From the Guidelines
The most effective treatment for toenail fungus is oral terbinafine 250mg daily for 12-16 weeks. This recommendation is based on the British Association of Dermatologists' guidelines for the management of onychomycosis 2014, which suggests that terbinafine should be considered as the first choice of treatment due to its higher efficacy and tolerability compared to itraconazole 1.
Key Points to Consider
- Terbinafine has been shown to be more effective than itraconazole in several large studies, with complete cure rates of 55% compared to 26% for pulsed itraconazole at 72 weeks follow-up 1.
- The dosage of terbinafine is 250mg per day, and treatment duration is 12-16 weeks for toenail infection 1.
- Patients should be re-evaluated 3-6 months after treatment initiation, and further treatment should be given if the disease persists 1.
- To prevent recurrence, it is essential to keep feet dry, wear breathable shoes, change socks daily, avoid walking barefoot in public areas, and use antifungal powder in shoes.
- Treatment success requires patience, as infected nails must grow out completely, which may take 9-12 months even after the fungus is eliminated.
Alternative Treatment Options
- For those who cannot take oral medications, topical solutions like ciclopirox 8% nail lacquer or efinaconazole 10% solution may be considered, although they are less effective than oral terbinafine.
- Combination therapy with both oral and topical medications may be necessary for severe or resistant cases.
From the FDA Drug Label
1 INDICATIONS AND USAGE Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium).
The most effective treatment for toenail fungus is terbinafine (PO), as it is directly indicated for the treatment of onychomycosis of the toenail due to dermatophytes 2.
- Key points:
- Terbinafine is a systemic antifungal agent
- It is indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes
- Prior to initiating treatment, appropriate nail specimens for laboratory testing should be obtained to confirm the diagnosis of onychomycosis In contrast, ciclopirox (TOP) is indicated as a topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3.
From the Research
Treatment Options for Toe Nail Fungus
- Oral terbinafine is considered the most effective treatment for dermatophyte onychomycosis, with mycologic cure rates of up to 81% and complete cure rates of up to 35% 4, 5
- Terbinafine has a fungicidal effect on dermatophytes, inhibiting the biosynthesis of ergosterol and accumulating toxic levels of squalene in fungal cells 4
- The drug is generally well tolerated, with a low potential for drug interactions and a favorable pharmacoeconomic profile 4, 5
- Combination therapy with oral terbinafine and topical amorolfine may be beneficial for patients with onychomycosis, particularly those infected with non-dermatophyte fungi such as Scopulariopsis brevicaulis 6
- Other treatment options, including itraconazole, fluconazole, and griseofulvin, are available but may have lower efficacy rates or more significant side effects 4, 5, 7, 8
Efficacy of Terbinafine
- Studies have consistently shown that oral terbinafine is more effective than other antifungal agents, including itraconazole and griseofulvin, in treating dermatophyte onychomycosis 4, 5, 7
- Terbinafine has a high mycologic cure rate, with up to 76% of patients achieving a mycologic cure after 12 weeks of treatment 4
- The drug also has a high complete cure rate, with up to 35% of patients achieving a complete cure after 12 weeks of treatment 4