From the Guidelines
The management of subungual toenail issues should prioritize identifying the underlying cause and applying appropriate treatment, with oral antifungals like terbinafine being the most effective option for fungal infections, as supported by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. When considering the management of subungual toenail issues, it's essential to differentiate between various causes, including fungal infections (onychomycosis), subungual hematomas, ingrown toenails, and subungual exostosis.
- For fungal infections, oral antifungals like terbinafine (250mg daily for 12 weeks) or itraconazole (200mg twice daily for 1 week per month, for 3 months) are most effective, as topical treatments often can't penetrate the nail adequately, with cure rates of 80–90% for fingernail infection and 70–80% for toenail infection expected, as noted in the guidelines for treatment of onychomycosis 1.
- Subungual hematomas from trauma require drainage if painful, which can be done by creating a small hole in the nail using a heated paperclip or sterile needle.
- Ingrown toenails may require warm soaks, proper nail trimming straight across, and placing cotton wisps under the ingrown edge; severe cases need partial nail removal with phenolization to prevent regrowth.
- Subungual exostosis (bone growth under nail) requires surgical removal. Proper foot hygiene is essential for any subungual issue: keep feet dry, wear breathable shoes, change socks daily, and trim nails straight across, as emphasized in the british association of dermatologists' guidelines for the management of onychomycosis 2014 1. Early treatment is crucial as subungual conditions worsen over time and can lead to permanent nail damage or spread to other nails, with the nail's thick, dense structure making it difficult for medications to penetrate, which is why oral treatments are often necessary for complete resolution of infections beneath the nail plate, as discussed in the guidelines for treatment of onychomycosis 1 and the british association of dermatologists' guidelines for the management of onychomycosis 2014 1.
From the FDA Drug Label
The patient should be told to: ... If possible, Ciclopirox Topical Solution, 8%, (Nail Lacquer), should be applied to the nail bed, hyponychium, and the under surface of the nail plate when it is free of the nail bed (e.g., onycholysis). Removal of the unattached, infected nail, as frequently as monthly, by a health care professional is needed with use of this medication
- Management of subungual toenail issues involves:
- Application of Ciclopirox Topical Solution, 8%, (Nail Lacquer) to the nail bed, hyponychium, and under surface of the nail plate
- Removal of the unattached, infected nail by a healthcare professional as frequently as monthly 2
- Use of Ciclopirox Topical Solution, 8%, (Nail Lacquer) as part of a comprehensive management program for onychomycosis 2
From the Research
Management of Subungual Toenail Issues
The management of subungual toenail issues, particularly onychomycosis, involves a combination of oral and topical antifungal treatments.
- Oral antifungals such as terbinafine have been shown to be effective in treating onychomycosis, with high mycological and clinical cure rates 3, 4.
- Topical antifungals such as ciclopirox and amorolfine can be used in combination with oral antifungals to enhance treatment efficacy 3, 5.
- The choice of treatment depends on the severity of the infection, the causative organism, and the patient's medical history and preferences.
Treatment Options
Some treatment options for subungual toenail issues include:
- Oral terbinafine 250 mg/day for 12-16 weeks 4
- Topical ciclopirox 8% lacquer applied once daily for 48 weeks 6
- Topical efinaconazole 10% solution applied once daily for 48 weeks 6
- Topical tavaborole 5% solution applied once daily for 48 weeks 6
- Combination therapy with oral terbinafine and topical amorolfine or ciclopirox 3, 5
Diagnosis and Assessment
Diagnosis of subungual toenail issues involves clinical evaluation, microscopy, and fungal culture 7.
- Clinical signs such as subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration can indicate onychomycosis 7.
- Assessment of treatment efficacy involves evaluation of clinical and mycological cure rates, as well as patient-reported outcomes 7, 6.
Specialist Referral
Specialist referral may be necessary for patients with severe or recurrent onychomycosis, or those with underlying medical conditions that may affect treatment outcomes 7.
- Factors that may necessitate specialist referral include lack of treatment effectiveness, need for additional therapies, concurrent presence of other diseases or comorbidities, severe DLSO, and presence of a dermatophytoma or involvement of the nail matrix 7.