What topical antifungal cream should be prescribed for onychomycosis (Fungal infection of the nail)?

From the Guidelines

For onychomycosis, I recommend ciclopirox 8% nail lacquer (Penlac) as the first-line topical antifungal treatment. Apply it daily to the affected nail and surrounding skin, covering the entire nail plate and 5mm of surrounding skin. Each application should be allowed to dry for about 30 seconds before touching anything. The previous day's application should be removed with alcohol once weekly before reapplying. Treatment typically continues for up to 48 weeks, as nail fungus requires prolonged therapy due to the slow growth of nails. Alternatively, amorolfine 5% nail lacquer can be used once or twice weekly in some regions. Topical treatments are most effective for mild to moderate cases involving less than 50% of the nail, particularly distal subungual onychomycosis. These treatments work by penetrating the nail plate to reach the nail bed where the fungus resides. However, be aware that topical treatments alone have limited efficacy for severe onychomycosis, and oral antifungals like terbinafine or itraconazole may be necessary for more extensive infections or those involving the nail matrix. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, ciclopirox has broad-spectrum antifungal activity against T. rubrum, S. brevicaulis and Candida species. The guidelines also mention that amorolfine 5% nail lacquer has been shown to be effective in around 50% of cases of distal fingernail and toenail onychomycosis 1. However, the choice of treatment should be based on the severity of the infection and the patient's overall health.

Some key points to consider when using topical antifungal treatments for onychomycosis include:

• The treatment should be applied daily for up to 48 weeks for ciclopirox 8% nail lacquer 1
• The treatment should be applied once or twice weekly for 6-12 months for amorolfine 5% nail lacquer 1
• Topical treatments are most effective for mild to moderate cases involving less than 50% of the nail, particularly distal subungual onychomycosis
• Oral antifungals like terbinafine or itraconazole may be necessary for more extensive infections or those involving the nail matrix 1

It's also important to note that the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1 provide a summary of drug therapies in adults, including the strength of recommendation, treatment, contraindications and cautions, suggested method of use and monitoring, and common adverse reactions.

From the FDA Drug Label

INDICATIONS AND USAGE ... 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 The topical antifungal cream that should be prescribed for onychomycosis is ciclopirox (TOP) 8% nail lacquer.

• It is indicated for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum.
• The treatment should be part of a comprehensive management program, including removal of the unattached, infected nails as frequently as monthly, by a health care professional 2.

From the Research

Topical Antifungal Creams for Onychomycosis

• Amorolfine and ciclopirox are two commonly used topical antifungal agents for the treatment of onychomycosis 3, 4.
• A study comparing the efficacy of amorolfine and ciclopirox in combination with terbinafine found that combining terbinafine with amorolfine tended to be more effective than terbinafine in conjunction with ciclopirox 3.
• Ciclopirox 8% nail lacquer has been shown to be effective in the treatment of onychomycosis, with mycologic cure rates ranging from 29% to 85.7% in different studies 5, 6.
• However, newer agents such as efinaconazole 10% solution and tavaborole 5% solution have been developed and have shown superior efficacy to ciclopirox 8% nail lacquer in clinical trials 7.
• Amorolfine 5% nail lacquer is also a valuable therapeutic option, and its use in combination with oral antifungal agents such as terbinafine and itraconazole may improve efficacy 4.

Choice of Topical Antifungal Cream

• Based on the available evidence, amorolfine 5% nail lacquer may be a suitable option for the treatment of onychomycosis, particularly when used in combination with oral antifungal agents 3, 4.
• However, the choice of topical antifungal cream ultimately depends on the specific needs and circumstances of the patient, and other factors such as the severity of the infection and the presence of any underlying medical conditions should also be taken into account 7.