What is the treatment for a fungal toe infection where the nail is partially off?

Treatment for Fungal Toe Infection with Partially Detached Nail

For a fungal toe infection with a partially detached nail, the most effective treatment is oral terbinafine 250 mg daily for 12-16 weeks, combined with partial removal of the affected nail area to improve drug penetration and cure rates. 1

Diagnostic Confirmation

Before initiating treatment:

• Obtain proper mycological confirmation through KOH preparation, fungal culture, or nail biopsy 1, 2
• Identify the causative organism, as treatment varies based on pathogen type 1
• Dermatophytes are the most common cause (primarily Trichophyton rubrum) 3

Treatment Algorithm

Step 1: Assess Nail Involvement

• If nail is partially detached (onycholysis) with visible fungal infection:
  • Consider partial removal of the detached portion before starting oral therapy 1
  • This significantly improves treatment outcomes, as subungual fungal masses (dermatophytomas) prevent drug penetration 1

Step 2: Systemic Antifungal Therapy (First-Line)

• For dermatophyte infections (most common):

  • Terbinafine 250 mg daily for 12-16 weeks for toenail infections 1
  • Terbinafine is superior to other antifungals for dermatophyte onychomycosis 1, 4

• For Candida infections:

  • Itraconazole 400 mg daily for 1 week per month, repeated for 3-4 pulses for toenail infections 1
  • Fluconazole 150-450 mg weekly for at least 6 months is an alternative 1, 5

Step 3: Topical Therapy (Adjunctive)

• Apply topical antifungals to the nail bed after partial removal of the detached nail 1
• For yeast infections with paronychia: alternate imidazole lotion with antibacterial lotion until cuticle integrity is restored 1
• Topical therapy alone is generally inferior to systemic treatment except in very distal infections 1

Efficacy and Expectations

• Cure rates with terbinafine: 70-80% for toenail infections 1
• Higher success rates (close to 100%) can be achieved when partial nail removal is combined with oral therapy 1
• Treatment failure occurs in 20-30% of cases, often due to:
  • Poor compliance
  • Poor drug absorption
  • Immunosuppression
  • Dermatophyte resistance
  • Presence of dermatophytoma 1

Monitoring and Safety

• For terbinafine:

  • Baseline liver function tests and complete blood count recommended for patients with history of hepatotoxicity or hematological abnormalities 1
  • Common adverse effects: headache, taste disturbance, gastrointestinal upset 1, 2

• For itraconazole:

  • Monitor hepatic function in patients with pre-existing liver issues or those receiving continuous therapy for more than a month 1
  • Common adverse effects: headache and gastrointestinal upset 1

Prevention of Recurrence

• Keep nails short 1
• Wear protective footwear in public bathing facilities 1
• Apply antifungal powders to shoes and feet 1
• Wear cotton, absorbent socks 1
• Consider discarding heavily contaminated footwear or treating with antifungal solutions 1
• Treat all infected family members simultaneously 1

Important Caveats

• Complete nail regrowth may take up to 18 months due to slow toenail growth 1
• Nail appearance may not return to completely normal if there was pre-existing dystrophy 1
• Recurrence is common without preventive measures 1
• Partially detached nails with dense white lesions visible underneath (dermatophytomas) require nail removal for successful treatment 1