in color. Pitting of nails may be mistaken for tinea unguium. Clinical differentiation will usually suffice for tinea capitis, unguium, or corporis.Image
Differentiating Tests
- KOH microscopy is infrequently done, and rarely fungal culture or biopsy may be undertaken to exclude dermatophyte infection.
Trichotillomania
Differentiating Signs/Symptoms
- History of obsessive habit of twisting hair with fingers. Usually no inflammatory changes in scalp, and broken hairs are of different lengths.
Differentiating Tests
- Clinical diagnosis. Trichoscopy shows broken hairs of different length.
Differentiating Signs/Symptoms
- History of tightly braided hair styles. Broken hairs with patchy alopecia. Usually no scaling and inflammation of scalp
Differentiating Tests
- Clinical diagnosis.
Alopecia areata
Differentiating Signs/Symptoms
- Complete rather than patchy hair loss.
Differentiating Tests
- Diagnosis is clinical. Trichoscopy shows "exclamation mark" hair and other types of broken hairs.
Erythema chronicum migrans
Differentiating Signs/Symptoms
- Rapidly enlarging and reddening, single or multiple bull's eye lesions on trunk. History of tick exposure or associated symptoms of Lyme disease.
Differentiating Tests
- Occasionally, KOH microscopy is required to distinguish this from tinea corporis. Antibody titers or skin biopsy for diagnosis of Lyme disease.
Pityriasis versicolor
Differentiating Signs/Symptoms
- Hypopigmented truncal lesions in dark-skinned individuals, darker than normal color with scaling in light-skinned individuals; commonly, below neck level.
Differentiating Tests
- Clinical differentiation usually sufficient; occasionally KOH microscopy is required to distinguish this from tinea corporis.
- Ultraviolet light from Wood lamp shows a pale yellow-white fluorescence.
Differentiating Signs/Symptoms
- Hyperpigmented nodules in beard area with incurving hairs in patients with dark skin.
Differentiating Tests
- Clinical diagnosis.
Seborrheic dermatitis
Differentiating Signs/Symptoms
- Greasy and scaly area in scalp (with scaling but no hair loss, i.e., dandruff) and erythema in the nasolabial folds and occasionally central chest.
Differentiating Tests
- Clinical diagnosis.
Acne rosacea
Differentiating Signs/Symptoms
- Acneiform eruption with erythema and easy blushing in nasal and malar area.
Differentiating Tests
- Clinical diagnosis.
Discoid lupus erythematosus
Differentiating Signs/Symptoms
- Malar rash, sun sensitivity.
Differentiating Tests
- Skin biopsy is confirmatory.
Contact dermatitis
Differentiating Signs/Symptoms
- Pattern of eruption, intense pruritus, erythema, and occasional vesicular eruption.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- Usually uniformly red without central clearing or sparing of scrotum; satellite lesions.Image
Differentiating Tests
- Clinical differentiation usually sufficient from tinea cruris; responds to all topical therapies recommended for tinea cruris.
Differentiating Signs/Symptoms
- Uniformly brown and scaly, with no active edge; groin or axillae.
Differentiating Tests
- Fluoresces a brilliant coral red under Wood lamp.
Differentiating Signs/Symptoms
- Absence of interdigital maceration or moccasin pattern of scaling; bulla primarily at points of contact with ill-fitting footwear; acute in onset.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- Thickened and deviated toenails resembling a ram's horn. Easily misdiagnosed as tinea unguium, this change occurs in older adults where vascular disease and diabetes may play a role. Recurrent trauma (such as that caused by ill-fitting shoes) may play a role.
Differentiating Tests
- KOH microscopy of nail scrapings, fungal culture, or nail biopsy may be necessary to distinguish from tinea unguium; both conditions may co-exist.
