From the Guidelines
Terbinafine should be considered as the first choice for the treatment of onychomycosis nails foot due to its higher efficacy and tolerability. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend terbinafine as the first-line treatment, unless there are contraindications 1.
Treatment Options
- Terbinafine is licensed at a dose of 250 mg per day for 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.
- Several large studies demonstrate higher efficacy rates for terbinafine in comparison with itraconazole, with complete cure rates of 55% for terbinafine compared to 26% for pulsed itraconazole 1.
Treatment Outcomes
- Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists 1.
- Treatment success requires patience as complete nail regrowth takes 9-12 months for toenails, and recurrence rates remain high (10-50%) even after successful treatment.
- Mechanical debridement of the infected nail by a podiatrist before starting medication can improve treatment outcomes by allowing better penetration of medications.
- Patients should keep feet clean and dry, wear breathable footwear, and treat any concurrent tinea pedis (athlete's foot) to prevent recurrence.
From the FDA Drug Label
Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). 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 options for onychomycosis of the toenail include:
- Terbinafine (PO): indicated for the treatment of onychomycosis of the toenail due to dermatophytes 2
- Ciclopirox (TOP): indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of toenails without lunula involvement, due to Trichophyton rubrum, as part of a comprehensive management program that includes removal of the unattached, infected nails 3
From the Research
Treatment Options for Onychomycosis
- Oral antifungal medications, such as terbinafine and azoles, have been shown to be effective in treating onychomycosis, with high-quality evidence supporting their use 4.
- Topical antifungal agents, including efinaconazole and tavaborole, have also been found to be effective in managing onychomycosis, particularly in cases of mild to moderate disease 5, 6.
- The choice of treatment depends on the clinical type of onychomycosis, the number of affected nails, and the severity of nail involvement 7.
Efficacy of Treatment Options
- Terbinafine has been shown to be more effective than placebo in achieving clinical and mycological cure, with a risk ratio of 6.00 and 4.53, respectively 4.
- Azoles have also been found to be effective in achieving clinical and mycological cure, with a risk ratio of 22.18 and 5.86, respectively 4.
- Topical antifungal agents, such as efinaconazole and tavaborole, have been shown to produce clinical and mycological cure in patients with mild to moderate toenail onychomycosis 6.
Safety and Tolerability of Treatment Options
- Systemic antifungals, such as terbinafine and azoles, are associated with risks of systemic toxicity and drug-drug interactions 8.
- Topical antifungal agents are generally well tolerated and safe, with only potential local side effects 8.
- Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding 8.