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 Table of Contents  
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 30-33

Management of dermatophytosis of nail and hair

Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi, India

Date of Web Publication10-Oct-2017

Correspondence Address:
Archana Singal
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi - 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CDR.CDR_31_17

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Dermatophyte infections are common worldwide, and dermatophytes are the prevailing causes of fungal infection of the skin, hair, and nails. These infections lead to a variety of clinical manifestations; nail infection known as onychomycosis (OM) and hair infection as Tinea capitis. The diagnosis and treatment of dermatophyte infections of the Nail and hair will be reviewed here.

Keywords: Management, nondermatophytic mold, onychomycosis, tinea capitis

How to cite this article:
Singal A, Kayarkatte MN. Management of dermatophytosis of nail and hair. Clin Dermatol Rev 2017;1, Suppl S1:30-3

How to cite this URL:
Singal A, Kayarkatte MN. Management of dermatophytosis of nail and hair. Clin Dermatol Rev [serial online] 2017 [cited 2022 Sep 28];1, Suppl S1:30-3. Available from: https://www.cdriadvlkn.org/text.asp?2017/1/3/30/216271

  Management of Onychomycosis Top

Onychomycosis (OM), a fungal infection of the nail, constitutes about 20%–40% of all onychopathies and encompasses infection of the nail unit with dermatophytes, nondermatophytic molds and Candida spp. Fingernail involvement may result in pain, discomfort, and impaired/lost tactile functions. The affection of toenails often interferes with walking, exercise, or proper shoe fit.[1] In addition, infected nail acts as a reservoir for infection, and hence, the treatment of OM is mandatory.


The management of OM is double pronged and includes diagnosis and treatment. As the treatment of OM is often prolonged, it is imperative to supplement the clinical diagnosis by laboratory investigations. Various modalities available for laboratory confirmation of OM have been listed in [Table 1].
Table 1: Laboratory diagnosis of onychomycosis

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Treatment of OM can be divided into

  • Topical therapy
  • Systemic therapy
  • Surgical modality
  • Laser
  • Combination of the above.

Topical therapy

In general, the treatment of OM demands systemic therapy except in some special circumstances that are as follows:

Indications of topical therapy

  • Involvement limited to distal 30% of nail plate with involvement of >3 nails
  • Matrix uninvolved
  • Superficial white OM
  • In children with thin, fast growing nails
  • Where oral therapy is inappropriate
  • As prophylaxis in patients at risk of recurrence.[2]

Various topical therapies have been employed but following three have US Food and Drug Administration (FDA) approval for the treatment of OM [Table 2].[3],[4],[5]
Table 2: Topical therapies for onychomycosis

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Tavaborole 5% solution[6] is a novel, boron based, topical treatment for toenail OM, approved by the US FDA in 2014. It inhibits protein synthesis and thus fungal cell growth. The drug has excellent ability to penetrate nail plate and has been found to be effective against dermatophytes, nondermatophyte molds, and yeasts including Fusarium and Malassezia species. The drug is awaiting commercial availability in India.

  Systemic Therapy Top

Systemic therapy in the form of oral antifungal drugs has been described the most commonly used drugs have been listed in [Table 3][2],[7],[8],[9] and their common side effects have been tabulated in [Table 4].[10]
Table 3: Systemic drugs for onychomycosis

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Table 4: Side effects of oral antifungal drugs

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  • Involvement of >30% of distal nail plate/multiple nail involvement
  • Involvement of nail matrix
  • Topical drug penetration is expected to be suboptimal.[2]

Nondermatophytic OM is difficult to treat and itraconazole having a broader spectrum of activity is commonly employed. The duration of therapy may be prolonged and often a combination of oral, topical, and surgical methods is required.[11]

Candidal OM responds well to systemic as well as topical treatment. Itraconazole and fluconazole are equally efficacious. Itraconazole can be used as continuous or pulse regime. Fluconazole is given as 50 mg/day or 300 mg/week to be continued for minimum 4 weeks for fingernail and 12 weeks for toenail OM also, 2–3 pulses of itraconazole have been used for the same.[11]

  Surgical Intervention Top

Stand-alone surgical intervention has given poorer outcomes as compared to combination with medical therapy. Total surgical removal must be discouraged; the distal nail bed may shrink and become dislocated dorsally. In addition, the loss of counter pressure produced by the removal of the nail plate allows expansion of the distal soft tissue that allows the distal edge of the regrowing nail to embed itself. This can be overcome by using partial nail avulsion.[3] The presence of dermatophytoma indicates the need for a surgical intervention as the biofilm prevents the penetration of drugs.

  Laser Top

Multiple studies have been done, employing 1064 nm neodymium: yttrium -aluminum-garnet laser system (long and short pulse types) either as a sole intervention or as a Q-switched 1064 nm/532 nm wavelengths system. Its efficacy has been found to be nonconclusive in a review of multiple studies, and its role has been justified as a supplemental modality.[12]

  Management of Tinea Capitis Top

Tinea capitis is dermatophyte infection of the scalp hair follicles and intervening skin, mainly caused by anthropophilic and zoophilic species of the genera Trichophyton and Microsporum.


