NO DRUG THERAPY IN PRIMARY CARE (ASSESS FIRST)
Confirm it before treating it. Send nail clippings for microscopy and culture: most thickened, discoloured nails are not candidal, and chronic paronychia, psoriasis and repeated trauma all look the same. Candidal nail disease is usually secondary to chronic paronychia in wet hands, so keeping the hands dry and treating the nail fold matters more than any nail preparation. - Assess, then decide
In a child, candidal nail disease is unusual and persistent or multiple-nail candidiasis raises chronic mucocutaneous candidiasis or immune deficiency. Refer rather than treat.
No dose - assessment step, no medicine given
No source reachable indicates a drug for candidal nail infection. The formulary licences itraconazole for onychomycosis caused by DERMATOPHYTES, and fluconazole for oesophageal, oropharyngeal, urinary and vaginal candidiasis - neither covers the nail. Clotrimazole says in its own monograph: not effective for treatment of scalp or nails.
- Confirmed candidal nail disease is treated systemically and that is a dermatology decision - refer rather than starting an oral antifungal on a clinical guess.
- Look at the nail fold. Candidal nail disease usually follows chronic paronychia, and without keeping the hands dry it returns whatever is prescribed.
- A single dark streak in one nail is subungual melanoma until proved otherwise - refer urgently.
- In a diabetic, any nail or nail-fold infection is a foot-care problem first.