Fungal Nail Infections

• Fungal nail infection 
• Yellowish discolouration 
• Soft subungual hyperkeratosis 
• Spread from distal edge 
• Superficial white onychomycosis 

Perform mycological examination of nail clippings INCLUDING soft subungual material to detect fungal elements. 

Do not prescribe systemic antifungal drugs without laboratory confirmation of the diagnosis. 

Dermatophyte nail infection 

• No treatment is an option especially in the elderly - regular podiatry if required 
• Terbinafine 250mg od for six weeks for finger and 12–16 weeks for toe nails and review progress. Caution in patients with liver and auto- immune diseases 
• Itraconazole 200mg bd for one week pulsed monthly for two courses (fingernail) or three courses (toenail) 
• Topical amorolfine lacquer for superficial white distal and lateral nail involvement only

Dermatology Referral Criteria 

• Diagnosis uncertain 
• Suspicion of subungual tumour 
• Failure of fungal nail infections to respond to treatment 

Consider referral to podiatrist 

• Toe nail dystrophy secondary to trauma 
• Painful psoriatic toe nails 

Subungual haematoma 

• History of trauma 
• Discolouration migrates with nail growth 

Chronic paronychia 

• Rounded nail folds with loss of cuticle and ridged nail 
• Treat with clotrimazole cream four × daily 
• Protect hands with gloves for wet work 

Psoriasis 

Pitting and onycholysis 

• NHS Inform: www.nhsinform.scot 
• British Association of Dermatologists: http://www.bad.org.uk/for-the-public/patient-information-leaflets 
• Dermnet NZ www.dermnetnz.org 
• British Medical Journal www.bestpractice.bmj.com/best-practice/pdf/patient-summaries/532246.pdf