Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective

J Cutan Med Surg. 2018 Mar/Apr;22(2):129-141. doi: 10.1177/1203475417733461. Epub 2017 Sep 27.


Background: Onychomycosis can be investigated by sampling. Information gleaned includes nail bed involvement, nail plate penetration, fungal viability, and species identification. Testing samples can confirm a diagnosis. While diagnostic testing is considered useful in directing therapy, a substantial number of clinicians do not confirm diagnosis prior to treatment.

Objectives: The aim of this study is to quantify the benefit of confirmatory testing prior to treating toenail onychomycosis.

Methods: The cost of mycological cure (negative potassium hydroxide and negative culture) and the cost-effectiveness of confirmatory testing were determined using the average cost of potassium hydroxide (KOH), culture, periodic acid-Schiff (PAS), efinaconazole, ciclopirox, terbinafine, and itraconazole. Costs were obtained through literature searches, public domain websites, and telephone surveys to local pharmacies and laboratories. To represent the potential risks of prescribing onychomycosis treatment, the costs associated with liver monitoring, potential life-threatening adverse events, and drug-drug interactions were obtained through public domain websites, published studies, and product inserts.

Results: PAS was determined to be the most sensitive confirmatory test and KOH the least expensive. The overall cost of an incorrect diagnosis (no confirmatory test used) ranged between $350 and $1175 CAD per patient for treatment of 3 infected toenails. Comparatively, performing confirmatory testing prior to treatment decreases the overall cost to $320 to $930, depending on the therapy, physician, and test.

Conclusions: It is preferred to diagnose onychomycosis prior to treatment. Furthermore, there are cost savings when confirmatory testing is performed before initiating treatment with both topical and oral antifungals in Canada.

Keywords: KOH; PAS; cost; culture; oral antifungals; tinea unguium; topical antifungals.

MeSH terms

  • Antifungal Agents / administration & dosage
  • Antifungal Agents / economics*
  • Antifungal Agents / therapeutic use
  • Humans
  • Hydroxides / economics
  • Microbiological Techniques* / economics
  • Microbiological Techniques* / methods
  • Nails / microbiology
  • Onychomycosis* / diagnosis
  • Onychomycosis* / drug therapy
  • Onychomycosis* / economics
  • Periodic Acid-Schiff Reaction / economics
  • Potassium Compounds / economics


  • Antifungal Agents
  • Hydroxides
  • Potassium Compounds
  • potassium hydroxide