British Association of Dermatologists' guidelines for the management of onychomycosis 2014

Abstract

The overall objective of the guideline is to provide up‐to‐date, evidence‐based recommendations for the management of onychomycosis. The document aims to (i) offer an appraisal of all relevant literature since January 2002, focusing on any key developments; (ii) address important, practical clinical questions relating to the primary guideline objective, for example accurate diagnosis and identification of cases, and suitable treatment to minimize the duration of disease and discomfort; (iii) provide guideline recommendations and, where appropriate, with some health economic implications; and (iv) discuss potential developments and future directions. The guideline is presented as a detailed review with highlighted recommendations for practical use in the clinic, in addition to an updated patient information leaflet [available on the British Association of Dermatologists' (BAD) website, www.bad.org.uk]. The guideline development group consisted of consultant dermatologists and a consultant mycologist. The draft document was circulated to the BAD membership, the British Dermatological Nursing Group, the Primary Care Dermatological Society and the North West Region Kidney Patient Association for comments, and was peer reviewed by the Clinical Standards Unit of the BAD (made up of the Therapy & Guidelines Subcommittee) prior to publication. This set of guidelines has been developed using the BAD's recommended methodology1 and with reference to the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument (www.agreetrust.org).2 Recommendations were developed for implementation in the National Health Service using a process of considered judgement based on the evidence. The PubMed, Medline and Embase databases were searched for meta‐analyses, randomized and nonrandomized controlled clinical trials, case series, case reports and open studies involving onychomycosis published in the English language from January 2002 to February 2014; search terms and strategies are detailed in Data S1 (see Supporting Information). Additional relevant references were also isolated from citations in the reviewed literature, as well as from additional, independent targeted literature searches carried out by the coauthors. The preliminary results were split into four, with each consultant coauthor screening the identified titles; those relevant for first‐round inclusion were selected for further scrutiny. The abstracts for the shortlisted references were then reviewed and the full papers of relevant material were obtained. The structure of the guidelines was then discussed and different coauthors were allocated separate subsections. Each coauthor then performed a detailed appraisal of the relevant literature, and all subsections were subsequently collated and edited to produce the final guidelines. This document has been prepared on behalf of the BAD and is based on the best data available when the document was prepared. It is recognized that under certain conditions it may be necessary to deviate from the guidelines and that the results of future studies may require some of the recommendations herein to be changed. Failure to adhere to these guidelines should not necessarily be considered negligent, nor should adherence to these recommendations constitute a defence against a claim of negligence. Limiting the review to English language references was a pragmatic decision but the authors recognize that this may exclude some important information published in other languages. The proposed revision for this set of recommendations is scheduled for 2019; where necessary, important interim changes will be updated on the BAD website. The term tinea unguium is used to describe dermatophyte infections of the fingernails or toenails.3 4 5 Onychomycosis is a less specific term used to describe fungal disease of the nails. The condition is worldwide in distribution. In addition to dermatophytes, it can be caused by a number of other moulds and by Candida species. Some of the contributing factors causing this disease are occlusive footwear, repeated nail trauma, genetic predisposition and concurrent disease, such as diabetes, poor peripheral circulation and HIV infection, as well as other forms of immunosuppression. There is wide geographical and racial variation in the aetiological agents of onychomycosis, but in the U.K. 85–90% of nail infections are due to dermatophytes and about 5% are due to nondermatophyte moulds.4 5 6 The most commonly implicated dermatophyte is the anthropophilic species Trichophyton rubrum, followed by Trichophyton interdigitale. Zoophilic species are seldom involved, and usually only in fingernail infections. Onychomycosis is among the most common nail disorders in adults, accounting for 15–40% of all nail diseases.7 Onychomycosis is most prevalent in older adults but, because of the limited number of large‐scale studies, the actual incidence of the condition is difficult to assess. Moreover, many reports do n