What are the advances in the management of onychomycosis (fungal infection of the nail)?

From the Guidelines

Terbinafine should be considered as the first choice for the treatment of onychomycosis due to its higher efficacy and tolerability compared to itraconazole. Recent advances in onychomycosis management include both improved topical and oral therapies. Topical options now feature efinaconazole 10% solution and tavaborole 5% solution, which have better nail penetration than older lacquers. These are applied daily for 48 weeks with cure rates of 15-18%. For oral therapy, terbinafine remains the gold standard at 250mg daily for 6 weeks (fingernails) or 12 weeks (toenails), with cure rates of 70-80% 1.

Some key points to consider in the management of onychomycosis include:

• Early diagnosis and treatment remain crucial as thicker nails are harder to treat
• Patient education about proper foot hygiene, avoiding shared footwear, and treating tinea pedis concurrently are essential components of management to prevent recurrence, which affects up to 25% of patients within a year after successful treatment
• Newer approaches include combination therapy using both oral and topical agents simultaneously to improve outcomes
• Laser treatments, particularly Nd:YAG lasers, show promise but have variable results and are not FDA-approved specifically for onychomycosis
• Photodynamic therapy using photosensitizing agents with light exposure is another emerging option
• Device-based treatments like iontophoresis enhance drug delivery through the nail plate

It's worth noting that ciclopirox is another option for the treatment of onychomycosis, with a recommended duration of treatment of up to 24 weeks on the fingernails and up to 48 weeks on the toenails, and cure rates of 34% mycological cure and 8% clinical cure 1. However, terbinafine remains the preferred choice due to its higher efficacy and tolerability.

From the FDA Drug Label

The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures. Ciclopirox Topical Solution, 8%, (Nail Lacquer), should be used as a component of a comprehensive management program for onychomycosis. Removal of the unattached, infected nail, as frequently as monthly, by a health care professional, weekly trimming by the patient, and daily application of the medication are all integral parts of this therapy

Advances in management of onychomycosis include:

• A comprehensive management program that combines removal of infected nails, trimming, and daily application of medication
• Nail care by health care professionals, including removal of unattached infected nails and trimming of onycholytic nails
• Nail care by patients, including filing away loose nail material and trimming nails as directed by a health care professional
• Daily application of Ciclopirox Topical Solution, 8%, (Nail Lacquer), to all affected nails, preferably at bedtime or eight hours before washing 2 2

From the Research

Advances in Management of Onychomycosis

• Onychomycosis is a difficult-to-treat fungal infection with high relapse rates, and combining oral and topical antifungal drugs is associated with higher success rates 3.
• The investigation of combined effects of antifungal drugs in vitro with different modes of action and application on clinical isolates from mycotic nails has shown that combining terbinafine with amorolfine tends to be more effective than terbinafine in conjunction with ciclopirox 3.
• Additive or synergistic modes of action are expected to enhance treatment success rates, and in most combinations, additive effects were observed, with synergy detected in combinations involving amorolfine in S. brevicaulis 3.

Diagnosis and Management

• A thorough history and physical examination, including dermoscopy, should be performed for each patient presenting with nail findings suggestive of onychomycosis, and confirmatory testing should be performed prior to initiating any antifungal therapies 4.
• Several therapeutic options are available, including oral and topical medications as well as device-based treatments, and oral antifungals are generally recommended for moderate to severe onychomycosis, while topical antifungals are recommended for mild to moderate disease 4.
• The choice of treatment should consider the disease severity, infecting pathogen, medication safety, efficacy, and cost, as well as patient age, comorbidities, medication history, and likelihood of compliance 4.

Safety of Current Therapies

• Safety is the most important consideration in choosing the most appropriate therapeutic modality for onychomycosis, and systemic antifungals offer greater efficacy but are limited by risks of systemic toxicity and drug-drug interactions 5.
• Topical antifungals are well tolerated and generally safe, with only potential local side effects, and laser therapy is likely less effective than systemic and topical therapies but may be safely used during pregnancy and breastfeeding 5.

Topical Antifungal Therapy

• Topical antifungal therapy for onychomycosis has emerged as a viable option, with newer agents such as efinaconazole 10% solution and tavaborole 5% solution showing superior efficacy compared to older agents like ciclopirox 8% nail lacquer 6.
• These newer topical agents may provide viable monotherapy alternatives to oral therapy for onychomycosis and may also find a role in combination therapy and/or as continued therapy after initial clearance to reduce recurrence or re-infection 6.

Treatment with Oral Antifungal Agents

• Oral antifungal agents are commonly used to treat onychomycosis, and the goals for antifungal therapy are mycological cure and a normal looking nail 7.
• The type of nail invasion depends on both the fungus responsible and on host susceptibility, and treatment of onychomycosis depends on the clinical type of the onychomycosis, the number of affected nails, and the severity of nail involvement 7.