How to manage nail fungus after nail removal?

From the Guidelines

Managing nail fungus after nail removal requires immediate treatment with oral antifungal medications, such as itraconazole, due to its higher efficacy and shorter treatment duration compared to terbinafine, as demonstrated in a study published in the British Journal of Dermatology 1. To assess and manage nail fungus after nail removal, it is essential to consider the type of fungus and the severity of the infection.

• The treatment approach should include oral antifungal medications, such as itraconazole (200 mg per day or 400 mg per day for 1 week each month), which has been shown to have higher cure rates for Candida onychomycosis compared to terbinafine 1.
• In addition to oral antifungal medications, topical treatments like ciclopirox 8% solution, amorolfine 5% nail lacquer, or terbinafine cream can be applied to the exposed nail bed daily to prevent recurrence.
• It is crucial to keep the area clean and dry, washing daily with mild soap and thoroughly drying afterward, and allowing maximum air exposure when possible.
• The treatment duration should be at least 4 weeks for fingernail and 12 weeks for toenail onychomycosis, as recommended in the British Association of Dermatologists' guidelines 1.
• During the nail regrowth period (4-6 months for fingernails, 12-18 months for toenails), it is essential to continue treatment and maintain good hygiene practices to prevent reinfection.
• Regular follow-up appointments with a healthcare professional are necessary to monitor the progression of the infection and adjust the treatment plan as needed.

From the FDA Drug Label

The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures. Up to 48 weeks of daily applications with Ciclopirox Topical Solution, 8%, (Nail Lacquer), and professional removal of the unattached, infected nail, as frequently as monthly, are considered the full treatment needed to achieve a clear or almost clear nail (defined as 10% or less residual nail involvement)

To assess nail fungus after nail has been removed due to fungus, follow-up appointments with a health care professional are necessary to:

• Monitor the progress of the treatment
• Remove the unattached, infected nail as frequently as monthly
• Apply Ciclopirox Topical Solution, 8%, (Nail Lacquer) daily for up to 48 weeks
• Evaluate the nail involvement and mycology results to determine the effectiveness of the treatment 2 It is essential to note that six months of therapy with professional removal of the unattached, infected nail may be required before initial improvement of symptoms is noticed 2

From the Research

Assessing Nail Fungus After Nail Removal

• After nail removal due to fungus, assessing the nail fungus involves checking for clinical signs of fungal nail infections, which are non-specific, and may include discomfort, cosmetic complaints, nail hyperkeratosis, and leukonychia 3.
• Detection of fungal structures by direct examination of a nail sample is strongly suggestive of fungal nail infection, while cases of negative direct examination with positive culture must be interpreted with caution due to the risk of contamination 3.

Management of Nail Fungus After Nail Removal

• Topical treatments, such as antifungal lacquers (5% amorolfine and 8% ciclopirox), can be used to treat nail fungus, with cure rates of around 30% 3.
• Chemical nail destruction with a combination of urea and bifonazole, followed by treatment with an antifungal ointment, can be used when the nail is markedly thickened, with cure rates of up to 70% at three months when the matrix is not involved 3.
• Oral terbinafine is effective in more than 50% of cases, but its use is limited by the risk of severe adverse effects 3.
• Other treatment options, such as efinaconazole 10% solution, tavaborole 5% solution, and luliconazole 5% solution, have shown promise in clinical trials, with varying degrees of effectiveness and risk of adverse events 4.
• The use of laser systems, such as the 1064-nm Nd:YAG laser, has also been studied, but the evidence is uncertain due to the limited number of studies and the risk of bias 4.
• A combination of 2% butenafine and 20% urea cream has been shown to be effective in curing toenail onychomycosis, with a cure rate of 88% compared to placebo 5.
• Fluconazole has been studied as an alternative to terbinafine and itraconazole for onychomycosis treatment, with a recommended dose of 150 mg weekly for more than 6 months 6.
• Current and emerging options for the treatment of onychomycosis include systemic therapy, topical agents, and laser systems, with the goal of reducing the risk of recurrence by adherence to preventive measures 7.