What are the topical treatment options for Onychomycosis (Fungal Nail Infection)?

From the Guidelines

Topical treatment with efinaconazole 10% solution is the most effective option for onychomycosis, with mycological cure rates approaching 50% and complete cure in 15% of patients after 48 weeks of application.

Treatment Options

The available topical treatments for onychomycosis include:

• Ciclopirox 8% nail lacquer, applied daily for up to 48 weeks, with nail debridement and removal of previous applications weekly 1
• Amorolfine 5% nail lacquer, applied once or twice weekly for 6–12 months, after removal of as much of the diseased areas of the nail as possible by gentle filing 1
• Efinaconazole 10% solution, applied daily without nail debridement for 48 weeks 1
• Tavaborole 5% solution, applied daily without nail debridement for 48 weeks These medications work by disrupting fungal cell membranes or inhibiting protein synthesis in the fungi.

Treatment Success

Treatment success requires patience as complete nail regrowth takes 6-12 months for fingernails and 12-18 months for toenails.

Best Results

For best results, keep nails trimmed short, file down thickened areas, and continue treatment for the full prescribed duration even if improvement is seen earlier.

Effectiveness

Topical treatments are most effective for mild to moderate infections limited to distal portions of the nail or for patients who cannot tolerate oral antifungals.

Side Effects

They generally have fewer systemic side effects than oral medications but lower cure rates (approximately 5-12% for ciclopirox, 15-18% for efinaconazole) 1.

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 The topical treatment for Onychomycosis is Ciclopirox Topical Solution, 8% (Nail Lacquer), as part of a comprehensive management program, for immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 2.

• The treatment should be used under medical supervision.
• The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional.
• Concomitant use of 8% ciclopirox topical solution and systemic antifungal agents for onychomycosis is not recommended.

From the Research

Topical Treatment for Onychomycosis

• Onychomycosis is a common infection of the nail unit that can be treated with topical antifungal therapy 3.
• Ciclopirox nail lacquer 8% is a topical solution that has been used to treat onychomycosis, with mycologic cure rates ranging from 29% to 36% in clinical trials 4, 5.
• The efficacy of ciclopirox nail lacquer can be improved when combined with oral terbinafine, with mycologic cure rates of up to 66.7% 4.
• Other topical antifungal agents, such as efinaconazole 10% solution and tavaborole 5% solution, have shown superior efficacy to ciclopirox 8% nail lacquer in clinical trials, with mycologic cure rates comparable to those achieved with oral itraconazole 3.
• The combination of oral and topical antifungal drugs can enhance treatment success rates, with additive or synergistic modes of action expected to improve outcomes 6.

Efficacy of Topical Antifungal Agents

• Ciclopirox nail lacquer 8% has been shown to be effective in treating mild to moderate toenail onychomycosis, with a broad spectrum of activity against dermatophytes and non-dermatophytes 5, 7.
• Efinaconazole 10% solution and tavaborole 5% solution have demonstrated superior efficacy to ciclopirox 8% nail lacquer in clinical trials, with higher mycologic cure rates and treatment success rates 3.
• The efficacy of topical antifungal agents can be influenced by factors such as the severity of the infection, the type of fungus involved, and the duration of treatment 4, 5, 7, 6, 3.

Safety and Tolerability

• Ciclopirox nail lacquer 8% has been shown to be safe and well-tolerated, with most treatment-emergent adverse events being mild and transient 5, 7.
• Efinaconazole 10% solution and tavaborole 5% solution have also been shown to be safe and well-tolerated, with low rates of adverse events reported in clinical trials 3.
• The safety and tolerability of topical antifungal agents can be influenced by factors such as the duration of treatment and the presence of underlying medical conditions 4, 5, 7, 6, 3.