**7. Treatment algorithm**

Defining the resolution of onychomycosis can be achieved through clinical, mycological, and complete cure. Clinical cure is described as 100% improvement depicted by clear nail, while mycological cure is described as negative KOH microscopy and negative fungal culture, respectively. Ultimately, complete cure comprises 100% clear nail and mycological cure. The goal of treating onychomycosis for physicians and affected stakeholders are achieving the complete cure. However, it is difficult for an infected nail to return into an utterly normal appearance, particularly in advanced stage although mycological cure has been attained [3].

The treatment choices (**Figure 1**) available for managing onychomycosis are oral medication, topical therapy, and devices. Oral antifungals (**Table 5**) are the firstline therapy because they result in high success rates. Nevertheless, oral antifungals are contraindicated in patients with chronic or active liver disease, congestive heart failure, and kidney failure. Besides, oral antifungals may interact with other pharmacological agents, which can trigger a severe adverse reaction. These setbacks urged the request for the safer option which leads to the awareness of topical therapy. Topical treatments (**Table 6**) are indicated in mild–moderate cases and patients with contraindication for oral antifungals. However, they also have limitations which are smaller cure rate, prolonged therapy and difficulty applying for patients with mobility problems. Ultimately, lasers are FDA-approved device therapy for short-term clearance and/or nail enhancement. However, laser therapy is lacking conclusive guidance and its efficacy demonstrates notable disparities among all treatment modalities. Topical antifungals eradicate the fungus from the outward penetrating the dorsal part of the nail, whereas oral antifungals eliminate from the inward infiltrating the ventral part of the nail [3].

Another proposed treatment algorithm is based on the severity of onychomycosis assessed with SCIO (**Table 7**) [12].

#### **Figure 1.**

*Treatment algorithm of onychomycosis [16]. Cited as is from Christenson et al. [16].*

#### *Candida Onychomycosis: Mini Review DOI: http://dx.doi.org/10.5772/intechopen.96650*


*CYP, cytochrome P450; NDM, non-dermatophyte molds; MC, mycological cure; CC, complete cure. \* Data provided are clinical cure rates.*

*† Fluconazole was FDA-approved for use in humans in 1990, but is not yet approved for treatment of onychomycosis in the US or Canada.*

*Cited as is from Gupta et al. [3].*

#### **Table 5.**

*Summary of available oral antifungal [3].*



*CC, complete cure; MC, mycological cure; NDM, non-dermatophyte molds. †Not approved by FDA, thus no pregnancy classification. Cited as is from Gupta et al. [3].*

#### **Table 6.**

*Summary of available topical antifungal [3].*


#### **Table 7.**

*Proposed treatment approach based on scoring clinical index of onychomycosis (SCIO) [12].*
