Management of Peri-Nail Skin in Onychomycosis During Oral Terbinafine Treatment
While oral terbinafine effectively treats the nail infection itself, concurrent treatment of the surrounding peri-nail skin and feet with topical antifungal agents is essential to prevent reinfection and optimize outcomes. 1
Rationale for Treating Peri-Nail Skin
The skin surrounding the nails serves as a reservoir for fungal organisms, particularly Trichophyton rubrum, which commonly causes both onychomycosis and tinea pedis. Even when oral terbinafine successfully eradicates the nail infection, failure to address fungal colonization of the surrounding skin significantly increases recurrence risk.
Specific Treatment Recommendations
Topical Antifungal Application
- Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate to the feet and inside shoes 1
- These agents help eliminate fungal elements from the skin and prevent re-exposure
- Continue application throughout and after oral therapy completion
Environmental Decontamination
The British Association of Dermatologists guidelines emphasize that fungal elements persist in the environment and footwear 1:
- Footwear management: Discard old, contaminated shoes when possible
- If disposal isn't feasible, decontaminate by placing naphthalene mothballs in shoes, sealing in plastic bags for minimum 3 days
- Alternative: Spray terbinafine solution into shoes periodically
- Continue antifungal powder application in shoes even after decontamination
Preventive Measures
- Always wear protective footwear in public areas (gyms, pools, hotel rooms, changing facilities) where T. rubrum is commonly found 1
- Keep nails trimmed short
- Wear cotton, absorbent socks
- Apply absorbent powder to feet
Family and Household Considerations
All infected family members must be treated simultaneously 1. Since both onychomycosis and tinea pedis are contagious, treating only one individual while others remain infected creates a cycle of reinfection. Avoid sharing nail clippers or other nail care implements.
Clinical Pitfall to Avoid
The most common mistake is focusing exclusively on oral therapy for the nail while ignoring the surrounding skin and environmental reservoirs. This oversight contributes substantially to the 23% mycological relapse rate observed even with effective terbinafine therapy 2. The nail may appear cured, but persistent fungal colonization of the peri-nail skin and toe web spaces leads to reinfection of the newly grown nail.
Monitoring Considerations
While the guidelines don't specify topical agents as causing adverse effects on peri-nail skin, be aware that:
- Topical ciclopirox can rarely cause periungual and nail fold erythema 1
- Tioconazole may cause allergic contact dermatitis 1
- These reactions are uncommon with antifungal powders
The combination of oral terbinafine for nail penetration plus topical agents for skin decolonization addresses both the primary infection and its environmental reservoir, maximizing cure rates and minimizing recurrence.