Treatment Approach
Tinea capitis
Tinea barbae, tinea manuum, Majocchi granuloma, extensive tinea corporis
Tinea faciale, tinea corporis, tinea cruris, or tinea pedis
Tinea unguium (onychomycosis)
Treatment Options
tinea capitis
systemic antifungal therapy
Primary Options
- griseofulvin microsize
children ≥2 years of age: 10-20 mg/kg/day orally given in 1-4 divided doses for 4-6 weeks, maximum 1000 mg/day; adults: 500-1000 mg/day orally given in 1-4 divided doses for 4-6 weeks
- griseofulvin microsize
- terbinafine
children ≥4 years of age and body weight <25 kg: 125 mg orally once daily for 6 weeks; children ≥4 years of age and body weight 25-35 kg: 187.5 mg orally once daily for 6 weeks; children ≥4 years of age and body weight >35 kg: 250 mg orally once daily for 6 weeks; adults: 250 mg orally once daily for 6 weeks
- terbinafine
Secondary Options
- itraconazole
children: 5-10 mg/kg/day orally given in 1-2 divided doses for 4-6 weeks, maximum 600 mg/day; adults: 200 mg orally once or twice daily for 4-6 weeks
- itraconazole
- fluconazole
children: 3-6 mg/kg/day orally for 6 weeks; adults: 200 mg orally once daily for 6 weeks
- fluconazole
Comments
- Oral systemic antifungal therapy is necessary. Topical agents are not effective as they do not penetrate the hair shaft, where the fungal infection resides.
- Griseofulvin is considered the gold standard treatment for Microsporum infections and terbinafine is considered the gold standard treatment for Trichophyton infections.[30] [33] [34] In the case of Trichophyton rubrum syndrome, antifungals are to be used for a longer period, and can go up to 3 months. Sometimes they may have to be combined with other antifungals.[21]
- Fluconazole is not approved for tinea capitis; however, it is sometimes used off-label in refractory cases in exceptional circumstances. Its use is limited by adverse effects. It may cause abdominal adverse effects and rare hepatotoxicity in children.[30]
topical antifungal shampoo
Primary Options
- selenium sulfide topical
(1 to 2.5% shampoo) children and adults: apply to scalp twice weekly for 2 weeks, leave each application on scalp for 2-3 minutes then rinse
- selenium sulfide topical
- ketoconazole topical
(1-2% shampoo) children: apply to scalp two to three times weekly for 2-4 weeks, leave each application on scalp for 5 minutes then rinse; adults: apply to scalp twice weekly for 4 weeks, leave each application on scalp for 5 minutes then rinse
- ketoconazole topical
Comments
- Topical therapy is useful to reduce the likelihood of spread of tinea capitis to siblings or classmates; in situations where a widespread daycare or school outbreak occurs, topical therapy may shorten the time that viable dermatophytes may be spread through use of shared clothing or grooming items.
tinea barbae, tinea manuum, or Majocchi granuloma
systemic antifungal therapy
Primary Options
- griseofulvin microsize
adults: 500-1000 mg/day orally given in 1-4 divided doses for 4-8 weeks
- griseofulvin microsize
- terbinafine
adults: 250 mg orally once daily for 6 weeks
- terbinafine
- itraconazole
adults: 200 mg orally once daily for 2-4 weeks
- itraconazole
Secondary Options
- fluconazole
adults: 200 mg orally once daily for 2-4 weeks
- fluconazole
Comments
- Similar to tinea capitis, systemic therapy is needed to deliver effective antifungal therapy to the hair shaft, where the infection resides in tinea barbae, or the thick, keratinized skin of the palmar surface of the hand(s).
- When tinea manuum is associated with tinea unguium of the fingernails, longer treatment times of 8 to 12 weeks are necessary.
- Majocchi granuloma is a fungal infection in hair, hair follicles, and surrounding skin that also requires systemic antifungal therapy for cure.
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
topical allylamine antifungal therapy
Primary Options
- terbinafine topical
(1%) children ≥12 years of age and adults: apply to the affected area(s) twice daily for 1-3 weeks
- terbinafine topical
- naftifine topical
(1% gel) adults: apply to the affected area(s) twice daily for up to 4 weeks; (1% cream) adults: apply to the affected area(s) once daily for up to 4 weeks; (2% cream or gel) children ≥12 years of age and adults: apply to the affected area(s) once daily for 2 weeks
- naftifine topical
- butenafine topical
(1%) children ≥12 years of age and adults: apply to the affected area(s) once or twice daily for 1-2 weeks
- butenafine topical
Comments
- These types of dermatophytosis are generally found in superficial skin structures and are usually responsive to topical therapy.
