What is the referral for onychomycosis (fungal infection of the nail)?

From the Guidelines

Referral to a dermatologist or podiatrist is recommended for onychomycosis cases that are resistant to standard treatments, severe, or complicated by other conditions. Before referral, first-line treatment typically includes oral antifungals such as terbinafine (250 mg daily for 6 weeks for fingernails or 12 weeks for toenails) or itraconazole (pulse therapy of 200 mg twice daily for 1 week per month, for 2 months for fingernails or 3 months for toenails) 1. Topical options like ciclopirox 8% nail lacquer or efinaconazole 10% solution may be used for mild cases or as adjunctive therapy.

Consider referral if there's no improvement after a complete course of oral therapy, if the patient has diabetes or peripheral vascular disease with significant nail involvement, if there's extensive nail dystrophy, or if the diagnosis is uncertain 1. Patients with liver disease, who cannot take oral antifungals, may also need specialist care. Early referral is important as untreated severe onychomycosis can lead to secondary bacterial infections, pain, and functional limitations, particularly in high-risk patients.

Some key points to consider when deciding on referral include:

• The severity of the onychomycosis and the impact on the patient's quality of life
• The presence of underlying medical conditions that may affect treatment or increase the risk of complications
• The patient's response to initial treatment and the need for alternative or adjunctive therapies
• The potential for topical treatments, such as ciclopirox or efinaconazole, to be used as monotherapy or in combination with oral antifungals 1.

In general, referral to a specialist is recommended when the diagnosis is uncertain, or when the patient has not responded to standard treatments, in order to provide the best possible outcome in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Prior to initiating treatment, appropriate nail specimens for laboratory testing (KOH preparation, fungal culture, or nail biopsy) should be obtained to confirm the diagnosis of onychomycosis. The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures.

The referral for onychomycosis should be to a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures, for:

• Laboratory testing (KOH preparation, fungal culture, or nail biopsy) to confirm the diagnosis
• Removal of the unattached, infected nails as frequently as monthly
• Comprehensive management of onychomycosis 2 3

From the Research

Referral for Onychomycosis

Referral for onychomycosis is considered in certain cases, including:

• Lack of treatment effectiveness 4
• Need for additional therapies 4
• Concurrent presence of other diseases or comorbidities 4
• Severe distal lateral subungual onychomycosis (DLSO) 4
• Presence of a dermatophytoma or involvement of the nail matrix 4
• Involvement of several/all nails 4

Factors to be Evaluated for Referral

Before referring a patient with onychomycosis, the following factors should be evaluated:

• Clinical signs, including subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration 4
• Predisposing factors, such as concurrent tinea pedis diagnosis, immunocompromised status, and diabetes 4
• Treatment effectiveness, including normal appearance and color of the nail, reduction or absence of scales under the nail, and absence of onycholysis 4

Diagnosis and Treatment

Diagnosis of onychomycosis is predominantly based on clinical aspects, and microscopy and fungal culture are commonly employed to establish the diagnosis 4. Treatment options include oral antifungals, topical antifungals, and nail debridement 4, and the choice of treatment should be patient-tailored, taking into account the severity of the disease, the infecting pathogen, and the patient's medical history and comorbidities 5, 6.