Management of Onychomycosis Under Artificial Nails

Artificial‑nail removal

Removal of the artificial nail is essential to allow adequate drug penetration and achieve effective treatment of onychomycosis. 1

Oral terbinafine is the preferred first‑line agent for dermatophyte onychomycosis because it provides higher cure rates and better tolerability than alternatives. 1
Recommended dose for fingernail infection: 250 mg once daily for 6 weeks. 1
Recommended dose for toenail infection: 250 mg once daily for 12–16 weeks. 1
Clinical cure (complete resolution) is achieved in approximately 55 % of patients after 72 weeks, compared with 26 % for itraconazole. 1
At 5‑year follow‑up, mycological cure is observed in 46 % of patients treated with terbinafine versus 13 % with itraconazole. 1
Relapse occurs in 23 % of terbinafine‑treated patients versus 53 % with itraconazole. 1

Itraconazole is used when terbinafine is contraindicated. 1
Continuous regimen: 200 mg once daily for 12 weeks. 1
Pulse regimen: 400 mg once daily for 1 week per month; two pulses for fingernail disease, three pulses for toenail disease. 1

Fluconazole is an off‑label third‑line option. 1
Fingernail infection: 450 mg once weekly for 3 months. 2
Toenail infection: 450 mg once weekly for at least 6 months. 2
Although less effective than terbinafine or itraconazole, weekly dosing may improve patient adherence. 2

Baseline liver‑function tests and a complete blood count are recommended in patients with heavy alcohol use, hepatitis, or hematologic disorders before starting terbinafine. 1
Terbinafine is contraindicated in individuals with active or chronic liver disease. 1
A rare but potentially permanent taste disturbance can occur; patients should be counseled about this risk. 1
Drug‑interaction potential is minimal, limited to agents metabolised by CYP2D6. 1

Patients should be reassessed 3–6 months after therapy initiation; additional treatment is indicated if onychomycosis persists. 1