Continuing Education Activity

Onychomycosis, a common fungal infection of the nail unit, affects both fingernails and toenails, with toenail involvement occurring far more frequently. Dermatophytes, such as Trichophyton rubrum, cause most cases, while yeasts, such as Candida albicans, and nondermatophytic molds, such as Fusarium or Aspergillus, contribute to others. This course reviews this infection, which arises from the invasion of fungi into the nail bed through minor trauma or moisture, and thrives in warm, enclosed environments. Participants will also gain an understanding of the clinical features of onychomycosis, including nail changes such as thickening, discoloration, and dystrophy, and the clinical disease stages, progressing from subtle subungual changes to chronic total dystrophic onychomycosis.

This activity explores the pathogenesis, clinical variations, diagnostic modalities, including mycological testing and dermoscopy, and evolving therapeutic strategies for onychomycosis. The need for diagnostic accuracy and histopathologic confirmation is also discussed, as nearly half of abnormal nails are nonfungal. This activity for healthcare professionals is designed to enhance the learner's competence in identifying onychomycosis, performing the recommended evaluation, and implementing an appropriate interprofessional approach when managing this condition. 

Objectives:

• Identify various causative agents contributing to onychomycosis, distinguishing between dermatophytes, yeasts, and saprophytic molds.
• Assess the various clinical presentations of onychomycosis.
• Implement alternative strategies such as combination therapy, topical agents, periodic debridement, and chemical nail avulsion to treat onychomycosis.
• Coordinate care with the interprofessional team to optimize patient outcomes, emphasizing the holistic approach to managing onychomycosis and preventing complications.

Introduction

Onychomycosis is a fungal infection of the nail unit and is among the most prevalent nail disorders encountered in clinical practice, often posing diagnostic and therapeutic challenges due to its diverse etiologies and chronic nature. When dermatophytes cause onychomycosis, this condition is called tinea unguium.[1] The term onychomycosis encompasses dermatophyte, yeast, and saprophytic mold infections. Caused primarily by dermatophytes, eg, Trichophyton rubrum, and less frequently by yeasts and nondermatophytic molds, onychomycosis affects millions worldwide, leading to nail discoloration, thickening, and dystrophy. An abnormal nail not caused by a fungal infection is a dystrophic nail.

Onychomycosis can infect both fingernails and toenails, but onychomycosis of the toenail is much more prevalent. Despite advances in diagnostic tools and antifungal therapies, misdiagnosis and suboptimal management remain common, resulting in persistent infection and patient dissatisfaction. Therefore, an in-depth understanding of evidence-based strategies is vital to enhance diagnostic precision, therapeutic decision-making, and interprofessional coordination, thereby improving outcomes and preventing recurrence.[2][3][4]

Etiology

The most frequent cause of onychomycosis is Trichophyton rubrum, but other dermatophytes, including Trichophyton mentagrophytes and Epidermophyton floccosum, can also cause it. The dermatophytes are identified in 90% of the toenail and 50% of the fingernail onychomycosis.[5] Candida albicans cases account for 2% of onychomycosis cases, especially of the fingernails. Nondermatophytic mold onychomycosis is cultured primarily from toenails. Examples of these saprophytic molds include Fusarium, Aspergillus, Acremonium, Scytalidium, and Scopulariopsis brevicaulis,[6] accounting for about 8% of nail infections.[7]

Epidemiology

Onychomycosis is a common infection that is increasing in incidence. Initially, in the United States, Trichophyton rubrum was considered a culture contaminant. However, since the advent of international travel to Asia, T. rubrum has become the dominant causative organism in the United States.[8] At least half of abnormal toenails are mycotic. Prevalence estimates range from 1% to 8%, and the incidence is increasing. Patients are genetically susceptible to dermatophyte infections in an autosomal dominant pattern. Risk factors include aging, diabetes, tinea pedis, psoriasis, immunodeficiency, and living with family members with onychomycosis.[9][10]

