Treatment of Nailbed Infections

Diagnostic Considerations

Obtain bacterial cultures if infection is suspected to guide appropriate antibiotic therapy, keeping the affected area clean and dry between soaks, and avoiding manipulation of the cuticles and nail biting, as recommended by the American Society of Clinical Oncology 1

For mild to moderate bacterial nailbed infections, the British Association of Dermatologists recommends cephalexin as an effective first-line antibiotic, particularly against Staphylococcus aureus and Streptococcus pyogenes 2

If abscess is present, drainage is mandatory before antibiotic therapy, and keeping the affected area clean and dry between soaks is crucial, as suggested by the American Society of Clinical Oncology 1
Avoid manipulation of the cuticles and nail biting to prevent further infection 1

If painful hematoma or subungual abscess is suspected, partial or total nail avulsion may be required, especially in immunocompromised patients 1
For chronic or recurrent infections, addressing underlying factors such as immunocompromised status is essential 1

Fungal infections (onychomycosis) usually present with gradual nail discoloration, thickening, and minimal pain, and appropriate antifungal therapy should be initiated instead of antibiotics, as recommended by the British Association of Dermatologists 2, 3

Inadequate duration of antibiotic therapy leading to recurrence can be prevented by following the recommended treatment duration 1

Reassess after 2 weeks of treatment, and if infection worsens or does not improve, consider alternative antibiotics based on culture results or surgical intervention for drainage 1

Bacterial infections typically present with acute onset, pain, erythema, purulent discharge, and potential abscess formation, according to the Annals of Oncology 4

Clean the nail bed and obtain cultures at the time of drainage, as recommended by the Annals of Oncology 4

Terbinafine 250 mg daily is the preferred first-line treatment for dermatophyte onychomycosis, with treatment duration of 6 weeks for fingernails and 12-16 weeks for toenails, as stated in the British Journal of Dermatology 5
Itraconazole pulse therapy is equally effective as first-line treatment, with 2 pulses for fingernails and 3 pulses for toenails, according to the British Journal of Dermatology 5
Baseline liver function tests and complete blood count are recommended before initiating terbinafine, as stated in the British Journal of Dermatology 5
Fluconazole 150-450 mg weekly for 3 months or longer duration may be useful in patients unable to tolerate terbinafine or itraconazole, according to the British Journal of Dermatology 5
Remove dermatophytomas mechanically, as these can be resistant to antifungal treatment alone, as stated in the British Journal of Dermatology 5 and 6
Apply topical emollients daily to periungual folds, matrix, and nail plate, as recommended by the Annals of Oncology 4
Keep nails as short as possible and avoid sharing nail clippers, as stated in the British Journal of Dermatology 6

The British Journal of Dermatology recommends that fungal infections (onychomycosis) be treated with terbinafine 250 mg daily, with a treatment duration of 6 weeks for fingernails and 12-16 weeks for toenails 7
For mild to moderate fungal infections, topical agents such as amorolfine or ciclopirox may be appropriate, especially for patients with high risk of drug interactions or infections involving less than 50% of the nail plate 8
The British Journal of Dermatology suggests that mechanical removal of dermatophytomas is necessary, as these fungal masses can be resistant to antifungal treatment alone 8
Azole antifungals, such as fluconazole or itraconazole, are advocated for onychomycosis caused by Candida species, with fluconazole 150-450 mg weekly for 3 months or longer being a recommended treatment option 7

The British Journal of Dermatology recommends terbinafine as the oral antifungal agent of choice in diabetic patients due to its low risk of drug interactions and hypoglycemia, with onychomycosis being a significant predictor for foot ulcer development in diabetes 8, 7
For immunosuppressed patients, such as those with HIV, terbinafine and fluconazole are preferred for onychomycosis, with itraconazole and ketoconazole having an increased risk of interactions with antiretrovirals 8, 7

The British Journal of Dermatology emphasizes the importance of confirming diagnosis with microscopy and culture, rather than relying on clinical appearance alone, to ensure accurate treatment 9
The Clinical Infectious Diseases journal notes that terbinafine has limited and unpredictable activity against yeasts, making it an inappropriate choice for Candida onychomycosis 10