What medications are used to treat toenail injuries?

Medications for Toenail Injuries

For toenail injuries, the primary medications include antifungal agents (both topical and oral) for fungal infections, antibiotics for bacterial infections, and supportive treatments for trauma-related injuries.

Fungal Nail Infections (Onychomycosis)

Oral Antifungal Medications

• Terbinafine: First-line treatment for dermatophyte onychomycosis, generally preferred over itraconazole 1, 2

  • Adult dosing: 250 mg daily for 6 weeks (fingernails) or 12-16 weeks (toenails) 1, 2
  • Pediatric dosing: 62.5 mg/day if <20 kg, 125 mg/day for 20-40 kg, 250 mg/day if >40 kg 1
  • Requires baseline liver function tests and complete blood count 1

• Itraconazole: Alternative first-line treatment 1

  • Adult dosing: 200 mg daily for 12 weeks continuously, or "pulse therapy" of 400 mg daily for 1 week per month (2 pulses for fingernails, 3 for toenails) 1
  • Contraindicated in heart failure due to negative inotropic effects 1
  • Should be taken with food and acidic pH for optimal absorption 1

• Fluconazole: Alternative when terbinafine or itraconazole cannot be tolerated 1

  • Adult dosing: 150-450 mg weekly for 3 months (fingernails) or at least 6 months (toenails) 1
  • Requires baseline liver function tests and monitoring 1

• Griseofulvin: Lower efficacy and higher relapse rates compared to newer agents 1

  • Adult dosing: 500-1000 mg daily for 6-9 months (fingernails) or 12-18 months (toenails) 1
  • Should be taken with fatty food to increase absorption 1

Topical Antifungal Medications

• Amorolfine: 5% lacquer applied once or twice weekly for 6-12 months 1

  • Useful for superficial and distal onychomycosis 1
  • Rare side effects include local burning, pruritus, and erythema 1

• Ciclopirox: 8% lacquer applied once daily for up to 48 weeks 1

  • Useful for patients in whom systemic therapy is contraindicated 1
  • Rare side effects include periungual and nail fold erythema 1

• Tioconazole: 28% solution applied twice daily for 6-12 months 1

  • Side effects include allergic contact dermatitis 1

Bacterial Nail Infections

Antibiotics

• Amoxicillin-clavulanate (Augmentin): Recommended for mild to moderate paronychia 3

  • Adult dosing: 500 mg/125 mg every 12 hours 3
  • Bacterial cultures should be obtained before starting antibiotics, especially in severe cases 3

• Ciprofloxacin: Specifically recommended for Pseudomonas infections of the nail 4

• Topical options:

  • Antiseptic agents (octenidine) 4
  • Topical antibiotics (nadifloxacin, gentamicin) for specific cases 4

Traumatic Nail Injuries

Management of Ingrown Toenails

• Antiseptic soaks: Epsom salt or combinations of Epsom salt with pHisoHex or Betadine 5
• Topical povidone iodine 2%: For nail fold edema or erythema 1
• Topical antibiotics with corticosteroids: For nail fold edema or erythema with pain 1
• Oral antibiotics: For cases with discharge or nail plate separation 1

Management of Subungual Hematoma

• Drainage procedures rather than medications are the primary treatment 6
• Antiseptic solutions for cleaning after drainage to prevent infection 6

Special Populations

Diabetic Patients

• Terbinafine: Preferred oral agent due to low risk of drug interactions and hypoglycemia 1
• Topical treatments: Appropriate for mild-to-moderate infections and when risk of drug interaction is high 1

Immunosuppressed Patients

• Terbinafine or fluconazole: Preferred due to decreased risk of interactions with antiretrovirals compared to itraconazole 1

Important Considerations

• Proper diagnosis is essential before starting treatment - appropriate nail specimens for laboratory testing (KOH preparation, fungal culture, or nail biopsy) should be obtained to confirm fungal infections 2
• Secondary fungal infections may occur in up to 25% of paronychia cases and may require antifungal therapy if not responding to antibiotics 3
• Combination therapy (systemic plus topical, or multiple systemic agents) may improve efficacy and reduce drug-related adverse effects in difficult cases 1
• Onychomycosis is a significant predictor for the development of foot ulcers in diabetes, making proper treatment especially important in this population 1

Common Pitfalls to Avoid

• Failing to obtain appropriate cultures before starting antibiotics 3
• Using griseofulvin as first-line therapy (lower efficacy, higher relapse rates) 1
• Not monitoring liver function tests when using oral antifungals, especially in patients with pre-existing liver conditions 1
• Inadequate treatment duration leading to recurrence, particularly with toenail infections which require longer treatment courses 1, 7
• Not addressing underlying factors such as improper nail trimming, repetitive trauma, hyperhidrosis, or poor foot hygiene that contribute to ingrown toenails 8