Pathophysiology

Hotel carpets, public showers, and pool decks can culture causative organisms. An asymptomatic, dry hyperkeratotic tinea pedis usually precedes onychomycosis. Over time, the dark, warm, moist environment of shoes and microtraumatic pressure on the nail unit compromise and break the hyponychial seal, allowing penetration of the dermatophyte into the nail bed (Image 1. Left Hallux Nail Plate). Repeated exposure to water in wet work compromises fingernails. Dermatophytes only live on the keratin of dead corneocytes in the skin, nails, and hair.[11]

In the foot, the dermatophytes produce keratinases that begin the infection between the lesser toes, spread to the hyperkeratotic sole, and gradually extend to the distal hyponychial space of micro-traumatized nail units. The dermatophytes breach the nail bed through the distal nail hyponychium, spreading proximally as onycholysis and subungual hyperkeratosis.[12][13]

The primary site of the infection is the nail bed, where the acute infection triggers a low-grade inflammatory response and progresses to a chronic phase characterized by total dystrophic onychomycosis. Histologically, the acute lesion of onychomycosis manifests as spongiosis, acanthosis, papillomatosis with edema, and hyperkeratosis. These signs resemble psoriasis pathology.[14] As in most infections, a dense inflammatory infiltrate develops. Onychomycosis also eventually infects the viable nail matrix (Image. Onychomycosis Nail Changes). Onychomycosis secondarily damages the nail matrix as the nail bed becomes hyperkeratotic and thickened to shed the fungal infection. The dermatophyte also invades the overlying nail plate, detaching and distorting it over time (Image 2. White Superficial Onychomycosis). The nail plate becomes elevated and misaligned as the infection enters the chronic total dystrophic clinical stage of onychomycosis (TDO) (Image 3. Onychomycosis Nail Changes).[15] At this chronic stage of the infection, there are large amounts of compact hyperkeratosis, hypergranulosis, acanthosis, and papillomatosis with sparse perivascular infiltrate. Dermatophytosis and subungual seromas can occur.[16] Zaikovska et al found high levels of interleukin-6- and interleukin-10-positive cells in the nail bed and the bloodstream in onychomycosis. Many fibers containing human beta defensin-2 can be found in the bed and plate of the mycotic nails. 

Histopathology

Histologically, the acute lesion of onychomycosis manifests as spongiosis, acanthosis, papillomatosis with edema, and hyperkeratosis. At the chronic stage of the infection, there are large amounts of compact hyperkeratosis, hypergranulosis, acanthosis, and papillomatosis with sparse perivascular infiltrate. Dermatophytosis and subungual seromas can occur.[16]

History and Physical

The duration, progression, and success of prior treatments are important aspects of evaluating a patient with nail disease. In addition, in suspected onychomycosis, medication history is important to assess the potential impact of systemic antifungals on current medications.[10] A history of hepatitis or travel to areas where hepatitis is endemic is an important aspect in considering appropriate tests to order in the laboratory workup. Alcohol usage should be properly chronicled. Recreational activities can predispose patients to recurrent or reinfecting infections. Tinea manuum, cruris, or psoriasis often accompanies onychomycosis. The focused cutaneous examination should include special attention to both hands, feet, and scalp.[17]

Pedal onychomycosis often presents as one or more thickened, discolored toenails. Usually, one or both great toenails are affected. Most cases have concurrent mild, dry, hyperkeratotic tinea pedis that patients often mistake for simple xerosis.[18] Baseline images of the target nail and measurement of the infection's extent are important for predicting treatment duration and evaluating therapeutic progress, as an infection can take 12 months to clear. Estimate toenail growth at approximately one millimeter per month and measure the infected area of the nail unit to estimate the duration of the treatment. Keep in mind that fingernails grow faster than toenails, and aging and peripheral vascular insufficiency slow growth rates.

