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Fungal Nail Infection (Onychomycosis)

NICE CKS Fungal nail infection. Last revised: Aug 2023.

Background Information

85-95% are caused by dermatophyte infections
  • Most common: Trichophyton rubrum

5-10% are caused by Candida species

2-5% of toenail onychomycosis are caused by non-dermatophyte moulds (e.g. Scopulariopsis, Scytalidium, Aspergillus, Fusarium, and Acremonium species)

Guidelines

Clinical diagnosis.

If antifungal treatments are being considered → arrange nail clippings and/or scrapings for fungal microscopy and culture

Self management:
  • Keep nails trimmed short and filed down
  • Wear well-fitting non-occlusive shoes, without high heels or narrow toes
  • Wear cotton, absorbent socks
  • Maintain good foot hygiene, including prompt treatment of any associated tinea pedis
  • Wear protective footwear when using communal bathing places, locker rooms, and gymnasiums, to avoid re-exposure.
  • Avoid prolonged or frequent exposure to warm, damp conditions if possible
  • Avoid trauma to the nails if possible


Measures to prevent spread and transmission:
  • Avoid sharing toenail clippers
  • Replace old footwear that could be contaminated with fungal spores

DO NOT routinely offer antifungal to all patients, treatment is only indicated if:
  • Symptomatic (walking is uncomfortable)
  • Psychological distress due to cosmetic appearance
 

For early distal and superficial nail involvement: amorolfine 5% nail lacquer
 

If self-care measures alone and/or topical treatment not successful or appropriate: oral antifungal
  • If dermatophyte nail infection confirmed
    • 1st line: oral terbinafine
    • 2nd line: oral itraconazole
 
  • If non-dermatophyte nail infection (including Candida) confirmed
    • 1st line: oral itraconazole
    • 2nd line: oral terbinafine

References

NICE CKS Fungal nail infection​​​​​​​
Author: Adams Lau
Reviewer:
Last edited: 14/07/25