INTRODUCTION
Onychomycosis is a fungal infection of the nails and surrounding skin often presenting as thickening of the nail, onycholysis, and discoloration. It is the most common nail pathology and accounts for nearly 90% of toenail infections globally.1 Causes of onychomycosis are broad but the most common are due to dermatophytes, specifically Trichophyton and Epidermophyton. Toenails are more often involved than fingernails, with the great toenail being the most affected area.2 It is important to diagnose and treat onychomycosis in a timely manner to prevent secondary symptoms such as pain, paresthesia, spread to other nails, and impairment of daily activities. Additionally, onychomycosis does not resolve without treatment, further emphasizing the need for a proper therapy regimen.1
Onychomycosis is considered a chronic infection and is difficult to treat in patients with other comorbidities like diabetes, cardiovascular disease, HIV, and widespread immunosuppression. Given nail thickness and the slow growth rate of nails, prolonged and recurrent treatment is often required.3 Additional factors responsible for disease progression include warm environments, suboptimal footwear, genetic predisposition, and nail injury. While debridement allows some symptom relief and improves cosmetic appearance, it does not address the fungal infection and therefore should be used in combination with medication.4
The newer oral antifungals such as itraconazole and terbinafine have higher cure rates, shorter treatment periods, and fewer
Onychomycosis is considered a chronic infection and is difficult to treat in patients with other comorbidities like diabetes, cardiovascular disease, HIV, and widespread immunosuppression. Given nail thickness and the slow growth rate of nails, prolonged and recurrent treatment is often required.3 Additional factors responsible for disease progression include warm environments, suboptimal footwear, genetic predisposition, and nail injury. While debridement allows some symptom relief and improves cosmetic appearance, it does not address the fungal infection and therefore should be used in combination with medication.4
The goal of treatment is to eradicate the fungal infection and restore a healthy nail. Management considers disease severity, comorbidities, drug interactions, and cost. Over the past decade, treatment options for onychomycosis have expanded, primarily with the introduction of more effective oral antifungal medications.5 Older, systemic medications such as griseofulvin and ketoconazole are associated with low cure rates, prolonged treatment durations, and increased risk for side effects.
The newer oral antifungals such as itraconazole and terbinafine have higher cure rates, shorter treatment periods, and fewer
