Onychomycosis: Current trends in diagnosis and treatment

Am Fam Physician. 2013 Dec 1;88(11):762-70.


Onychomycosis is a fungal infection of the nails that causes discoloration, thickening, and separation from the nail bed. Onychomycosis occurs in 10% of the general population, 20% of persons older than 60 years, and 50% of those older than 70 years. It is caused by a variety of organisms, but most cases are caused by dermatophytes. Accurate diagnosis involves physical and microscopic examination and culture. Histologic evaluation using periodic acid-Schiff staining increases sensitivity for detecting infection. Treatment is aimed at eradication of the causative organism and return to a normal appearance of the nail. Systemic antifungals are the most effective treatment, with meta-analyses showing mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole. Concomitant nail debridement further increases cure rates. Topical therapy with ciclopirox is less effective; it has a failure rate exceeding 60%. Several nonprescription treatments have also been evaluated. Laser and photodynamic therapies show promise based on in-vitro evaluation, but more clinical studies are needed. Despite treatment, the recurrence rate of onychomycosis is 10% to 50% as a result of reinfection or lack of mycotic cure.

Publication types

  • Review

MeSH terms

  • Administration, Topical
  • Algorithms
  • Antifungal Agents / therapeutic use
  • Combined Modality Therapy
  • Debridement
  • Decision Support Techniques
  • Humans
  • Lasers, Solid-State / therapeutic use
  • Nonprescription Drugs
  • Onychomycosis* / classification
  • Onychomycosis* / diagnosis
  • Onychomycosis* / microbiology
  • Onychomycosis* / therapy
  • Photochemotherapy
  • Treatment Failure


  • Antifungal Agents
  • Nonprescription Drugs