Evaluation

Determining the severity and clinical stage of the infection helps guide therapy and improve outcomes. The most common clinical subtype of onychomycosis is distal lateral subungual onychomycosis (DSLO) (Image 4. Lateral Onychomycosis).[19] This condition presents as partial distal onycholysis with subungual hyperkeratosis or crumbling. Much less common is white superficial onychomycosis (WSO), which appears as white, chalky deposits on the surface of the affected nail plate.[20] WSO can be easily scraped away with a curette or a rotary burr.[21] The rarest subtype of onychomycosis is proximal subungual onychomycosis (PSO), which develops overlying the nail matrix.[22] PSO has been associated with acquired immunodeficiency syndrome (AIDS) and spreads through a hematogenous route. The infection first occurs in the nail plate, and the key feature of subungual hyperkeratosis of the nail bed is not evident in the endonyx subtype.[23] Total dystrophic onychomycosis (TDO) is the most advanced form. TDO is a later severe stage of the chronic subungual dermatophyte infection that may take 10 to 15 years to develop. Significant subungual hyperkeratosis accompanies TDO, and destruction of the abnormal nail plate and nail bed ridging may ensue. This is not only the most challenging stage to clear but also the type with the highest risk of developing subungual ulcerations, secondary bacterial infection, and precipitating gangrene in patients with impaired peripheral circulation.[24][25][26]

It is essential to know that almost half of the abnormal-appearing toenails are not mycotic, so mycological testing is vital to establish an accurate diagnosis and is especially important if systemic therapy is planned. The traditional potassium hydroxide (KOH) wet-mount preparation of subungual debris is only 60% sensitive and cannot identify the species. However, if the KOH is positive, it can separate dermatophytes from saprophytes.[27] Currently, the most sensitive test (95%) is a pathologist-interpreted nail clip biopsy stained with periodic acid-Schiff (PAS) plus Grocott methenamine silver. Today, a mycologist is required to interpret fungal culture testing. Fungal cultures are very specific but not very sensitive (60%). Fungal cultures grow slowly, adding weeks and costs to the workup.

Fungal culture or PCR is required to identify the cause of the infection. They help determine the source of infection in atypical cases or when a primary saprophytic infection is suspected. Confirm this suspicion by obtaining 2 subsequent cultures of the same saprophyte before concluding that the saprophyte is the primary pathogen and not a contaminant. PCR improves species-specific detection of dermatophytes by 20% compared with fungal cultures alone.[28]

Dermoscopy can clinically diagnose onychomycosis and readily differentiate it from nail dystrophy (Image 5. Onychomycosis, Aurora Borealis). The presence of subungual short spikes and longitudinal striae indicates onychomycosis, while transverse onycholysis is consistent with microtraumatic nail dystrophy (Image 6. Onychomycosis, Longitudinal Striae).[29]

Treatment / Management

The most effective treatments for onychomycosis are systemic antifungals. Due to an increased risk of subungual ulceration, one should also consider oral antifungal therapy in moderate to severe disease, especially in patients with diabetes mellitus. Combination therapy with topical agents, periodic debridement, or chemical nail avulsion may produce better results than systemic medication alone. The newer topical antifungal therapies have improved cure rates in patients who prefer to avoid systemic antifungals for mild-to-moderate cases. Meta-analyses have shown that the mycological cure rate with terbinafine is 76%, with itraconazole pulse dosing 63%, and with fluconazole 48%. Conversely, mycological cure rates for topical therapy are 55% with efinaconazole and 36% with tavaborole or ciclopirox.[12][30][31]

Negative mycology and a 100% clear nail—the gold standard for comparing efficacies—define the complete cure rate. However, this is a very stringent criterion, as residual nail dystrophy from chronic infection may scar the nail plate and prevent some results from being completely clear, even with significant clinical improvement. On the other hand, the nail unit could be 100% clear, but the post-treatment fungal culture may detect fungal colonization. The complete cure rate for systemic terbinafine is 38%.[32]

Oral therapy is the most effective therapy for severe onychomycosis, but it is medically inappropriate for some patients. Additionally, many patients have a strong personal preference for a non-systemic approach. Topical therapy is a good solution to the problem if the efficacy rates are better. Many over-the-counter and prescription products are available, suggesting no effective topical choices exist. The evidence indicates that complete cure rates for FDA-approved topical therapies have recently improved from 8.5% with ciclopirox lacquer to 18% with efinaconazole solution.[33] The tavaborole solution has a complete cure rate of 9.1% in mild-to-moderate distal subungual onychomycosis.[34]

