From the Guidelines
Terbinafine is the recommended first-line treatment for nail fungus due to its higher efficacy and tolerability compared to other options, such as itraconazole and fluconazole, as demonstrated in several large studies 1.
Treatment Options
When considering treatment for nail fungus, the following options are available:
- Terbinafine: licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 1
- Itraconazole: 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 1
- Fluconazole: can be used 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
Efficacy and Safety
The efficacy of these treatments varies, with terbinafine showing higher cure rates compared to itraconazole and fluconazole 1.
- Terbinafine has been shown to have a complete cure rate of 55% in patients receiving 16 weeks of continuous treatment, compared to 26% for pulsed itraconazole 1
- Fluconazole has been shown to have mycological cure rates ranging from 47% to 62% in toenail infections and from 89% to 100% in fingernail infections 1
Important Considerations
It is essential to continue treatment for the full recommended duration, even if the nail appears improved, to prevent recurrence 1.
- Liver function tests may be necessary before starting oral medications, as they can occasionally cause liver problems 1
- Patients should be re-evaluated 3–6 months after treatment initiation, and further treatment should be given if the disease persists 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 ... 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
Medications for nail fungus include:
- Terbinafine (PO), which is indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
- Ciclopirox (TOP), which is indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3
From the Research
Medication Options for Nail Fungus
- Oral antifungal medications such as terbinafine and azoles (e.g., itraconazole, ketoconazole) are effective treatments for onychomycosis, with terbinafine being more effective than azoles in achieving clinical and mycological cure 4.
- Terbinafine is effective in more than 50% of cases, but its use is associated with cutaneous, hepatic, and haematological adverse effects in about 1 in 2000 patients, which can be life-threatening 5.
- Azoles are more effective than placebo for achieving clinical and mycological cure, but they carry a risk of serious adverse effects and numerous drug interactions 4.
- Griseofulvin is rarely used for treatment of onychomycosis due to its low cure rates and high relapse rates 6.
- Topical antifungal treatments, such as antifungal lacquers (5% amorolfine and 8% ciclopirox), can cure about 30% of fungal infections, but their effectiveness is lower compared to oral antifungal treatments 5.
Treatment Considerations
- The choice of treatment depends on the severity of the infection, the type of fungus causing the infection, and the patient's medical history and current medications 7, 8.
- Laboratory confirmation of onychomycosis before beginning a treatment regimen is recommended to ensure proper diagnosis and treatment 7.
- Topical monotherapy can be considered for mild to moderate onychomycosis, while oral antifungal agents are generally recommended for more severe cases 7.
- Device-based therapies and nail avulsion or debridement by chemical or surgical procedures are also available treatment options 8.