- There is limited evidence to favor the allylamine group (e.g., terbinafine, naftifine, butenafine) for topical therapy.[37] [38] A higher-strength formulation of naftifine has been tried for tinea cruris and tinea pedis.[39] [40] [41] [42] Two weeks of treatment with the 2% strength was as effective as 4 weeks of treatment with the 1% formulation in the management of tinea pedis.[40]
- Apply topical agents until no further infection is visible and for 1 to 2 weeks after, generally a total treatment time of 2 to 6 weeks, depending on the topical agent.
- Tinea pedis can be difficult to eradicate or may easily recur if there is a reservoir of infection in the toenails, or inadequate application of antifungal therapy to the entire surface of the foot and sides in moccasin-type tinea pedis. Disinfection of footwear or replacement footwear at the time of treatment may reduce recurrence of tinea pedis. In moccasin-type tinea pedis also spread the topical agent along the sole and sides of the feet.
topical aluminum acetate
Primary Options
aluminum acetate topical
children and adults: soak twice daily for 15-30 minutes for 7 days
Comments
- If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminum acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.
other topical antifungal therapy
Primary Options
- miconazole topical
(2%) children ≥2 years of age and adults: apply to the affected area(s) twice daily for 2-4 weeks
- miconazole topical
- clotrimazole topical
(1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily for 2-4 weeks
- clotrimazole topical
- econazole topical
(1%) children and adults: apply to the affected area(s) once daily for 2 weeks
- econazole topical
- ketoconazole topical
(2%) children and adults: apply to the affected area(s) once daily for 2-6 weeks
- ketoconazole topical
- luliconazole topical
(1%) children ≥2 years of age and adults: apply to the affected area(s) once daily for 1-2 weeks
- luliconazole topical
- tolnaftate topical
(1%) children and adults: apply to the affected area(s) twice daily for 2-4 weeks
- tolnaftate topical
- ciclopirox topical
(0.77%) children ≥10 years of age and adults: apply to the affected area(s) twice daily for 1-4 weeks
- ciclopirox topical
Comments
- Topical azoles, ciclopirox, or tolnaftate are less preferred and are typically second-line agents.
- Apply topical agents until no further infection is visible and for 1 to 2 weeks after, generally a total treatment time of 2 to 6 weeks depending on the topical agent.
- Tinea pedis can be difficult to eradicate or may easily recur if there is a reservoir of infection in the toenails, or inadequate application of antifungal therapy to the entire surface of the foot and sides in moccasin-type tinea pedis. Disinfection of footwear or replacement footwear at the time of treatment may reduce recurrence of tinea pedis. In moccasin-type tinea pedis also spread the topical agent along the sole and sides of the feet.
topical aluminum acetate
Primary Options
aluminum acetate topical
children and adults: soak twice daily for 15-30 minutes for 7 days
Comments
- If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminum acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.
systemic antifungal therapy
Primary Options
- terbinafine
children ≥2 years of age: consult specialist for guidance on dose; adults: 250 mg orally once daily
- terbinafine
- itraconazole
children: consult specialist for guidance on dose; adults: 200-400 mg/day orally given in 1-2 divided doses
- itraconazole
- griseofulvin microsize
children ≥2 years of age: consult specialist for guidance on dose; adults: 500-1000 mg/day orally given in 1-4 divided doses
- griseofulvin microsize
- fluconazole
children: consult specialist for guidance on dose; adults: 150-200 mg orally once weekly
- fluconazole
Comments
- Systemic antifungal therapy may be needed, particularly in immunosuppressed individuals with extensive tinea pedis.
