Fungal Nail Infection - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 17/06/2020  
Next review: 17/06/2023  
Clinical Guideline
CURRENT 
ID: 2262 
Approved By: LAPC 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Fungal Nail Infection in Primary Care

 Preferred Option

Alternative Option

Notes

Terbinafine Description: electronic Medicines Compendium information on Terbinafine 6A-
250mg orally OD
Fingers: 6-12 weeks; Toes: 3-6 months
OR
Amorolfine (Superficial only)
5% nail lacquer 5B-
1-2x/weekly
Fingers: 6 months; Toes: 12 months

Itraconazole Description: electronic Medicines Compendium information on Itraconazole 6A
200mg orally BD
Pulsed (7 days in each month)
Fingers: 2 courses; Toes: 3 courses

Take nail clippings: start therapy only if infection is confirmed by laboratory 1B-
Terbinafine is more effective than azoles 6A+
Liver reactions rare with oral anti-fungals 2A+
If Candida or non-dermatophyte infection confirmed, use oral Itraconazole Description: electronic Medicines Compendium information on Itraconazole  3B+ 4C
For children, seek specialist advice 3C

https://cks.nice.org.uk/fungal-nail-infection
https://www.gov.uk/government/publications/fungal-skin-and-nail-infections-diagnosis-and-laboratory-investigation

General Principles for Treating Infections

This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

  1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
  2. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
  3. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
  4. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
  5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
  6. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
  9. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
  10. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
  11. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
  12. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.
    Note
    Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
    Letters indicate strength of evidence:
    A+ = systematic review: D = expert opinion

Provenance

Record: 2262
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition: Fungal Nail Infection
Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Management of Infection guidance for primary care for consultation and local adaptation


Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

Dermatophyte infection – nail

  1. Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. Brit J Dermatol 2003;148:402–410. RATIONALE: Confirmation of diagnosis: only 50% of cases of nail dystrophy are fungal, and it is not easy to identify these clinically. The length of treatment needed (6-12 months) is too long for a trial of therapy.
  2. Chung CH, Young-Xu Y, Kurth T, Orav JE, Chan AK. The safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. Am J Med 2007;120:791-798. RATIONALE: Pooled data from about 20,000 participants found that both continuous and pulse therapy with terbinafine, itraconazole, or fluconazole were well tolerated. The risk of having asymptomatic raised liver transaminases was less than 2% for all treatments. The risk of having raised liver transaminases that required treatment discontinuation with continuous treatment ranged from 0.11% (itraconazole 100mg/day) to 1.22% (fluconazole 50mg/day). The risk with pulse treatment ranged from 0.39% (itraconazole 400mg/day) to 0.85% (fluconazole 300-450mg/week).
  3. CKS. Fungal nail infection. Clinical Knowledge Summaries 2018. Available from: https://cks.nice.org.uk/fungal-nail-infection#!scenario  Accessed 15.06.20
  4. Public Health England (PHE). Fungal skin and nail infections: diagnosis and laboratory investigation. Quick reference guide for primary care: for consultation and local adaptation. Jun 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/619770/Fungal_skin_and_nail_infections_guidance.pdf
  5. Reinel, D. Topical treatment of onychomycosis with amorolfine 5% nail lacquer: comparative efficacy and tolerability of once and twice weekly use. Dermatology. 1992;184(Suppl 1): 21-24. RATIONALE: One RCT (n=456) without a placebo control found that 46% of those randomized to amorolfine applied once a week for 6 months achieved mycological cure of dermatophyte infection compared with 54% of those who applied topical amorolfine twice a week.
  6. Crawford F & Ferrari J. Fungal toenail infections. In Clinical Evidence Concise. London. BMJ Publishing Group. 2006; 15: 561-63. RATIONALE: Terbinafine vs itraconazole: one systematic review pooled data from two randomized controlled trials (n=501). At 1-year follow-up, the cure rate following 12 weeks of treatment was greater for people with dermatophyte onychomycosis treated with oral terbinafine 250mg once a day (69%) compared with oral itraconazole 200mg daily (48%). Absolute risk reduction 21%, 95% CI 13% to 29%. Pulsed vs continuous itraconazole: four small RCTs were identified that found no statistically significant difference between continuous and pulsed itraconazole for dermatophyte onychomycosis.
  7. Crawford F and Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Systematic Reviews 2007. Issue 3. Available from: https://pubmed.ncbi.nlm.nih.gov/17636672/ Accessed 15.06.20 This review concluded that there is little evidence that topical anti-fungals are effective in the management of onychomycosis or fungally infected toe nails. The majority of available data demonstrate low cure rates after long treatment times with ciclopiroxolamine. Amorolfine and butenafine may be much more effective than ciclopiroxolamine and tea tree oil but only a few observations are available. Large randomised controlled trials comparing the effectiveness of topical amorolfine and butenafine.

Approved By

LAPC

Document history

LHP version 2.0

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