What criteria should I use to decide whether to refer a patient with onychomycosis to a specialist?

Refer a patient with onychomycosis to a specialist if any of the following criteria apply:

• The diagnosis is uncertain after initial assessment in primary care.
• Treatment in primary care has been unsuccessful, including failure of topical or oral antifungal therapy.
• The patient is a child, as fungal nail infection is rare in children and oral or topical antifungal treatments are often off-label or ineffective in this group.
• The patient is immunocompromised, depending on clinical judgement, due to increased risk of complications and treatment failure.
• There is co-existent nail disease such as psoriasis or lichen planus complicating the diagnosis or management.
• There is severe or extensive nail involvement causing significant symptoms, discomfort, or functional impairment.

Referral may be to dermatology for diagnostic clarification, specialist treatment initiation, or to podiatry for procedures such as nail debridement or avulsion, especially in severe disease or when thickened nails cause discomfort or trauma.

Specialist referral is also advised if oral antifungal treatment is being considered for children or if combination treatment or advanced management is needed due to resistant or recurrent infection.

These criteria help ensure appropriate specialist input for complex, refractory, or high-risk cases of onychomycosis.

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