Treatment options – development of consensus guidelines

Background  There are currently three main treatment strategies for onychomycosis: topical, oral and combination. Amorolfine nail lacquer appears to be the most effective form of topical monotherapy. However, the best mycological and clinical cure rates are obtained with combination therapy. Combination therapy increases antifungal spectrum, fungicidal activity and safety. New antifungals (triazoles and echinocandins) were recently developed, enabling new protocols. Objectives  To review available therapies. To design an algorithm for the management of onychomycoses in daily practice. Results  Therapeutic choice should be based on numerous factors including patient's age and health, aetiology, extent of involvement and clinical form. The consensus was that topical monotherapy is recommended when 50% of the nail, including the matrix area, is involved. Topical treatments should not be used alone when topical drug transport is suboptimal (i.e. when dermatophytoma, onycholysis or spikes are present). Chemical or mechanical removal should also be considered whenever applicable (interruption of drug transport). Conclusion  In conclusion, treatment decision-making tools (e.g. an illustrated booklet or CD-ROM presenting each type of onychomycosis and criteria to be considered before selecting treatment regimen) would be valuable supports for the successful treatment of onychomycoses.