What are the topical compounds for onychomycosis (nail fungus)?

From the Guidelines

Topical antifungal medications, specifically amorolfine 5% nail lacquer applied once or twice weekly for 6-12 months, are the most effective first-line treatments for nail fungus (onychomycosis) in terms of morbidity, mortality, and quality of life. When considering treatment options, it's essential to weigh the benefits and drawbacks of each.

• Amorolfine 5% nail lacquer has been shown to be effective in around 50% of cases of distal fingernail and toenail onychomycosis, as reported in the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.
• Ciclopirox 8% nail lacquer is another option, applied daily for up to 48 weeks, with a mycological cure rate of 34% and a clinical cure rate of 8% 1.
• It's crucial to note that the clinical improvement obtained with amorolfine and other topical antifungals may not be synonymous with mycological cure, which has invariably lower rates, often by 30% 1.
• To achieve the best results, it's recommended to keep nails short, dry, and clean, wear breathable footwear, and continue treatment for the recommended duration even if improvement is seen early.
• Topical treatments work by disrupting fungal cell membranes or inhibiting essential fungal enzymes, but may take months to show results as healthy nail must grow out to replace infected portions.
• Other treatment options, such as efinaconazole 10% solution and tavaborole 5% solution, are also available, but amorolfine 5% nail lacquer remains the most effective option based on the available evidence 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 One topical compound for nail fungus is ciclopirox.

• It is used for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum.
• The treatment should be part of a comprehensive management program, including removal of the unattached, infected nails as frequently as monthly, by a health care professional. 2

From the Research

Topical Compounds for Nail Fungus

• Ciclopirox nail lacquer 8% is a topical antifungal agent used to treat onychomycosis, with mycologic cure rates ranging from 29% to 36% in US studies 3 and 46.7% to 85.7% in non-US studies 3.
• Amorolfine 5% nail lacquer is another topical antifungal agent used to treat onychomycosis, with cure rates of around 30% 4.
• Combining oral terbinafine with topical amorolfine or ciclopirox may be beneficial in treating onychomycosis, with additive or synergistic effects observed in vitro 5.
• Ciclopirox nail lacquer 8% has been shown to be safe and effective in the treatment of mild to moderate onychomycosis of the toenails, with a meta-analytic mean mycologic cure rate of 52.6% +/- 4.2% in ten studies conducted worldwide 6.

Combination Therapy

• The combination of ciclopirox nail lacquer 8% and oral terbinafine has been evaluated in a randomized, evaluator-blinded study, with mycologic cure rates of 66.7% and 70.4% in the combination therapy groups, respectively 7.
• The combination of amorolfine and terbinafine has been shown to be more effective than terbinafine in conjunction with ciclopirox in vitro, with additive or synergistic effects observed 5.

Safety and Efficacy

• Ciclopirox nail lacquer 8% has been found to be extremely safe, with mild, transient irritation at the site of application reported as the most common adverse event 3, 6.
• Amorolfine 5% nail lacquer has been shown to be safe and effective, with cure rates of around 30% and mild irritation as the most common adverse event 4.