Investigations that are commonly employed for tinea capitis:[13]

  1. Woods lamp examination: Most ectothrix infections caused by Microsporum species give a bright yellow fluorescence under Woods lamp. It is a noninvasive rapid method that can be used for screening but has a high false negative result since all fungal infections do not produce fluorescence
  2. 1,2-dimethoxyethane with sodium hydroxide (KOH): Ten percentages KOH is used to digest keratin following which it is examined for fungal elements under a microscope. It is a rapid method with high sensitivity
  3. Culture: It is a highly specific test, but has the disadvantage of longer duration of up to 6 weeks for results
  4. Trichoscopy: Noninvasive, rapid office-based procedure. On trichoscopy, we find broken hairs, dystrophic hairs, corkscrew hairs, comma hairs, and black dots.[14]

Although universal protocols have not been described for its treatment, systemic therapy is essential [Table 5].[15],[16],[17]
Table 5: Drugs used in tinea capitis

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In case of kerion formation, wet compresses with removal of crusts are essential followed by antibiotics if necessary. The use of oral steroids in severe cases with widespread id reactions is also recommended under the cover of systemic antifungals. For defining mycological cure, it is recommended to examine hair root for infection at the end of the standard treatment period and then monthly until negative.[16]

Topical antifungal therapy has little place in the management of tinea capitis except as an adjunct to oral therapy. However, topical agents are used to reduce transmission of spores, and povidone–iodine, ketoconazole 2% and selenium sulfide 1% shampoos have been used. Screening family and treatment of pets with precautions for reducing transmission through fomites helps in reducing recurrences.[18]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kaur R, Kashyap B, Bhalla P. Onychomycosis – Epidemiology, diagnosis and management. Indian J Med Microbiol 2008;26:108-16.  Back to cited text no. 1
[PUBMED]  [Full text]  
Singal A, Khanna D. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol 2011;77:659-72.  Back to cited text no. 2
[PUBMED]  [Full text]  
Baran R, Hay R, Haneke E, Tosti A. Review of antifungal therapy. Onychomycosis: The Current Approach to Diagnosis and Therapy. 2nd ed. Florida: Taylor and Francis; 2003.  Back to cited text no. 3
Lecha M, Effendy I, Feuilhade de Chauvin M, Di Chiacchio N, Baran R; Taskforce on Onychomycosis Education. Treatment options – Development of consensus guidelines. J Eur Acad Dermatol Venereol 2005;19 Suppl 1:25-33.  Back to cited text no. 4
Pollak RA. Efinaconazole topical solution, 10%: The development of a new topical treatment for toenail onychomycosis. J Am Podiatr Med Assoc 2014;104:568-73.  Back to cited text no. 5
Zane LT, Plattner J, Chanda S, Coronado D, Merchant T, Alley MR, et al. Tavaborole topical solution, 5% for the treatment of toenail onychomycosis. Drugs Today (Barc). 2015;51:599-607.  Back to cited text no. 6
Brown SJ. Efficacy of fluconazole for the treatment of onychomycosis. Ann Pharmacother 2009;43:1684-91.  Back to cited text no. 7
de Sá DC, Lamas AP, Tosti A. Oral therapy for onychomycosis: An evidence-based review. Am J Clin Dermatol 2014;15:17-36.  Back to cited text no. 8
Gupta AK, Lynch LE, Kogan N, Cooper EA. The use of an intermittent terbinafine regimen for the treatment of dermatophyte toenail onychomycosis. J Eur Acad Dermatol Venereol 2009;23:256-62.  Back to cited text no. 9
Tosti A, Vlahovic TC, Arenas R. Onychomycosis: An Illustrated Guide to Diagnosis and Treatment. 1st ed. Switzerland: Springer; 2017.  Back to cited text no. 10
Tosti A, Piraccini BM, Lorenzi S, Iorizzo M. Treatment of nondermatophyte mold and Candida onychomycosis. Dermatol Clin 2003;21:491-7, vii.  Back to cited text no. 11
Bristow IR. The effectiveness of lasers in the treatment of onychomycosis: A systematic review. J Foot Ankle Res 2014;7:34.  Back to cited text no. 12
Bennassar A, Grimalt R. Management of tinea capitis in childhood. Clin Cosmet Investig Dermatol 2010;3:89-98.  Back to cited text no. 13
Ekiz O, Sen BB, Rifaioğlu EN, Balta I. Trichoscopy in paediatric patients with tinea capitis: A useful method to differentiate from alopecia areata. J Eur Acad Dermatol Venereol 2014;28:1255-8.  Back to cited text no. 14
Chen X, Jiang X, Yang M, Bennett C, González U, Lin X, et al. Systemic antifungal therapy for tinea capitis in children: An abridged cochrane review. J Am Acad Dermatol 2017;76:368-74.  Back to cited text no. 15
Hay RJ. Tinea capitis: Current status. Mycopathologia 2017;182:87-93.  Back to cited text no. 16
Kakourou T, Uksal U, European Society for Pediatric Dermatology. Guidelines for the management of tinea capitis in children. Pediatr Dermatol 2010;27:226-8.  Back to cited text no. 17
Fuller LC, Barton RC, Mohd Mustapa MF, Proudfoot LE, Punjabi SP, Higgins EM, et al. British association of dermatologists' guidelines for the management of tinea capitis 2014. Br J Dermatol 2014;171:454-63.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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