It is essential to carefully review the patient's history of alcohol use disorder and hepatitis. Ordering alanine aminotransferase and aspartate aminotransferase hepatic function tests before the beginning of continuous therapy establishes a baseline. If there is a history of living overseas where hepatitis is endemic, add a hepatitis antigen screening panel to the workup. Follow-up hepatic function tests at 5 weeks can detect less than 2% of idiosyncratic reactions. One can stop the drug and retest if the follow-up tests are significantly elevated.[35]

Additionally, concurrent medications may preclude the use of oral antifungals. Terbinafine may alter the metabolism of many drugs, so monitoring is appropriate. Concerns regarding drug-to-drug interactions with statin therapy and systemic antifungal therapy are actually with the azole class of antifungals and not terbinafine.[36] Avoiding systemic therapy in patients on psychotropic medications might be best. Terbinafine carries a contraindication for concurrent use with phenothiazines and pimozide for increased risk of QT prolongation.[37] Terbinafine can be used safely in children and older people. However, clinicians should always exercise caution in patients with polypharmacy. Using an alternative therapy or periodic debridement alone to control symptoms in these cases (to avoid adverse drug reactions in patients with essentially benign disease) may be best. 

Differential Diagnosis

Clinicians should differentiate onychomycosis from other nail pathologies with similar clinical features, including:

• Yellow nail syndrome
• Drug reaction
• Hypothyroidism
• Nail malignancy
• Psoriatic nail
• Contact dermatitis

Prognosis

 The prognosis of onychomycosis varies depending on several factors, including:

• Type and severity of infection: The type of fungus and the extent of the involvement of infection can affect the prognosis, with limited and superficial infections resulting in better outcomes.
• Immune system status: Immunocompromised people, such as those with diabetes, HIV, or other immunodeficiency conditions, may experience a more chronic course of disease.[11]
• Response to treatment: The effectiveness of the chosen regimen plays a crucial role in the prognosis. Some cases of onychomycosis can be successfully treated with antifungal oral and topical treatments, leading to complete resolution. However, in some cases, the infection may resist conventional treatment, leading to a more prolonged or recurring condition.
• Compliance with treatment: Adherence to the prescribed treatment plan is necessary for a favorable prognosis. Non-compliance can lead to chronic infection.[38]
• Underlying health conditions: Certain medical conditions, such as poor circulation or peripheral vascular disease, can affect blood flow to the nails and impede the effectiveness of systemic treatment, leading to slowed improvement. 

Complications

While the infection is not fatal, some of the complications seen in patients with the condition include the following: 

• Cellulitis
• Sepsis
• Osteomyelitis
• Tissue damage
• Loss of nail

Deterrence and Patient Education

Encourage patients to wear proper footwear, maintain hygiene, and be conscious of cleaning their hands and feet when using public washrooms, pools, or water parks, and to avoid using wet towels. If there is any change in the nails, patients should see the clinician for a timely diagnosis and treatment. Once treatment commences, patients should be advised on compliance, as nonadherence to medication can alter the course of the disease. 

Pearls and Other Issues

To control symptoms and reduce the risks of subungual ulceration and secondary bacterial infection, clinicians can use periodic debridement to successfully manage severe onychomycosis in patients who elect to avoid systemic therapy or cannot apply topical antifungals. In addition, many patients are reluctant to accept the potential risk of idiosyncratic hepatic reactions that may occur during 90 days of continuous systemic antifungal therapy. Some patients, however, will receive and do well with pulsed systemic treatment. In moderate onychomycosis, 250 mg of terbinafine daily for 1 week, every 9 weeks for 3 pulses, is acceptable.

Although periodic thorough debridement is unlikely to clear onychomycosis, it appears to improve immediate patient satisfaction and aid the efficacy of medications. Undertake concurrent treatment of the tinea pedis and the long-term daily use of an antifungal powder to reduce reinfection and recurrence.

