SUMMARY

* Unsightly nails due to fungal infection can cause significant embarrassment and, in some cases, may impair the function of the hands or feet.

* Fungal toenail infections are most commonly caused by dermatophytes (tinea); Candida is more likely to affect the fingernails. About 5% of cases are due to non-dermatophyte moulds.

* A firm diagnosis should always be made before initiating drug treatment. A specimen of the infected nail should be assessed for mycology, as treatment differs according to the micro-organism responsible. Drug therapy should only be initiated if infection is confirmed by microscopy and/or culture.

* Patients referred to their GPs by chiropodists may not always be unduly concerned about the condition of their nails. There should always be a good reason for prescribing drug therapy, as all oral antifungals have the potential to cause serious side-effects.

* Generally, terbinafine is considered the agent of choice in confirmed dermatophyte infection of the nail. Pulsed itraconazole should be used for infections caused byyeasts. Itraconazole is also thought to be the treatment of choice in non-dermatophyte mould infections, although it is not licensed for this use.

* Griseofulvin is no longer regarded as a first choice therapy, especially in toenail infections. Topical agents should only be considered when infection is confined to the distal ends of the nails. Such infections may not require treatment at all.

* Patients taking oral antifungals should be reassured that their nail infection may still respond even after the treatment course is finished. The importance of good nail hygiene should be emphasised.