- In case of systemic antifungal agents, terbinafine is recommended in treatment-naive cases of tinea pedis, while itraconazole is recommended in recalcitrant and severe cases. The minimum treatment duration should be 2 to 4 weeks in treatment-naive tinea pedis and >4 weeks in recalcitrant cases.[21]
- Evidence suggests that systemic therapy with terbinafine, itraconazole, griseofulvin, or fluconazole may be considered as alternative treatment for patients with tinea corporis with extensive skin involvement, or patients who are refractory to topical therapy. Treatment duration is usually 2 to 4 weeks but depends on response. A longer course may be required in recalcitrant cases.[43]
- Failure of treatment of tinea faciale or faciei, tinea cruris, tinea pedis, or tinea corporis may be due to patient nonadherence to treatment recommendations, misdiagnosis, or immunosuppressive illness or therapy. With treatment failure, a search for these possibilities and/or dermatologic consultation may be warranted.
topical aluminum acetate
Primary Options
aluminum acetate topical
children and adults: soak twice daily for 15-30 minutes for 7 days
Comments
- If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminum acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.
tinea unguium (onychomycosis)
systemic terbinafine therapy
Primary Options
- terbinafine
children: consult specialist for guidance on dose; adults: 250 mg orally once daily for 12 weeks (toenails) or 6 weeks (fingernails)
- terbinafine
Comments
- Do not start treatment before mycologic confirmation of infection.[13]
- Systemic antifungal treatment is recommended for most patients. Both terbinafine and azoles have been found to be effective in achieving a normal-looking nail and curing the toenail infection, with terbinafine being more effective than azoles; therefore, consider terbinafine as first-line treatment.[44] [45] [46]
- Toenail infections require a longer duration of therapy than fingernails due to the slower rate of nail growth. One systematic review found that continuous terbinafine for 24 weeks, but not 12 weeks, was significantly more likely to result in mycologic cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9 to 12 months.[47]
- Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]
systemic azole therapy or topical treatment
Primary Options
- itraconazole
children: consult specialist for guidance on dose; adults: 200 mg orally twice daily for 7 days, followed by no treatment for 21 days, then 200 mg twice daily for 7 days (fingernails); adults: 200 mg orally once daily for 12 weeks (toenails)
- itraconazole
- fluconazole
children: consult specialist for guidance on dose; adults: 150-450 mg orally once weekly for 6-12 months (toenails) or 3-6 months (fingernails)
- fluconazole
Secondary Options
- ciclopirox topical
(8%) children ≥12 years of age and adults: apply to affected nail(s) once daily, remove with acetone every 7 days and repeat application cycle
- ciclopirox topical
- efinaconazole topical
(10%) children ≥6 years of age and adults: apply to the affected nail(s) once daily for 48 weeks
- efinaconazole topical
- tavaborole topical
(5%) children ≥6 years of age and adults: apply to the affected nail(s) once daily for 48 weeks
- tavaborole topical
Comments
- Do not start treatment before mycologic confirmation of infection.[13]
- Systemic treatment is recommended for most patients. Itraconazole and fluconazole are second-line options; adverse-effect profile and cost determine which is the most appropriate choice.[13] Toenail infections require a longer duration of therapy than fingernails due to the slower rate of nail growth.
- For a small number of patients with very distal infection or superficial white onychomycosis, mechanical debridement followed by topical treatment may suffice.[49] Although some evidence supports the use of topical treatments for fungal infections of the toenails, complete cure rates are relatively low.[50] Efinaconazole and tavaborole topical solutions have been reported to effectively treat toenail onychomycosis in randomized, vehicle-controlled trials.[51] [52] [53] Both are approved by the Food and Drug Administration for the treatment of toenail distal subungual onychomycosis due to Trichophyton rubrum or Trichophyton mentagrophytes. One Cochrane review confirmed the effectiveness of efinaconazole and tavaborole topical solutions, and that of ciclopirox nail lacquer.[50] The effectiveness of ciclopirox nail lacquer is enhanced when delivered in a water-soluble biopolymer vehicle.[50] [54] Ciclopirox nail lacquer requires debridement of hyperkeratotic nail for best effect.[55]
- Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]
additional course of alternative systemic therapy
Primary Options
- terbinafine
children: consult specialist for guidance on dose; adults: 250 mg orally once daily for 12 weeks (toenails) or 6 weeks (fingernails)
- terbinafine
Secondary Options
- itraconazole
children: consult specialist for guidance on dose; adults: 200 mg orally twice daily for 7 days, followed by no treatment for 21 days, then 200 mg twice daily for 7 days (fingernails); adults: 200 mg orally once daily for 12 weeks (toenails)
- itraconazole
- fluconazole
children: consult specialist for guidance on dose; adults: 150-450 mg orally once weekly for 6-12 months (toenails) or 3-6 months (fingernails)
- fluconazole
Comments
- Only 30% to 60% of people will report a clinical cure following treatment with oral antifungals.[48]
- Review diagnostic findings to ensure that a differential diagnosis or concomitant condition does not explain nail change. Only consider a second course of oral treatment after confirming diagnosis, and ensure that an agent other than the one used for initial treatment is used.
- Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]
Emerging Tx
Laser treatment
Systemic second-generation azole antifungals
Prevention
Primary Prevention
- Avoiding infected pets, farm animals, exposure to infected fomites, skin occlusion with clothing or footwear that does not allow for moisture evaporation, and high humidity
- Avoidance of walking barefoot in public bathing areas
- Lifestyle changes, such as glucose control and diet to manage obesity and diabetes.
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
Ameen M, Lear JT, Madan V, et al. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol. 2014 Nov;171(5):937-58.[Abstract][Full Text]
Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association of Dermatologists' guidelines for the management of tinea capitis 2014. Br J Dermatol. 2014 Sep;171(3):454-63.[Abstract][Full Text]
Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association of Dermatologists' guidelines for the management of tinea capitis 2014. Br J Dermatol. 2014 Sep;171(3):454-63.[Abstract][Full Text]
Foley K, Gupta AK, Versteeg S, et al. Topical and device-based treatments for fungal infections of the toenails. Cochrane Database Syst Rev. 2020 Jan 16;(1):CD012093.[Abstract][Full Text]
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Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Includes introductory descriptions of the disease and recommendations for diagnosis.Published by
Japanese Dermatological Association
Published
2019
Summary
Evidence based approach to the diagnosis of fungal skin and nail infections.Published by
Public Health England (UK)
Published
2017
Summary
Evidence based recommendations on the diagnosis of onychomycosis.Published by
British Association of Dermatologists
Published
2014
Summary
Evidence based recommendations on the diagnosis of tinea capitis.Published by
British Association of Dermatologists
Published
2014
Treatment
Summary
Describes the treatment options for symptomatic but non-life threatening fungal infections in immunocompetent children.Published by
Canadian Paediatric Society
Published
2019
Summary
Recommendations for minimizing risks associated with animals in public settings. Skin contact with animals in public settings has been associated with ringworm.Published by
National Association of State Public Health Veterinarians; Centers for Disease Control and Prevention
Published
2017
Summary
Clinical recommendations for practice when diagnosing and managing tinea infections.Published by
American Academy of Family Physicians
Published
2014
Summary
Addresses medical mycology and recent advances in treatment.Published by
Japanese Dermatological Association
Published
2019
Summary
Describes a simple, effective, and empiric approach to the treatment of fungal skin and nail infections, with particular emphasis on minimizing the emergence of antibiotic resistance in the community.Published by
Public Health England (UK)
Published
2017
Summary
Treatment should not be commenced before mycologic confirmation of infection. Systemic therapy is preferable for onychomycosis.Published by
British Association of Dermatologists
Published
2014
Summary
Evidence based recommendations on the management of tinea capitis.Published by
British Association of Dermatologists
Published
2014
Summary
Practice guidelines for the treatment of tinea capitis.Published by
European Society for Pediatric Dermatology
Published
2010
Credits
Patient Instructions
- Disinfect hairbrushes and combs, because spores have been isolated on these fomites
- Wear loose-fitting clothing
- Avoid sharing clothes and hairbrushes/combs
- Avoid walking barefoot in public bathing areas
- After washing, thoroughly dry any areas that have become infected before dressing.