Onychomycosis: past, present and future with Glynis Ablon, MD, FAAD

A summary of dermatologist Dr Glynis Ablon's overview of onychomycosis — how treatment has evolved, where the current options sit, and what comes next.

Dr Glynis Ablon is a board-certified dermatologist, clinical researcher and founder of the Ablon Skin Institute Research Center in California, and one of the more widely published voices on low-level laser therapy. Her overview of onychomycosis — past, present and future — is a useful frame for clinicians deciding what to offer, because it separates what the literature actually supports from what has simply been done for a long time.

The past: a long run of partial answers

For most of the twentieth century, treatment meant griseofulvin, keratolytics, surgical avulsion or simply managing the nail with regular debridement. Cure rates were modest, courses were long, and recurrence was assumed. Topical lacquers improved convenience but ran into the same physical barrier: the nail plate is a dense keratin shield, and drug concentration falls dramatically between the outer surface and the nail bed where the organism lives.

The present: better drugs, unchanged obstacles

Terbinafine and itraconazole moved mycological cure rates substantially, and newer topicals such as efinaconazole and tavaborole improved penetration. Yet the gap between mycological cure and complete clinical clearance persists, relapse is reported in a large minority of patients, and systemic therapy remains unattractive for older patients on polypharmacy — precisely the group with the highest prevalence.

Device-based therapy

Thermal lasers were the first device answer and work by heating the nail bed, which introduces discomfort as part of the mechanism. Non-thermal, low-level laser took a different route: rather than destroying tissue, the dual 405 nm and 635 nm wavelengths disrupt the organism's oxidative defences while up-regulating the host's own immune and circulatory response. Because no heat is delivered, there is no anaesthetic, no downtime and no reported adverse events in the published series.

The future: combination and prevention

• Combination protocols — device therapy alongside targeted topical or, where appropriate, short oral courses.
• Better diagnostics, including PCR, so clinicians treat confirmed fungal disease rather than any dystrophic nail.
• Formal reinfection control: footwear decontamination, tinea pedis management and household screening built into the care plan.
• Longer follow-up in trials, with clear-nail growth measured in millimetres rather than global assessment scores.
• Treating onychomycosis as a medical rather than cosmetic problem in diabetic and immunocompromised patients.

The through-line is consistent with the wider literature: the drugs were rarely the weak point, delivery and adherence were. Any protocol that removes the year of daily patient effort, and pairs treatment with genuine reinfection control, starts ahead.