What is the treatment for a patient with onycholysis?

Treatment for Onycholysis

The first-line treatment for onycholysis depends on the underlying cause, with antifungal therapy being indicated when onychomycosis is confirmed, preferably using oral terbinafine (250 mg daily for 6 weeks in fingernails and 12-16 weeks in toenails) as it is generally preferred over itraconazole for dermatophyte infections. 1

Diagnostic Approach

• Before initiating treatment, it's essential to confirm the underlying cause of onycholysis, as treatment varies based on etiology 1
• Mycological confirmation (microscopy and culture) should be obtained before starting antifungal treatment 1
• Common causes of onycholysis include:
  • Fungal infection (onychomycosis) - most commonly dermatophytes 1
  • Trauma or mechanical factors - especially in toenails 2
  • Psoriasis and other dermatological conditions 2
  • Chemical exposure or occupational factors 2
  • Phototoxic reactions from medications 2

Treatment Algorithm

1. For Fungal (Onychomycosis) Causes:

Systemic Therapy (First-line for confirmed dermatophyte infection):

• Terbinafine (preferred):

  • Adults: 250 mg daily for 6 weeks (fingernails) or 12-16 weeks (toenails) 1, 3
  • Children: Weight-based dosing (62.5 mg if <20 kg, 125 mg if 20-40 kg, 250 mg if >40 kg) 1
  • Monitor liver function tests in patients with history of hepatotoxicity 1

• Itraconazole (alternative):

  • Continuous: 200 mg daily for 12 weeks 1
  • Pulse therapy: 400 mg daily for 1 week per month (2 pulses for fingernails, 3 pulses for toenails) 1
  • Contraindicated in heart failure; requires monitoring of hepatic function 1

• Fluconazole (if unable to tolerate terbinafine or itraconazole):

  • 150-450 mg weekly for 3 months (fingernails) or at least 6 months (toenails) 1

• For Candida infections specifically:

  • Itraconazole is the most effective agent when the nail plate is invaded 1

Topical Therapy (For superficial or distal onychomycosis):

• Amorolfine: 5% lacquer applied once or twice weekly for 6-12 months 1
• Ciclopirox: 8% lacquer applied once daily for up to 48 weeks 1
• Tioconazole: 28% solution applied twice daily for 6-12 months 1

2. For Non-Fungal Causes:

• Traumatic onycholysis:

  • Keep nails short and avoid trauma 2, 4
  • Dry the nail area thoroughly (using a hair dryer can help eliminate moisture-loving organisms) 2
  • Avoid water exposure and use gloves for wet work 4

• Psoriasis-related onycholysis:

  • Treat underlying psoriasis with appropriate therapy 2
  • Consider topical steroids or vitamin D analogs for nail bed involvement 2

• Chemical exposure:

  • Identify and eliminate the offending agent 2
  • Protective measures to prevent recurrence 4

Special Populations

• Diabetics:

  • Terbinafine is preferred due to lower risk of drug interactions and no negative inotropic effects 1
  • Careful monitoring is essential as onychomycosis is a risk factor for foot ulcers 1

• Immunosuppressed patients:

  • Terbinafine or fluconazole preferred due to fewer interactions with antiretrovirals 1
  • May require longer treatment courses 1

Prevention of Recurrence

• Keep nails trimmed short and straight across 1
• Wear protective footwear in public areas 1
• Use absorbent powders and antifungal powders in shoes 1
• Consider discarding old footwear or treating with antifungal solutions 1
• Treat all infected family members simultaneously 1

Treatment Pitfalls and Caveats

• Never start antifungal treatment without mycological confirmation of infection 1
• Treatment failure may occur due to:
  • Poor compliance with long treatment regimens 1
  • Inadequate drug penetration into the nail 1
  • Presence of dermatophytomas requiring mechanical debridement 1
• Recurrence rates for onychomycosis are high (40-70%), requiring patient education about prevention 1
• Liver function monitoring is recommended for patients on systemic antifungals, especially with pre-existing liver conditions 1
• Alternative pulse therapy regimens (such as quarterly terbinafine pulses) may be considered to improve compliance while maintaining efficacy 5