Enhancing Healthcare Team Outcomes

The effective management of onychomycosis requires an interprofessional approach. While the fungal infection is not life-threatening, this condition has enormous morbidity, and the key to success is patient education. When visiting community swimming pools, saunas, and health clubs, the public should be educated about appropriate footwear. If the patient works in a wet environment, such as dishwashing, they should be encouraged to wear gloves. A family physician or dermatologist usually diagnoses the disease after a detailed examination. The pharmacist should inform the patient that treatment may take at least 12 months, and that some patients may require prophylactic treatment to prevent recurrence. Pharmacists should also monitor compliance and educate patients about use and adverse effects. Dermatology and foot and nail care nurses are involved in screening, arranging follow-ups, and documenting progress and compliance for the team. Refer patients who want a faster option to a dermatologist or a surgeon for complete nail removal.[38][39] 

For patients who delay seeking care, nail deformity usually progresses and may lead to disfigurement and pain. Even though antifungal drugs are available, the treatment often takes months or years before one sees an obvious improvement.[40] Several studies have shown that terbinafine is more effective than other antifungals. However, individuals with yellow streaks along the lateral nail border tend to have poor treatment responses. Overall, fungal infections of the toenails have a much poorer outcome than fingernail infections. Finally, despite treatment, the recurrence rate remains high, ranging from 5% to 50%.[41][42] Therefore, prompt commencement of treatment and follow-ups is mandatory. 

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

Asz-Sigall D, Tosti A, Arenas R. Tinea Unguium: Diagnosis and Treatment in Practice. Mycopathologia. 2017 Feb;182(1-2):95-100. [PubMed: 27787643]

2.

Karaman BFO, Açıkalın A, Ünal İ, Aksungur VL. Diagnostic values of KOH examination, histological examination, and culture for onychomycosis: a latent class analysis. Int J Dermatol. 2019 Mar;58(3):319-324. [PubMed: 30246397]

3.

Haghani I, Shams-Ghahfarokhi M, Dalimi Asl A, Shokohi T, Hedayati MT. Molecular identification and antifungal susceptibility of clinical fungal isolates from onychomycosis (uncommon and emerging species). Mycoses. 2019 Feb;62(2):128-143. [PubMed: 30255665]

4.

Becker BA, Childress MA. Common Foot Problems: Over-the-Counter Treatments and Home Care. Am Fam Physician. 2018 Sep 01;98(5):298-303. [PubMed: 30216025]

5.

Appelt L, Nenoff P, Uhrlaß S, Krüger C, Kühn P, Eichhorn K, Buder S, Beissert S, Abraham S, Aschoff R, Bauer A. [Terbinafine-resistant dermatophytoses and onychomycosis due to Trichophyton rubrum]. Hautarzt. 2021 Oct;72(10):868-877. [PubMed: 34459941]

6.

Pote ST, Khan U, Lahiri KK, Patole MS, Thakar MR, Shah SR. Onychomycosis due to Achaetomium strumarium. J Mycol Med. 2018 Sep;28(3):510-513. [PubMed: 30104134]

7.

Youssef AB, Kallel A, Azaiz Z, Jemel S, Bada N, Chouchen A, Belhadj-Salah N, Fakhfakh N, Belhadj S, Kallel K. Onychomycosis: Which fungal species are involved? Experience of the Laboratory of Parasitology-Mycology of the Rabta Hospital of Tunis. J Mycol Med. 2018 Dec;28(4):651-654. [PubMed: 30107987]

8.

Gupta AK, Versteeg SG, Shear NH. Onychomycosis in the 21st Century: An Update on Diagnosis, Epidemiology, and Treatment. J Cutan Med Surg. 2017 Nov/Dec;21(6):525-539. [PubMed: 28639462]

9.

Arsenijević VA, Denning DW. Estimated Burden of Serious Fungal Diseases in Serbia. J Fungi (Basel). 2018 Jun 25;4(3) [PMC free article: PMC6162477] [PubMed: 29941824]

10.

Lipner SR, Scher RK. Onychomycosis: Clinical overview and diagnosis. J Am Acad Dermatol. 2019 Apr;80(4):835-851. [PubMed: 29959961]

11.

Aragón-Sánchez J, López-Valverde ME, Víquez-Molina G, Milagro-Beamonte A, Torres-Sopena L. Onychomycosis and Tinea Pedis in the Feet of Patients With Diabetes. Int J Low Extrem Wounds. 2023 Jun;22(2):321-327. [PubMed: 33891512]

12.

