From the Guidelines
Terbinafine is the first-line treatment for onychomycosis due to its high cure rates and fewer drug interactions, with a recommended dose of 250mg daily for 6 weeks for fingernails and 12 weeks for toenails 1. The treatment of onychomycosis depends on the severity and type of infection. Oral antifungals are the most effective treatment option, with terbinafine being the preferred choice due to its higher efficacy and tolerability compared to itraconazole 1.
Treatment Options
- Oral antifungals:
- Terbinafine (250mg daily for 6 weeks for fingernails, 12 weeks for toenails)
- Itraconazole (pulse therapy of 200mg twice daily for 1 week per month, for 2 months for fingernails or 3 months for toenails)
- Fluconazole (150-300mg weekly for 3-6 months)
- Topical treatments:
- Ciclopirox 8% nail lacquer
- Amorolfine 5% nail lacquer
- Efinaconazole 10% solution
- Tavaborole 5% solution
Important Considerations
- Liver function monitoring is required for oral treatments
- Patients should keep nails short, dry, and clean to prevent reinfection
- Treatment success depends on patient adherence, as recurrence is common
- For severe cases, nail removal (surgical or chemical) may be necessary before antifungal treatment
- Laser therapy is an emerging option but has variable results 1.
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).
INDICATIONS AND USAGE (To understand fully the indication for this product, please read the entire INDICATIONS AND USAGE section of the labeling.) 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 current treatment options for onychomycosis include:
- Oral antifungal agents: Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2.
- Topical antifungal agents: Ciclopirox Topical Solution, 8%, (Nail Lacquer) is indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum, as a component of a comprehensive management program 3. Key points:
- Treatment should be initiated after confirming the diagnosis of onychomycosis with laboratory testing.
- The comprehensive management program for topical treatment includes removal of the unattached, infected nails as frequently as monthly, by a health care professional.
From the Research
Current Treatment Options for Onychomycosis
- Oral antifungal agents, such as terbinafine, itraconazole, and griseofulvin, are effective treatments for onychomycosis, with terbinafine being the most effective option for dermatophyte onychomycosis 4
- Topical antifungal agents, including tavaborole and efinaconazole, have shown good nail penetration and high negative culture rates in clinical trials, making them suitable for patients with mild to moderate onychomycosis 5, 6
- The choice of treatment depends on the clinical type of onychomycosis, the number of affected nails, and the severity of nail involvement, as well as the patient's medical history and potential drug interactions 7, 8
Oral Antifungal Agents
- Terbinafine has demonstrated excellent fungicidal activity against dermatophytes and is generally well tolerated, with a low potential for drug interactions 4
- Itraconazole and griseofulvin are also effective, but may have a higher risk of drug interactions and adverse events 4, 7
Topical Antifungal Agents
- Tavaborole and efinaconazole have shown good efficacy in clinical trials, with efinaconazole demonstrating the highest clinical and mycological cure rates 5, 6
- Amorolfine and ciclopirox are also available as topical treatments, but may have lower efficacy rates compared to tavaborole and efinaconazole 6
Treatment Considerations
- The treatment of onychomycosis should be individualized based on the patient's unique characteristics, including medical history, comorbidities, and potential drug interactions 5, 8
- Topical treatments may be preferred for patients with mild to moderate onychomycosis, while oral antifungal agents may be necessary for more severe cases or those with a high risk of complications 7, 6