What to consider in Primary Care before referring:
General Comments
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The thickness of nail plates is normally 0.5mm;
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This consistently increases in manual workers and many disease states such as:
Old age
Onychomycosis (Dermatophyte fungal infection)
Psoriasis
Chronic Eczema
Trauma e.g. from footwear
Lichen Planus
Alopecia areata
Darier’s Disease
Norwegian scabies
Congenital ichthyosis
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General cutaneous examination and examination of all the nails is necessary.
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Send samples (nail clippings including scrapings of thickened crumbly material on the underside of the nail if present) for mycology.
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If repeatedly negative, advise regular filing of nails to keep nails short and thin.
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Asymptomatic patients may be advised to ‘leave well alone’.
Treatment in primary care
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If mycology is positive and dystrophy does not extend to nail matrix (distal onychomycosis) use:
Amorolfine (Loceryl nail lacquer) Weekly continued for 6–12 months.
Alternatively oral antifungals: Always obtain +ve mycology before starting oral antifungal agents.
Terbinafine (Lamisil) 250mg od 12–16 weeks for toenails, 6–12 weeks for fingernails.
Itraconazole (Sporanox) Pulse treatment, each pulse of Sporanox bd for 7 days repeated monthly (3 cycles for toenails, 2 for fingernails).
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Matrix involved Onychomycosis.
Where matrix involvement is encountered, a combination of oral terbinafine and Amorolfine Lacquer provides more effective cure rates than terbinafine alone.
A dose of 250mg of terbinafine should be given daily for up to 12 weeks and Amorolfine Lacquer applied once a week for up to 15 months.
NB: Do not prescribe expensive oral antifungal without first proving the diagnosis from nail sampling. If negative, repeat sampling.
Referral Threshold
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Doubt over diagnosis
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Symptomatic nails
