What is the treatment for yellow nails (onychchromosis)?

Treatment for Yellow Nails (Onychochromosis)

The treatment for yellow nails depends on the underlying cause, with fungal infection (onychomycosis) being the most common cause requiring oral terbinafine for dermatophytes or fluconazole for yeast infections, while true Yellow Nail Syndrome responds best to vitamin E combined with triazole antifungals.

Diagnostic Approach

Before initiating treatment, it's crucial to determine the cause of yellow nails:

1. Fungal infection (onychomycosis):

   • Most common cause of yellow nails
   • Laboratory confirmation via microscopy and culture is essential 1
   • Nail appears soft and friable with subungual debris

2. Yellow Nail Syndrome (YNS):

   • Rare condition with characteristic triad: yellow nails, lymphedema, and respiratory symptoms
   • Light green-yellowish pigmentation with hardness and elevated longitudinal curvature 1
   • Often misdiagnosed as fungal infection

3. Other causes:

   • Bacterial infection (particularly Pseudomonas - green/black discoloration)
   • Trauma
   • Psoriasis
   • Lichen planus

Treatment Algorithm

For Fungal Infection (Onychomycosis)

1. If confirmed dermatophyte infection:

   • First-line: Oral terbinafine 250mg daily
     • For fingernails: 6 weeks
     • For toenails: 12 weeks
     • Superior efficacy with 70-80% mycological cure rates 2
     • Fungicidal action against Trichophyton species

2. If confirmed Candida infection:

   • Oral fluconazole (preferred for yeast infections) 3
   • Alternative: Itraconazole 400mg daily for 1 week per month (2 pulses for fingernails, 3-4 pulses for toenails) 1

3. Topical therapy (only for very early or superficial infections):

   • Amorolfine 5% nail lacquer once or twice weekly for 6-12 months 1
   • Approximately 50% effective in distal nail infections 1
   • File away diseased nail before application

For Yellow Nail Syndrome

1. First-line: Oral vitamin E combined with triazole antifungals

   • Can achieve partial or total disappearance of nail discoloration 4
   • Pulsed fluconazole has shown good response 5

2. Address associated conditions:

   • Lymphedema: Compression garments, manual lymph drainage 4
   • Respiratory symptoms: Appropriate antibiotics for bronchiectasis 4

3. Alternative therapies:

   • Octreotide has shown benefit in some cases with pleural effusions 6

Important Considerations

• Avoid misdiagnosis: Yellow Nail Syndrome is often falsely identified as fungal infection 1

• Treatment duration: Clinical improvement lags behind mycological cure - optimal effect seen months after treatment completion 2

• Monitor for side effects:

  • Terbinafine: Potential for liver toxicity and taste disturbances
  • Itraconazole: Multiple drug interactions, especially with anticoagulants and statins 1

• Treatment failure: If standard therapy fails, consider:

  • Confirming diagnosis with repeat testing
  • Partial nail removal in combination with antifungal therapy 1
  • Alternative systemic agents

Pitfalls to Avoid

1. Treating without diagnosis: Always confirm infection before starting systemic therapy 1
2. Inadequate treatment duration: Premature discontinuation leads to relapse
3. Ignoring underlying conditions: Yellow nails may signal systemic disease requiring treatment
4. Expecting immediate results: Clinical improvement takes months due to slow nail growth

Remember that successful treatment depends on accurate diagnosis, appropriate drug selection based on causative organism, and adequate treatment duration.