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  • Presentation

What's New in Onychomycosis

Description

The presentation discusses significant updates in the treatment of onychomycosis, highlighting the growing concern of antifungal resistance, particularly with terbinafine, which has been the leading treatment since its introduction in the 1990s. Reports of resistance, initially from the Indian subcontinent, have now spread globally, presenting challenges in patient management. The speaker emphasizes the importance of understanding squalene epoxidase gene mutations that contribute to resistance. In cases of partial resistance, extended courses of terbinafine may be effective, whereas complete resistance necessitates alternatives like itraconazole or off-label use of fluconazole. Novel therapies such as triazoles, including voriconazole and posaconazole, show promise for treating dermatophyte infections and can be utilized off-label. The discussion also covers topical treatments like efinaconazole and the importance of addressing reinfection through proper shoe hygiene. Prophylactic treatments for at-risk populations show potential benefits, underscoring the need for a comprehensive approach to management. The speaker advocates for antifungal stewardship, urging healthcare professionals to prescribe responsibly to prevent resistance. Patient compliance and appropriate diagnostics are critical for effective treatment outcomes.

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Conclusions

  • Antifungal resistance to terbinafine is becoming a significant global issue, especially in the US.
  • Approximately 8% of patients with abnormal toenails may have squalene epoxidase mutations, leading to possible terbinafine resistance.
  • Partial terbinafine resistance may be managed with higher doses or longer treatment durations.
  • Complete terbinafine resistance may require alternative antifungal treatments such as itraconazole or fluconazole.
  • Combination therapy combining oral and topical antifungals can reduce the risk of cross-resistance and improve treatment outcomes.
  • New oral therapies, including voriconazole and posaconazole, show promise in treating resistant onychomycosis.
  • Effective management of onychomycosis requires consideration of the patient's shoes and socks to prevent reinfection.
  • Prophylactic treatments with antifungals can help prevent recurrence, particularly in high-risk populations.
  • Thicker toenails may require extended treatment durations for effective cure rates with antifungal therapies.
  • Antifungal stewardship is essential to prevent overuse and contribute to the rising rates of resistance.
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