A plea to bridge the gap between antifungals and the management of onychomycosis

Onychomycosis represents a stubborn problem for the clinician facing up to the realities of antifungal treatments. There are obvious discrepancies between data given by in vitro antifungal testings, pharmacodynamics and pharmacokinetics, and those gathered from clinical experience. This critical review is an attempt at bridging the gap between in vitro and in vivo information about oral antifungals that aim to treat onychomycoses. Common sense shows that the in vitro concept of fungicidy cannot be simply extrapolated into clinical practice. Indeed, chlamidoconidia and arthroconidia present in vivo are much more resistant to antifungals than hyphae. Corneofungimetry may be a realistic bioassay in predicting antifungal activity in human infections. Boosting hyphae growth from conidia while taking antifungals is a new and appealing treatment modality that deserves controlled study.