Manejo do paciente com onicomise

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Onychomycosis is a fungal infection of the toenails or fingernails that may involve any component of the nail unit, including the matrix, bed, or plate. Onychomycosis can cause pain, discomfort, and disfigurement and may produce serious physical and occupational limitations, as well as reducing quality of life.

Onychomycosis has 5 main subtypes, as follows:

• Distal lateral subungual onychomycosis (DLSO)
  White superficial onychomycosis (WSO)
  Proximal subungual onychomycosis (PSO)
  Endonyx onychomycosis (EO)
  Candidal onychomycosis

Diagnosis
Direct microscopy of a 20% potassium hydroxide (KOH) preparation in dimethyl sulfoxide (DMSO) can screen for fungi.

Management
Medications for onychomycosis can be administered topically or orally. A combination of topical and systemic treatment increases the cure rate. Adjunctive surgical measures may also be used.

Topical therapy for onychomycosis is as follows:

• Ciclopirox olamine 8% nail lacquer solution
  Amorolfine or bifonazole/urea (available outside the United States)
  Can be used in WSO and DLSO limited to the distal nail
  Should be limited to cases involving less than half of the distal nail plate or for patients unable to tolerate systemic treatment
  Topical treatments may be useful to prevent recurrence in patients cured with systemic agents

Oral therapy for onychomycosis is as follows:

• Terbinafine
  Itraconazole
  Fluconazole and posaconazole are off-label alternatives
  Systemic treatment is always required in PSO and in DLSO involving the lunula region

Nonpharmacologic approaches include the following:

• Laser treatment
  Photodynamic therapy
  Mechanical, chemical, or surgical nail avulsion
  Chemical removal with a 40-50% urea compound in patients with very thick nails
  Removal of the nail plate as an adjunct to oral therapy

Complementação de informações sobre o tratamento:

Treatment of onychomycosis depends on the clinical type of the onychomycosis, the number of affected nails, and the severity of nail involvement. A systemic treatment is always required in proximal subungual onychomycosis and in distal lateral subungual onychomycosis involving the lunula region. White superficial onychomycosis and distal lateral subungual onychomycosis limited to the distal nail can be treated with a topical agent. A combination of systemic and topical treatment increases the cure rate. Because the rate of recurrence remains high, even with newer agents, the decision to treat should be made with a clear understanding of the cost and risks involved, as well as the risk of recurrence. Photodynamic therapy and lasers may represent future treatment options.

Topical antifungals
The use of topical agents should be limited to cases involving less than half of the distal nail plate or for patients unable to tolerate systemic treatment. Agents include amorolfine (approved in other countries), ciclopirox olamine 8% nail lacquer solution, and bifonazole/urea (available outside the United States).

Topical treatments alone are generally unable to cure onychomycosis because of insufficient nail plate penetration. Ciclopirox and amorolfine solutions have been reported to penetrate through all nail layers but have low efficacy when used as monotherapy. They may be useful as adjunctive therapy in combination with oral therapy or as prophylaxis to prevent recurrence in patients cured with systemic agents.

Oral therapy
The newer generation of oral antifungal agents (itraconazole and terbinafine) has replaced older therapies in the treatment of onychomycosis. They offer shorter treatment regimens, higher cure rates, and fewer adverse effects. Fluconazole and the new triazole posaconazole (both not approved by the US Food and Drug Administration [FDA] for treatment of onychomycosis) offer an alternative to itraconazole and terbinafine. The efficacy of the newer antifungal agents lies in their ability to penetrate the nail plate within days of starting therapy. Evidence shows better efficacy with terbinafine than with other oral agents (see Prognosis).

To decrease the adverse effects and duration of oral therapy, topical treatments and nail avulsion may be combined with oral antifungal management.

Referencia

Medscape -Onicomicose - http://emedicine.medscape.com/article/1105828-overview