What are the treatment options for onychomycosis (nail fungus)?

From the Guidelines

Nail fungus treatment should prioritize terbinafine as the first choice due to its higher efficacy and tolerability, as evidenced by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.

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, with patients re-evaluated 3–6 months after treatment initiation and further treatment given if the disease persists.
• 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, with two pulses recommended for fingernail onychomycosis and three pulses for toenail onychomycosis.
• Fluconazole may be considered as an alternative in patients unable to tolerate terbinafine or itraconazole, with a once-weekly dosing regimen of 450 mg per week for 3 months in fingernail infections and for at least 6 months in toenail infections 1.

Key Considerations

• Terbinafine has been shown to have higher efficacy rates compared to itraconazole, with complete cure rates of 55% and 26% respectively in a multicentre, randomized trial 1.
• Fluconazole appears to be less effective than itraconazole or terbinafine, but its once-weekly dosing regimen may improve compliance in some patients 1.
• Treatment should be continued even after symptoms improve to fully eliminate the fungus, and complete cure may take 6-12 months as healthy nail needs to grow out.
• Patients with diabetes or those who have not responded to over-the-counter treatments should consult a doctor for prescription options.

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 Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium)

The treatment for nail fungus includes:

• Topical treatment: Ciclopirox Topical Solution, 8%, (Nail Lacquer) for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 2
• Oral treatment: Terbinafine tablets for onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 3

From the Research

Nail Fungus Treatment Options

• Terbinafine is a commonly used treatment for nail fungus, with studies showing its effectiveness in achieving clinical and mycological cure 4, 5, 6, 7.
• The treatment duration for terbinafine can vary, with some studies showing that a pulse regimen can be effective in reducing side effects while still treating onychomycosis 5.
• Other oral antifungal treatments, such as azoles, can also be effective in treating nail fungus, but may have a higher risk of adverse events compared to terbinafine 7.
• Topical antifungal agents, such as efinaconazole and tavaborole, can also be used to treat nail fungus, especially in patients who cannot use systemic antifungals due to comorbid conditions or concomitant medications 8.

Efficacy of Terbinafine

• Studies have shown that terbinafine is more effective than placebo in achieving clinical and mycological cure, with high-quality evidence supporting its use 4, 7.
• Terbinafine has also been shown to be more effective than other oral antifungal treatments, such as azoles and griseofulvin, in achieving clinical and mycological cure 7.
• The efficacy of terbinafine can be influenced by the treatment duration, with longer treatment durations resulting in higher cure rates 6.

Safety of Terbinafine

• Terbinafine is generally well-tolerated, with common adverse events including gastrointestinal symptoms, infections, and headache 4, 7.
• The risk of adverse events with terbinafine is similar to that of azoles, but lower than that of griseofulvin 7.
• Terbinafine has a low potential for drug-drug interactions, making it a good option for patients with comorbid conditions or concomitant medications 4.