Drago L, Micali G, Papini M, Piraccini BM, Veraldi S. Management of mycoses in daily practice. G Ital Dermatol Venereol. 2017 Dec;152(6):642-650. [PubMed: 29050446]

13.

Maddy AJ, Tosti A. Hair and nail diseases in the mature patient. Clin Dermatol. 2018 Mar-Apr;36(2):159-166. [PubMed: 29566920]

14.

Zaikovska O, Pilmane M, Kisis J. Morphopathological aspects of healthy nails and nails affected by onychomycosis. Mycoses. 2014 Sep;57(9):531-6. [PubMed: 24661598]

15.

Vlahovic TC, Garcia M, Wotring K. Dermoscopy of Onychomycosis for the Podiatrist. Clin Podiatr Med Surg. 2021 Oct;38(4):505-511. [PubMed: 34538427]

16.

Nikitha S, Kondraganti N, Kandi V. Total Dystrophic Onychomycosis of All the Nails Caused by Non-dermatophyte Fungal Species: A Case Report. Cureus. 2022 Sep;14(9):e29765. [PMC free article: PMC9618008] [PubMed: 36324367]

17.

Gupta AK, Studholme C. Novel investigational therapies for onychomycosis: an update. Expert Opin Investig Drugs. 2016;25(3):297-305. [PubMed: 26765142]

18.

Daggett C, Brodell RT, Daniel CR, Jackson J. Onychomycosis in Athletes. Am J Clin Dermatol. 2019 Oct;20(5):691-698. [PubMed: 31111408]

19.

Yadav P, Singal A, Pandhi D, Das S. Clinico-mycological study of dermatophyte toenail onychomycosis in new delhi, India. Indian J Dermatol. 2015 Mar-Apr;60(2):153-8. [PMC free article: PMC4372907] [PubMed: 25814703]

20.

Grover C, Jakhar D, Sharma S. The grid pattern of white superficial onychomycosis. Indian J Dermatol Venereol Leprol. 2020 Sep-Oct;86(5):568-570. [PubMed: 32769307]

21.

Almeida HL, Boabaid RO, Timm V, Silva RM, Castro LA. Scanning electron microscopy of superficial white onychomycosis. An Bras Dermatol. 2015 Sep-Oct;90(5):753-5. [PMC free article: PMC4631245] [PubMed: 26560225]

22.

Mehta M, Sharma J, Bhardwaj SB. Proximal subungual onychomycosis of digitus minimus due to Aspergillus brasiliensis. Pan Afr Med J. 2020;35:79. [PMC free article: PMC7250194] [PubMed: 32537082]

23.

Bunyaratavej S, Bunyaratavej S, Muanprasart C, Matthapan L, Varothai S, Tangjaturonrusamee C, Pattanaprichakul P. Endonyx onychomycosis caused by Trichophyton tonsurans. Indian J Dermatol Venereol Leprol. 2015 Jul-Aug;81(4):390-2. [PubMed: 25994895]

24.

Hay R. Therapy of Skin, Hair and Nail Fungal Infections. J Fungi (Basel). 2018 Aug 20;4(3) [PMC free article: PMC6162762] [PubMed: 30127244]

25.

Hayette MP, Seidel L, Adjetey C, Darfouf R, Wéry M, Boreux R, Sacheli R, Melin P, Arrese J. Clinical evaluation of the DermaGenius® Nail real-time PCR assay for the detection of dermatophytes and Candida albicans in nails. Med Mycol. 2019 Apr 01;57(3):277-283. [PubMed: 29762721]

26.

Chetana K, Menon R, David BG. Onychoscopic evaluation of onychomycosis in a tertiary care teaching hospital: a cross-sectional study from South India. Int J Dermatol. 2018 Jul;57(7):837-842. [PubMed: 29700806]

27.

Gupta AK, Hall DC, Cooper EA, Ghannoum MA. Diagnosing Onychomycosis: What's New? J Fungi (Basel). 2022 Apr 29;8(5) [PMC free article: PMC9146047] [PubMed: 35628720]

28.

