Pharmacotherapy for onychomycosis: new and emerging treatments

[[[ Introduction: ]]] Onychomycosis is the most common nail disorder seen in clinical practice. It is not merely an aesthetic disorder and may cause significant disability and affect the quality of life. There are no strict guidelines for onychomycosis therapy. Therefore, medical management is individualized based on drug efficacy, taken together with clinical presentation, infecting organism, co-morbidities, concomitant medications, and patient preferences. [[[ Areas covered: ]]] This review provides a clinically oriented critical perspective on the pathophysiology of onychomycosis, infecting organisms, and prognostic factors, and how these play a role in choosing optimal pharmacotherapy. Clinical and pharmacological considerations are described in explaining the optimal medical management of onychomycosis. [[[ Expert opinion: ]]] Onychomycosis is a common nail disorder with significant burden; yet, there are only six Food and Drug Administration approved medical therapies for this indication. When therapy is applied to specific patients, the options become even more limited. In addition, mycological and complete cure rates of systemic medications have not yet approached 100%, and cure rates for topicals are much lower. Further insight into the pathophysiology of the disease focusing on the fungal life cycle and understanding biofilms will likely lead to more optimal cure rates, decreasing morbidity and enhancing the overall quality life of the affected individuals.