Let's Nail this Down: Modern Approaches to Onychomycosis

Boni E. Elewski, MD presented a streamlined, five-step framework for managing onychomycosis, beginning with accurate bedside diagnosis. Key clinical clues include asymmetric nail involvement, a history of tinea pedis, distal onycholysis, and yellow, white, or brown subungual debris. She highlighted specific diagnostic features such as dermatophytomas and collarettes of scale, which can strongly suggest dermatophyte infection. Laboratory confirmation remains essential, with KOH testing or PAS/GMS staining used to identify fungal elements, and fungal culture or PCR required to determine the causative organism. When hyphae are present, the likelihood exceeds 90% that Trichophyton rubrum is responsible.

Treatment decisions were framed around disease severity and patient factors, with options including oral therapy, topical therapy, or combination approaches. Oral antifungals such as terbinafine, itraconazole, and fluconazole remain mainstays for moderate-to-severe disease, while topical agents like efinaconazole, tavaborole, and ciclopirox are best suited for mild cases or as adjunctive therapy. Dr Elewski emphasized important safety considerations, particularly with itraconazole, including drug–drug interactions, absorption requirements, and cardiac risk. Monitoring response is critical, as toenails grow slowly; patients should demonstrate several millimeters of healthy new nail growth within 3–4 months of treatment initiation.

The session concluded with a focus on preventing reinfection, a common cause of treatment failure. Dr Elewski stressed aggressive management of concomitant tinea pedis and patient education on behavioral modifications, such as avoiding barefoot exposure in public spaces. By combining accurate diagnosis, tailored antifungal therapy, realistic expectations, and preventive strategies, clinicians can significantly improve long-term outcomes in patients with onychomycosis.