Pospischil I, Reinhardt C, Bontems O, Salamin K, Fratti M, Blanchard G, Chang YT, Wagner H, Hermann P, Monod M, Hoetzenecker W, Guenova E. Identification of Dermatophyte and Non-Dermatophyte Agents in Onychomycosis by PCR and DNA Sequencing-A Retrospective Comparison of Diagnostic Tools. J Fungi (Basel). 2022 Sep 27;8(10) [PMC free article: PMC9605175] [PubMed: 36294584]

29.

Litaiem N, Mnif E, Zeglaoui F. Dermoscopy of Onychomycosis: A Systematic Review. Dermatol Pract Concept. 2023 Jan 01;13(1) [PMC free article: PMC9946122] [PubMed: 36892372]

30.

Lok C. [What's new in clinical dermatology?]. Ann Dermatol Venereol. 2016 Dec;143 Suppl 3:S1-S10. [PubMed: 29429503]

31.

Wollina U, Nenoff P, Haroske G, Haenssle HA. The Diagnosis and Treatment of Nail Disorders. Dtsch Arztebl Int. 2016 Jul 25;113(29-30):509-18. [PMC free article: PMC5527843] [PubMed: 27545710]

32.

Aggarwal R, Targhotra M, Kumar B, Sahoo PK, Chauhan MK. Treatment and management strategies of onychomycosis. J Mycol Med. 2020 Jun;30(2):100949. [PubMed: 32234349]

33.

Gupta AK, Talukder M. Efinaconazole in Onychomycosis. Am J Clin Dermatol. 2022 Mar;23(2):207-218. [PubMed: 34902110]

34.

Frazier WT, Santiago-Delgado ZM, Stupka KC. Onychomycosis: Rapid Evidence Review. Am Fam Physician. 2021 Oct 01;104(4):359-367. [PubMed: 34652111]

35.

Wang Y, Geizhals S, Lipner SR. Retrospective analysis of laboratory abnormalities in patients prescribed terbinafine for onychomycosis. J Am Acad Dermatol. 2021 Feb;84(2):497-499. [PubMed: 32387655]

36.

Lipner SR, Joseph WS, Vlahovic TC, Scher RK, Rich P, Ghannoum M, Daniel CR, Elewski B. Therapeutic Recommendations for the Treatment of Toenail Onychomycosis in the US. J Drugs Dermatol. 2021 Oct 01;20(10):1076-1084. [PubMed: 34636509]

37.

Ricardo JW, Lipner SR. Safety of current therapies for onychomycosis. Expert Opin Drug Saf. 2020 Nov;19(11):1395-1408. [PubMed: 32990062]

38.

Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol. 2019 Apr;80(4):853-867. [PubMed: 29959962]

39.

Hanna S, Andriessen A, Beecker J, Gilbert M, Goldstein E, Kalia S, King A, Kraft J, Lynde C, Singh D, Turchin I, Zip C. Clinical Insights About Onychomycosis and Its Treatment: A Consensus. J Drugs Dermatol. 2018 Mar 01;17(3):253-262. [PubMed: 29537443]

40.

Zeichner JA. Onychomycosis to Fungal Superinfection: Prevention Strategies and Considerations. J Drugs Dermatol. 2015 Oct;14(10 Suppl):s32-4. [PubMed: 26461832]

41.

Shemer A, Gupta AK, Babaev M, Barzilai A, Farhi R, Daniel Iii CR. A Retrospective Study Comparing K101 Nail Solution as a Monotherapy and in Combination with Oral Terbinafine or Itraconazole for the Treatment of Toenail Onychomycosis. Skin Appendage Disord. 2018 Aug;4(3):166-170. [PMC free article: PMC6120394] [PubMed: 30197895]

42.

Salakshna N, Bunyaratavej S, Matthapan L, Lertrujiwanit K, Leeyaphan C. A cohort study of risk factors, clinical presentations, and outcomes for dermatophyte, nondermatophyte, and mixed toenail infections. J Am Acad Dermatol. 2018 Dec;79(6):1145-1146. [PubMed: 29860042]

Disclosure: Myron Bodman declares no relevant financial relationships with ineligible companies.

Disclosure: Hasnain Syed declares no relevant financial relationships with ineligible companies.

Disclosure: Karthik Krishnamurthy declares no relevant financial relationships with ineligible companies.