From the Guidelines
The primary treatment for onychomycosis is oral terbinafine 250 mg daily for 6 weeks for fingernails or 12-16 weeks for toenails, due to its higher efficacy and tolerability compared to itraconazole 1. The treatment of onychomycosis involves the use of oral antifungal medications, with terbinafine being the preferred choice over itraconazole due to its higher efficacy rates and better tolerability, as demonstrated in several large studies, including a multicentre, randomized trial involving 508 subjects 1. Some key points to consider when treating onychomycosis include:
- Terbinafine is licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 1
- Itraconazole is 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, with two pulses recommended for fingernail onychomycosis and three pulses for toenail onychomycosis 1
- Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists 1 In addition to medication, good foot hygiene practices, such as keeping nails short, dry, and clean, wearing breathable footwear, and changing socks daily, can help prevent recurrence and support the treatment of onychomycosis. It is also important to note that treatment can take several months to be effective, as the nail needs to grow out completely, and that oral antifungals work by inhibiting ergosterol synthesis, a vital component of fungal cell membranes, effectively killing the fungus 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium).
INDICATIONS AND USAGE ... 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 treatments for onychomycosis include:
- Terbinafine (PO), an oral medication, for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes 2
- Ciclopirox (TOP), a topical solution, as part of a comprehensive management program, for the treatment of mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3
From the Research
Treatment Options for Onychomycosis
- Oral antifungal drugs are the most effective available therapy for onychomycosis, but may be limited by safety concerns and the potential for drug-drug interactions (DDIs) 4.
- Topical therapy, including tavaborole and efinaconazole, has demonstrated good nail penetration and high negative culture rates in clinical trials of patients with onychomycosis 4.
- Fluconazole, itraconazole, and terbinafine are effective in the treatment of onychomycosis and have a good safety profile 5.
- Terbinafine is the primary choice for oral treatment, and efinaconazole 10% is recommended for topical treatment 6.
- Oral terbinafine, itraconazole, and griseofulvin, and topical ciclopirox 8% nail lacquer, efinaconazole 10% solution, and tavaborole 5% solution are approved by the Food and Drug Administration for treatment of onychomycosis in the United States 7.
Considerations for Treatment Selection
- The choice of treatment should be based on the unique characteristics of each patient, including medication history, comorbidities, and nature of onychomycosis 4.
- Disease severity, infecting pathogen, medication safety, efficacy, and cost, as well as patient age, comorbidities, medication history, and likelihood of compliance should be considered when determining management plans 7.
- Treatment should be tailored to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species to optimize treatment outcomes, patient satisfaction, and safety 8.