What is the treatment for onychomycosis (nail fungus)?

From the Guidelines

Terbinafine should be considered as the first choice for treating toenail fungus due to its higher efficacy and tolerability compared to itraconazole. When treating toenail fungus, it is essential to prioritize the most effective treatment option to minimize morbidity, mortality, and improve quality of life. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, terbinafine has been shown to be more effective than itraconazole in treating dermatophyte onychomycosis.

The recommended dose of terbinafine is 250 mg per day for 12–16 weeks in toenail infection 1. Patients should be re-evaluated 3–6 months after treatment initiation, and further treatment should be given if the disease persists. Several large studies demonstrate higher efficacy rates for terbinafine in comparison with itraconazole, with complete cure rates of 55% for terbinafine compared to 26% for pulsed itraconazole at follow-up at 72 weeks 1.

Key points to consider when treating toenail fungus include:

• Terbinafine is the preferred treatment option due to its higher efficacy and tolerability
• The recommended dose of terbinafine is 250 mg per day for 12–16 weeks
• Patients should be re-evaluated 3–6 months after treatment initiation
• Good foot hygiene, including keeping nails trimmed short, drying feet thoroughly after bathing, and wearing breathable footwear, is essential for preventing the spread of the fungus.

From the FDA Drug Label

Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). Ciclopirox Topical Solution, 8%, (Nail Lacquer), as a component of a comprehensive management program, is indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum

Treatment Options for Toe Nail Fungus:

• Terbinafine (PO): indicated for the treatment of onychomycosis of the toenail due to dermatophytes 2
• Ciclopirox (TOP): indicated as topical treatment for mild to moderate onychomycosis of toenails without lunula involvement, due to Trichophyton rubrum 3

From the Research

Treatment Options for Toe Nail Fungus

• Terbinafine is an effective treatment for toe nail fungus, with studies showing high mycologic and clinical cure rates 4, 5, 6, 7.
• The treatment duration for terbinafine can vary, with studies showing that 12 weeks of treatment is sufficient for many patients 5, while others may require 18 or 24 weeks of treatment 6.
• Terbinafine has a low potential for drug-drug interactions and is generally well tolerated, with most adverse events being mild to moderate gastrointestinal symptoms 4, 5, 7.

Efficacy of Terbinafine

• Studies have shown that terbinafine has a high efficacy rate in treating toe nail fungus, with mycologic cure rates ranging from 72% to 81% 4, 6, 7.
• Clinical cure rates are also high, with studies showing that 40% to 71% of patients achieve a complete cure 5, 6, 7.
• Terbinafine has been shown to be more effective than other treatments, such as itraconazole and griseofulvin, in treating toe nail fungus 4.

Safety and Tolerability

• Terbinafine is generally well tolerated, with most adverse events being mild to moderate gastrointestinal symptoms 4, 5, 7.
• The drug has a low potential for drug-drug interactions, making it a safe option for patients with comorbid conditions or those taking concomitant medications 4.
• Post-marketing surveillance has confirmed the good tolerability profile of terbinafine, with adverse events reported in only 10.5% of patients 4.