Toenail Onychomycosis-A Canadian Approach With a New Transungual Treatment: Development of a Clinical Pathway

J Cutan Med Surg. Sep-Oct 2015;19(5):440-9. doi: 10.1177/1203475415581310. Epub 2015 Apr 9.


Background: Onychomycosis is a difficult-to-treat infection whose current treatment paradigm relies primarily on oral antifungals. The emergence of new topical drugs broadens the therapeutic options and prompts a re-evaluation of the current Canadian treatment strategy.

Objective: To define a patient-centred Canadian treatment strategy for onychomycosis.

Methods: An expert panel of doctors who treat onychomycosis was convened. A systematic review of the literature on treatments for onychomycosis was conducted. Based on the results, a survey was designed to determine a consensus treatment system.

Results: First-line therapy should be selected based on nail plate involvement, with terbinafine for severe onychomycosis (>60% involvement), terbinafine or efinaconazole for moderate onychomycosis (20%-60% involvement), and efinaconazole for mild onychomycosis (<20% involvement). Comorbidities, patient preference and adherence, or nail thickness may result in the use of alternative oral or topical antifungals.

Conclusion: These guidelines allow healthcare providers and patients to make informed choices about preventing and treating onychomycosis.

Keywords: clinical pathway; toenail onychomycosis; transungual treatment.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Antifungal Agents / administration & dosage*
  • Antifungal Agents / therapeutic use*
  • Canada
  • Consensus
  • Critical Pathways
  • Humans
  • Nails / microbiology
  • Onychomycosis / drug therapy*
  • Practice Guidelines as Topic
  • Toes / microbiology


  • Antifungal Agents