Most nail abnormalities are associated with underlying medical conditions and resolve as those conditions are treated. Infections of the nails, such as with fungus or bacteria, are a significant exception in that they may respond to specific treatment. Although both topical and oral medications are available, topical agents typically are not very effective because infections are usually under the nail, and topical medications cannot penetrate the nail plate (Kyle 2004). For paronychia, or nail infection, antibiotics and surgical drainage of the infected nail fold may be recommended (Shaw 2005).
For nail fungus, one of two oral medications is usually prescribed: Lamisil® (terbinafine) or Sporanox® (itraconazole). The use of these drugs is associated with liver toxicity, however. In rare cases, liver failure and death have occurred, especially among people with severe underlying systemic conditions (Food and Drug Administration 2006). Use of these drugs should be closely monitored by a physician.
Lamisil®. In an open-label, randomized, multicenter trial, 75 patients age 65 or older who had moderate to severe onychomycosis were treated with 250 mg Lamisil® daily for 12 weeks. Half also underwent four sessions of aggressive debridement (surgical removal of fungus). At the 48-week follow-up, 64 percent of the patients had mycologic cure and reported that the drug had been well tolerated. Those who also underwent debridement appeared to fare better than those who did not (Tavakkol 2006).
In a comparative, randomized study of 30 patients with onychomycosis, either Lamisil® or Sporanox® was administered for 16 weeks, and patients were followed up for 36 weeks. At the end of follow-up, little or no nail deformity was seen in 86.7 percent of the Sporanox® group and 100 percent of the Lamisil® group. Reported side effects included nausea, abdominal cramps, back pain, flu-like syndrome, and headache (Sikder 2006).
While Lamisil® alone has proven to be effective in onychomycosis, researchers have found that Lamisil® combined with topical ciclopirox nail lacquer is more effective than Lamisil® alone. Eighty patients with onychomycosis received either oral Lamisil® 250 mg daily for 16 weeks or the same Lamisil® protocol plus ciclopirox nail lacquer applied once daily for 9 months. After nine months of follow-up, the infection cleared in 64.7 percent of the Lamisil®-only patients and 88.2 percent of those who got the combination therapy (Avner 2005).
Sporanox®. Use of Sporanox®, both alone and in combination with another medication, has proven effective in the treatment of onychomycosis. One study reported significant results when patients used 100 mg daily for six months (Kawada 2004), and another study found that pulse therapy (200 mg daily for one week per month over 5.6 ± 4.3 months) resulted in a 62 percent cure rate overall (Hiruma 2001).
Use of Sporanox® pulse therapy and amorolfine 5 percent solution nail lacquer was examined in a randomized study. Forty-five patients received two pulse treatments plus amorolfine for six months, and another 45 patients received three pulse treatments of Sporanox® without amorolfine. The investigators found that the combination treatment was as safe and effective as Sporanox® alone, with less cost per patient (Rigopoulos 2003).
For patients prone to onychomycosis, treatment may never completely eliminate the disease (Sigurgeirsson 2002; Tosti 1998). In fact, treatment fails in 25 to 40 percent of onychomycosis cases (Hay 2001). Combining drug therapies (an oral and topical medication) or combining drug therapy with mechanical debridement can be successful.
Treating nail psoriasis. Oral drug treatment of nail psoriasis remains problematic due to the high cost of the drugs (eg, methotrexate, acitretin, and cyclosporine) as well as their potential for systemic complications. Several topical medications may be helpful. Calcipotriol, for example, has proved effective for psoriatic nails and can be used in chronic cases (Zakeri 2005). In one study, a combination of one percent 5-fluorouracil cream and 20 percent urea resulted in improvement of more than 50 percent of the clinical signs of nail psoriasis in 59 patients (Fritz 1989). Side effects of topical agents may include burning, tingling, and swelling at or near application sites.
For serious ingrown toenails that have not responded to topical or oral medications, surgery is an option. Several types of operations that use a modification of the Zadik method and artificial skin have proven effective (Iida 2004).