From the Guidelines
Itraconazole should be considered the first-line treatment for Candida glabrata onychomycosis due to its shorter treatment duration and higher efficacy compared to terbinafine. When treating Candida glabrata onychomycosis, the goal is to achieve the best possible outcome in terms of morbidity, mortality, and quality of life. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, itraconazole has significantly greater efficacy than terbinafine for the treatment of onychomycosis.
Some key points to consider when treating Candida glabrata onychomycosis include:
- Itraconazole can be given at a dose of 200 mg per day or as pulse therapy (400 mg per day for 1 week each month) 1
- Fluconazole can be given either as 50 mg per day or 300 mg per week, and is believed to be equally effective as itraconazole in the treatment of Candida onychomycosis 1
- Treatment duration should be a minimum of 4 weeks for fingernail and 12 weeks for toenail onychomycosis 1
- Terbinafine is effective, but only when given for long treatment periods, with mycological cure rates of 70% and 85% demonstrated for C. albicans and C. parapsilosis, respectively, after 48 weeks of terbinafine 250 mg per day 1
It is essential to monitor treatment success through clinical improvement and follow-up cultures, and to consider nail debridement by a podiatrist or dermatologist before starting medication to improve treatment outcomes. Complete cure may take 12-18 months as the infected nail grows out and is replaced by healthy nail.
From the Research
Treatment Options for Candida glabrata Onychomycosis
- Oral antifungals such as terbinafine, itraconazole, and fluconazole are commonly used to treat onychomycosis, including cases caused by Candida species 2, 3, 4
- Itraconazole pulse therapy has been shown to be effective in treating Candida onychomycosis, with a mycological cure rate of 90.6% in patients with toe onychomycosis and 100% in patients with finger onychomycosis alone 5
- Fluconazole can be an alternative to terbinafine and itraconazole for onychomycosis treatment, with a recommended dosing regimen of 150 mg weekly for more than 6 months 4
- Topical antifungals such as ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are also available for the treatment of onychomycosis, although they may have lower cure rates compared to oral antifungals 3
Efficacy of Antifungal Agents
- The efficacies of different antifungal agents for dermatophyte great toenail onychomycosis treatment have been reported as follows: terbinafine (38%, 70%), itraconazole (14%, 54%), posaconazole (54.1%, 70.3%), fosravuconazole (59.4%, 82.0%), and oteseconazole (45%, 70%) 6
- Itraconazole pulse therapy has been shown to be effective in treating Candida onychomycosis, with a complete cure or marked improvement rate of 75.0% in patients with toe onychomycosis and 91.7% in patients with finger onychomycosis alone 5
Considerations for Treatment
- The choice of antifungal agent and treatment regimen should be based on the severity of the disease, the infecting pathogen, medication safety, efficacy, and cost, as well as patient age, comorbidities, medication history, and likelihood of compliance 3
- Onychomycosis is a chronic disease with high recurrence rates, and patients should be counseled on an appropriate plan to minimize recurrence risk following effective antifungal therapy 3