Therapies for the treatment of onychomycosis ☆ Aditya K. Gupta, MD, PhD, FRCP(C) a,b, ⁎ , Maryse Paquet, PhD b , Fiona C. Simpson, BSc b a Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada b Mediprobe Research, Inc., London, Ontario, Canada Abstract Onychomycosis treatments include nail avulsion and debridement by chemical or surgical procedures, topical and oral antifungals, and device-based therapies. The advantages, disadvantages, and limitations of the different types of treatments—including the most commonly prescribed topical (ciclopirox) and oral (terbinafine, itraconazole, and fluconazole) treatments for onychomycosis caused by dermatophytes, non-dermatophyte molds, and yeasts—are reviewed. Safety and efficacy data for the healthy adult population and for special populations such as children and diabetic patients have confirmed the importance of proper mycological diagnosis before the initiation of therapy as well as the evaluation of the risks and benefits of the different treatments. © 2013 Elsevier Inc. All rights reserved. Introduction A wide array of treatments is available for the treatment of onychomycosis. The infected nail can be removed either physically or chemically. The infectious agent can be eliminated by topical or oral antifungals or by laser therapy, and a number of antifungal and laser systems are now available for such treatment. 1 Several factors (eg, infecting organism, clinical presenta- tion, severity of the infection, comorbidities) should be taken into consideration when determining the best therapeutic strategy for onychomycosis. Indeed, onychomycosis can be caused by dermatophytes, nondermatophyte molds, or yeasts, and each possesses different susceptibility to antifungal therapies. 2,3 There are four major clinical pre- sentations of onychomycosis: distal subungual, proximal subungual, superficial, and total dystrophic. 4 An oral treatment would generally not be appropriate for a superficial onychomycosis, which can be easily treated with a topical antifungal. A treatment can be less effective when a larger proportion of the nail is affected (ie, with a larger fungal mass or when the matrix is involved); a topical treatment may be a good option when one or two nails are infected, but a systemic treatment would be preferable when several nails are involved. As a result of possible drug interactions, comorbidities may prevent the use of some oral treatments. Nail avulsion and debridement Nail avulsion, which is the separation of the nail plate from the nail bed, can be performed chemically or surgically for onychomycosis. Laser avulsion has also been used for other indications. The nail plate can be totally or partially removed on the basis of the extent of the infected area; however, the complete removal of the nail plate results in the loss of counterpressure on the nail bed, which may promote ☆ The authors have no conflicts of interest or funding sources to declare. ⁎ Corresponding author. Tel.: + 1 519 657 4222; fax: + 1 519 657 4233. E-mail address: agupta@execulink.com (A.K. Gupta). 0738-081X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clindermatol.2013.06.011 Clinics in Dermatology (2013) 31, 544–554