What is the treatment for onychomycosis (fungal infection of the nail)?

From the Guidelines

For the treatment of onychomycosis, terbinafine should be considered as the first choice due to its higher efficacy and tolerability, unless there are contraindications or the infection is caused by Candida, in which case itraconazole may be preferred. When considering the treatment of onychomycosis, several factors come into play, including the type of fungus causing the infection, the severity of the infection, and the patient's overall health.

Treatment Options

• Terbinafine is licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection, and has been shown to have higher efficacy rates compared to itraconazole, with complete cure rates of 55% compared to 26% for pulsed itraconazole at follow-up at 72 weeks 1.
• Itraconazole is licensed at a dose of 200 mg per day for 12 weeks continuously, or alternatively as pulse therapy at a dose of 400 mg per day for 1 week per month, and may be preferred for the treatment of Candida onychomycosis, with cure rates of 92% compared to 40% for pulse terbinafine 1.

Important Considerations

• The choice of treatment should be based on the specific type of fungus causing the infection, as well as the patient's medical history and potential contraindications.
• Treatment is often prolonged because the medication must reach the nail bed and new, healthy nail needs time to grow.
• Prevention includes keeping feet dry, wearing breathable footwear, avoiding walking barefoot in public areas, and not sharing nail tools.
• Complete cure can take 9-12 months as the nail grows out, and recurrence is common, requiring consistent treatment and preventive measures. In terms of specific treatment regimens, terbinafine 250 mg per day for 6-12 weeks is a common and effective treatment option for dermatophyte onychomycosis, while itraconazole 200 mg per day for 12 weeks or pulse therapy may be preferred for Candida onychomycosis 1.

From the FDA Drug Label

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 term onychomycriptosis is not found in the provided drug labels. However, onychomycosis is mentioned, which refers to a fungal infection of the nails.

• The ciclopirox topical solution is indicated for the treatment of onychomycosis in immunocompetent patients with mild to moderate infection of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 2.
• The terbinafine tablets are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 3.

From the Research

Onychomycriptosis Treatment Options

• Onychomycosis, a chronic fungal infection of the nail, can be treated using various modalities, including oral antifungal agents 4.
• Terbinafine is an effective treatment for onychomycosis, with high-quality evidence showing its efficacy in achieving clinical and mycological cure 5, 6.
• The combination of oral terbinafine and topical antifungal agents, such as amorolfine, may be beneficial in treating onychomycosis, particularly for non-dermatophyte fungi 7.

Comparison of Oral Antifungal Agents

• Terbinafine is probably more effective than azoles for achieving clinical and mycological cure, with moderate-quality evidence 6.
• Azoles and griseofulvin probably have similar efficacy for achieving clinical and mycological cure, but griseofulvin is associated with a higher risk of adverse events 6.
• Terbinafine may be more effective than griseofulvin in terms of clinical and mycological cure, with low-quality evidence 6.

Adverse Events and Recurrence Rate

• Oral antifungal agents, including terbinafine and azoles, are associated with adverse events, such as gastrointestinal symptoms, infections, and headache 5, 6.
• The recurrence rate of onychomycosis may be lower with terbinafine or azoles compared to placebo, but the evidence is of low quality 6.
• The quality of evidence for the treatment of onychomycosis varies widely, with limitations in study design and reporting of adverse events 6.