British Association of Dermatologists guideline for managing fungal nail infection (onychomycosis) 2026

Lay Summary

Fungal nail infection (FNI) is a common condition. It affects the toenails and fingernails. Fungi grow in the nail, causing thickening, discoloration or crumbling. Around 1 in 2000 children have FNI. This increases to one in three people aged over 65 years.

The British Association of Dermatologists brought together a group of experts on FNI. They included consultant dermatologists, pharmacists, podiatrists and people with lived experience of FNI. The group reviewed the published evidence on treatment. This UK-based group produced 44 recommendations.

Management of most people with FNI is in primary care. However, more complex cases may need referral to a dermatologist. Accurate diagnosis is important. Treatment decisions should always fit the person with FNI. Factors include the type of infection, age, general health and personal preference. People with FNI should be told the benefits and risks of treatment and how long treatment will take. Nails may not always return to their previous appearance even when the infection is cured.

Topical treatments are those applied to the affected nail. These may be suitable for mild infections or for people who cannot take oral medication. For many, an oral tablet called ‘terbinafine’ is the first-line treatment. When terbinafine is not suitable, other oral tablets called ‘itraconazole’ or ‘fluconazole’ can be used. Combination approaches may be helpful for stubborn infections. Children and young people can receive antifungal medicines. Doses should be adjusted according to their age and weight.

The authors present a management pathway for patients with FNI. This will guide clinicians through the treatment options. Recommendations for future research are also included. Finally, audit points are presented. These will allow hospitals to check that the care of patients with FNI is meeting the right standards.