From the Guidelines
The most effective topical treatment for onychomycosis is efinaconazole 10% nail solution, applied once daily to the affected nail(s) for up to 48 weeks. To use:
- Clean and dry the affected nail(s)
- Apply a thin layer of efinaconazole solution to the entire nail plate, undersurface, and surrounding skin
- Allow to dry for about 30 seconds
- Apply daily, preferably at bedtime
- Once weekly, remove all solution buildup with alcohol and file down thickened parts of the nail Efinaconazole works by inhibiting fungal growth and penetrating the nail plate to reach the nail bed where the infection resides, with mycological cure rates approaching 50% and complete cure in 15% of patients after 48 weeks of application 1. This treatment is most effective for mild to moderate cases and when less than 50% of the nail is affected. For severe cases or if topical treatment fails, oral antifungal medications like terbinafine or itraconazole may be necessary. Always consult a healthcare provider for proper diagnosis and treatment, as other nail conditions can mimic onychomycosis. Other options like ciclopirox 8% nail lacquer and amorolfine 5% nail lacquer are available, but efinaconazole has shown more promising results in recent studies 1. It's essential to note that the clinical improvement obtained with topical antifungals may not be synonymous with mycological cure, which has invariably lower rates, often by 30% 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 JUBLIA (efinaconazole) topical solution, 10% is an azole antifungal indicated for the topical treatment of onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes.
The topical treatment options for onychomycosis (fungal infection of the nail) are:
- Ciclopirox Topical Solution, 8% (Nail Lacquer), for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 2
- Efinaconazole Topical Solution, 10%, for onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes 3
From the Research
Topical Treatment Options for Onychomycosis
The following topical treatment options are available for onychomycosis:
- Ciclopirox 8% nail lacquer: This is the first topical antifungal agent to be approved by the US Food and Drug Administration for the treatment of onychomycosis 4. It has been shown to have a mycologic cure rate of 34% compared to 10% for the placebo 4.
- Efinaconazole 10% solution: This is a newer topical antifungal that has been shown to have superior mycologic cure rates compared to ciclopirox 8% nail lacquer 5.
- Tavaborole 5% solution: This is another newer topical antifungal that has been shown to have superior treatment success rates compared to ciclopirox 8% nail lacquer 5.
- Amorolfine 5%: This is a topical antifungal that has been compared to ciclopirox 8% HPCH nail lacquer in a randomized, controlled study, with ciclopirox 8% HPCH nail lacquer showing superior efficacy 6.
Combination Therapy
Combination therapy with topical and oral antifungals may also be an effective treatment option for onychomycosis. A study combining ciclopirox nail lacquer with oral terbinafine showed promising results, with mycological cure rates of 66.7% and 70.4% in two different treatment arms 7.
Efficacy and Safety
The efficacy and safety of topical treatment options for onychomycosis vary. Ciclopirox 8% nail lacquer has been shown to be safe and well-tolerated, with mild, transient irritation at the site of application reported as the most common adverse event 4. Efinaconazole 10% solution and tavaborole 5% solution have also been shown to be well-tolerated and effective in clinical trials 5.