Treatment of Onychomycosis from Acrylic Nails
Remove the acrylic nails immediately and start oral terbinafine 250 mg daily for 12-16 weeks as first-line treatment after confirming the diagnosis with laboratory testing (KOH preparation, fungal culture, or nail biopsy). 1, 2, 3
Immediate Management Steps
Remove the source of infection:
- Discontinue acrylic nail use completely, as the artificial nail creates a moist, occluded environment that promotes fungal growth and prevents effective treatment 1
- Keep nails as short as possible throughout treatment 1
Confirm the diagnosis before treatment:
- Obtain laboratory confirmation through KOH preparation, fungal culture, or nail biopsy before starting any systemic therapy 2, 3
- Incorrect diagnosis is the most common cause of treatment failure 2
First-Line Systemic Treatment
Oral terbinafine is the preferred first-line agent:
- Dose: 250 mg once daily for 12-16 weeks for toenails, or 6 weeks for fingernails 1, 2
- Terbinafine is generally preferred over itraconazole due to superior efficacy in dermatophyte infections 1, 2
- Obtain baseline liver function tests and complete blood count before starting treatment, especially in patients with history of hepatotoxicity or hematological abnormalities 1, 2
- Common side effects include headache, taste disturbance, and gastrointestinal upset 1
Alternative first-line option - Itraconazole:
- Continuous dosing: 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
- Monitor liver function tests in patients receiving continuous therapy for more than 1 month 1
- Contraindicated in heart failure; has multiple significant drug interactions 1
Second-Line Treatment
Fluconazole for patients unable to tolerate terbinafine or itraconazole:
- Dose: 150-450 mg per week for at least 6 months for toenails 1, 2
- Monitor baseline liver function tests and complete blood count 2
Topical Therapy Limitations
Topical antifungals are generally NOT recommended as monotherapy for established onychomycosis:
- Amorolfine 5% lacquer achieves only ~50% cure rates and is reserved for very early distal involvement or when systemic therapy is contraindicated 1
- Ciclopirox 8% lacquer shows even lower cure rates (8% complete cure vs. 1% with placebo) and requires up to 48 weeks of daily application 1, 4
- Systemic therapy is almost always more successful than topical treatment 1
Managing Treatment-Resistant Cases
Address factors that contribute to treatment failure:
- Nail thickness >2 mm, dermatophytoma (dense white lesion under nail), severe onycholysis, and slow nail growth all reduce treatment success 1, 2
- Dermatophytomas require mechanical removal of the lesion before or during antifungal therapy 2
- Full nail regrowth takes up to 18 months for toenails; therapeutic success depends on the newly grown nail being fungus-free 1
Prevention of Recurrence
Implement strict preventive measures to avoid reinfection:
- Always wear protective footwear in public areas (gyms, pools, hotel rooms) where fungal elements are common 1, 2
- Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) in shoes and on feet 1, 2
- Wear cotton, absorbent socks 1
- Discard old, moldy footwear or decontaminate shoes by placing naphthalene mothballs inside and sealing in plastic bags for minimum 3 days 1
- Do not share nail clippers with others 1
- Treat all infected family members simultaneously, as onychomycosis is contagious 1
Critical Pitfalls to Avoid
- Never start systemic antifungal therapy without laboratory confirmation - this is the most common cause of treatment failure 2
- Do not continue wearing acrylic nails during treatment - the occlusive environment will prevent cure and promote recurrence 1
- Do not use topical therapy alone for established nail involvement - cure rates are inadequate compared to systemic treatment 1, 4
- Do not stop treatment early - full treatment duration is essential even if nails appear improved, as fungal elements persist deep in the nail plate 1