What is the treatment for onychomycosis?

From the Guidelines

Terbinafine should be considered as the first choice of treatment for onychomycosis due to its higher efficacy and tolerability compared to other options. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend terbinafine as the first-line treatment, citing its higher efficacy rates compared to itraconazole 1.

Key Points to Consider

• Terbinafine is licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 1.
• Itraconazole is an alternative option, 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 may be considered as an alternative in patients unable to tolerate terbinafine or itraconazole, with a recommended dose of 450 mg per week for 3 months in fingernail infections, and for at least 6 months in toenail infections 1.
• The choice of treatment should be based on the individual patient's needs and medical history, with consideration given to potential drug interactions and adverse effects.

Treatment Outcomes

• Terbinafine has been shown to have higher efficacy rates compared to itraconazole, with complete cure rates of 55% compared to 26% in a multicentre, randomized trial 1.
• Fluconazole has been shown to be less effective than itraconazole or terbinafine, but may be a useful alternative in certain patients, with mycological cure rates ranging from 47% to 62% in toenail infections and from 89% to 100% in fingernail infections 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

The treatment for onychomycosis includes:

• Terbinafine (PO), for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
• Ciclopirox (TOP), as a component of a comprehensive management program, for 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

Treatment Options for Onychomycosis

• Onychomycosis can be treated with various modalities, including topical, oral, laser, light therapy, procedures such as avulsion and matrixectomy, supplements, over-the-counter medication, and plasma therapy, which can be used as monotherapy or in combination 4.
• The current Food and Drug Administration (FDA)-approved treatments for onychomycosis include topical (efinaconazole, tavaborole, ciclopirox), oral (terbinafine, itraconazole), and laser (1064nm Nd:YAG lasers, both short-pulsed and Q-switched lasers, carbon dioxide lasers, and the diode 870, 930nm) 4.
• New and emerging therapies, including new topical and oral medications, combination therapy, photodynamic light therapy, procedural, supplements, over-the-counter medication, and plasma therapy, are also available 4, 5.

Oral Antifungal Treatments

• Oral antifungal drugs, such as fluconazole, itraconazole, and terbinafine, are effective in the treatment of onychomycosis and have a good safety profile 6.
• Terbinafine produces the best results when a dermatophyte is the pathogen, while the azoles, mainly itraconazole, are recommended for Candida and nondermatophyte infections 6.
• Oral terbinafine, itraconazole, and griseofulvin are approved by the Food and Drug Administration for treatment of onychomycosis in the United States 7.

Topical Antifungal Treatments

• Topical antifungals, such as ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution, are approved by the Food and Drug Administration for treatment of onychomycosis in the United States 7.
• Amorolfine 5% nail lacquer is approved in Europe for the treatment of onychomycosis 7.
• Topical antifungals have more favorable safety profiles and are recommended for mild to moderate disease 7.

Considerations for Treatment Selection

• Treatment selection should involve ethical, evidence-based decision-making and consideration of each individual patient's needs, adherence, budget, the extent of quality of life discomfort, and aesthetic goals, independent of potential financial benefits to the clinicians 4.
• Physicians should consider the disease severity, infecting pathogen, medication safety, efficacy and cost, and patient age, comorbidities, medication history, and likelihood of compliance when determining management plans 7.