Ten Pearls For Treating Difficult Nails

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Preferred Dosing Regimens For Oral Antifungals

Terbinafine: 250 mg/day for 12 weeks
Itraconazole Continuous: 200 mg/day for 12 weeks
Itraconazole Pulse: 200 mg twice daily, given for one week on and three weeks off, repeated for a total of three pulses*
Fluconazole: 50 mg once weekly given until the abnormal-appearing nail has grown out*
* Not indicated for use in the United States

Here is a close-up view of moderate onychomycosis.
A close-up of severe onychomycosis.
Here you can see severe onychomycosis with onycholysis and 
subungual debris.
Longitudinal streak onychomycosis (as seen above) is one of several presentations of onychomycosis that may be more difficult to treat.
Patients with lateral nail involvement (as seen above) may benefit from partial nail avulsion in addition to antifungal therapy.
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Author(s): 
By Aditya K. Gupta, MD, PhD, and Jennifer Ryder, HBSc

Onychomycosis is a common nail infection, which is often chronic, difficult to eradicate and tends to recur.1 Current therapeutic approaches include mechanical or chemical avulsion, topical therapy, oral therapy or a combination of one or more of these treatment modalities. Treatment of onychomycosis has improved greatly with the addition of broad-spectrum oral antifungal agents and topical nail lacquers. However, even with the therapeutic advances, onychomycosis continues to increase in prevalence, treatment is not always successful, and relapse and reinfection may occur even after successful therapy.
With this in mind, here are 10 key tips for recognizing and treating difficult nail conditions.

1. Ensure A Correct Diagnosis Of Onychomycosis
Fungal infections of the nail apparatus may be classified as distal-lateral onychomycosis (DLSO), proximal subungual onychomycosis (PSO), superficial white onychomycosis (SWO), total dystrophic onychomycosis (TDO) and, more recently, endonyx onychomycosis (EO). The clinical presentation of the infection may provide you with information for identifying the causative organism. For instance, Candida infections are generally confined to the fingernails. Subungual hyperkeratosis with onycholysis is a common feature of dermatophyte infections.2

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