Fungal Nail Infection - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 15/03/2016  
Next review: 15/03/2019  
Clinical Guideline
ID: 2262 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  


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



Preferred option


Fungal Nail Infection

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 3B+ 4C
For children, seek specialist advice 3C

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

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

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Limit prescribing over the telephone to exceptional cases.
  5. Where a ‘best guess’ 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: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.


Record: 2262
  • 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
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

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

Study design


Good recent systematic review of studies


One or more rigorous studies, not combined


One or more prospective studies


One or more retrospective studies


Formal combination of expert opinion


Informal opinion, other information


Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

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 (onychomycosis) Clinical Knowledge Summaries 2009. Accessed 23.09.14. RATIONALE: Non-dermatophyte nail infection: there is limited evidence that both terbinafine and itraconazole are effective. Candidal nail infection: there is evidence that itraconazole is effective for candidal nail infection. There is weak evidence that terbinafine is also effective. Specialist advice for children: this is because fungal nail infection is rare in children, and the preferred treatments are not licensed for use in children.
  4. Public Health England Mycology Reference Laboratory recommends itraconazole for non-dermatophyte infections because although some of the infecting organisms are not particularly susceptible to this agent in vitro, it does reach high concentrations in nail tissue. It can be given as a pulse therapy regimen rather than continuous treatment.
  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. Accessed 23.09.14. 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.
  8. In 2014 amorolfine 5% nail lacquer cost between £11.35 and £19.99, compared to £10.20 for a three month course or oral terbinafine.

Document history

LHP version 1.0

Related information

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