Treatment of yeast, candidal onychomycosis

Localised chronic paronychia

• imidazole cream and paints, nystatin ointment, Terbinafine cream

Candidal nail infection

• distal nail involvement - treatment with tioconazole or amorolfine nail paint, usually for at least 6 months for fingernails and 12 months for toenails. A 40-50% cure rate is possible
• tioconazole nail paint is applied to the affected nail twice daily and can be used in children
• amorolfine nail lacquer is applied to the affected nail once weekly, but is not licensed for use in children
• severe or widespread Candida onychomycosis is likely to require systemic treatment, especially since such cases are often associated with an immune deficiency state. Prodigy guidance (1) has not detailed systemic therapies for Candida nail infections as this is rarely necessary, except in the context of immunosuppression, where treatment is usually supervised by a specialist. However the guidance states , the following:
  • oral itraconazole is active against most Candida species and dermatophytes, with cure rates of about 80% for dermatophyte nail infection. . It prescribed as pulse therapy - 200mg twice daily for 1 week a month for 2 months in fingernail and for 3 months in toenail infections (2). Itraconazole is not licensed for use in children, but a working party set up by the British Society for Medical Mycology suggests that older children, weighing over 20 kg, may be prescribed half the adult dosage
  • oral terbinafine has only been shown in clinical trials to be effective against dermatophyte nail infections. It has fungistatic activity against Candida albicans
  • fluconazole is not licensed for nail disease, but is used for severe infection in immunosuppressed people
  • griseofulvin is not effective against Candida

Notes (2):

• treat only if infection confirmed by laboratory
• only use topical treatment if superficial infection of the top surface of nail plate
• idiosyncratic liver and other severe reactions occur very rarely with terbinafine and itraconazole
• for infections with candida or non-dermatophyte moulds use oral itraconazole
• for children seek expert advice
• treatments available (2,3)
  • 5% amorolfine nail lacquer
    • 1-2x/weekly
    • fingers for 6 months
    • toes for 12 months
  • itraconazole
    • 200 mg BD
    • fingers for 2 courses of 7 days/month
    • toes for 3 courses of 7 days/month

Reference:

• (1) Prodigy Guidance (2002). Candida - Skin and nails.
• (2) Health Protection Agency 2011. Fungal nail & skin infections: diagnosis & laboratory investigation – Quick reference guide for primary care
• (3) Public Health England 2017. Fungal skin and nail infections: Diagnosis and laboratory investigation - Quick reference guide for primary care.