Should Fungal Nail Infection Be Treated?
Yes, medically confirmed onychomycosis should be treated 1. This recommendation is based on several disease-specific considerations: cosmetic and functional disability, lack of spontaneous remission, impairment of health and wellbeing (particularly in elderly patients), and the need to reduce contamination in communal bathing places 1.
Why Treatment is Necessary
Onychomycosis does not resolve spontaneously and creates ongoing problems:
- Progressive disease: Without treatment, the infection persists and typically worsens over time
- Quality of life impact: Causes cosmetic concerns and functional disability that affect daily activities
- Reservoir for spread: Infected nails serve as a source of contamination in shared spaces and can spread to family members
- Special populations at risk: In diabetics (who have up to one-third prevalence of onychomycosis), untreated infection is a significant predictor for development of more serious complications 2
Critical Caveat: Confirm Before Treating
Treatment should not be commenced before mycological confirmation of infection 3. This is essential because approximately half of nail dystrophies are attributable to non-fungal causes 4. The diagnostic workup should include microscopy, culture, and/or molecular testing of nail scrapings 5.
Treatment Approach
Once confirmed, treatment selection depends on severity:
Mild to Moderate Disease
- Topical antifungal nail polish (e.g., efinaconazole, amorolfine) 5, 6
- May be sufficient for limited nail involvement
Moderate to Severe Disease
- Oral terbinafine is first-line: 250 mg daily for 6 weeks (fingernails) or 12-16 weeks (toenails) 2
- Terbinafine demonstrates superior efficacy compared to itraconazole, with complete cure rates of 55% versus 26% at 72 weeks, and significantly lower relapse rates (23% vs 53%) 2
- Combination therapy recommended: Systemic plus topical agents provide optimal outcomes 2, 5
Alternative: Itraconazole
- Second-line option when terbinafine is contraindicated
- Pulse therapy: 400 mg daily for 1 week per month (2 pulses for fingernails, 3 for toenails) 2
Expected Outcomes
With appropriate treatment, cure rates of 70-80% for toenails and 80-90% for fingernails can be expected 3. However, a consistent 20-30% failure rate exists even with optimal therapy 3, emphasizing the importance of proper patient selection, adherence, and follow-up.
When NOT to Treat
The only scenario where treatment may be deferred is if mycological testing is negative—confirming the nail dystrophy has a non-fungal cause requiring different management.