From the Guidelines
Terbinafine should be considered as the first choice for treating onychomycosis due to its higher efficacy and tolerability, with a recommended dose of 250 mg per day for 12–16 weeks in toenail infection. This recommendation is based on the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. The guidelines suggest that terbinafine has been shown to be more effective than itraconazole in dermatophyte onychomycosis, with higher efficacy rates and lower relapse rates.
Some key points to consider when treating onychomycosis include:
- Terbinafine is licensed at a dose of 250 mg per day for 12–16 weeks in toenail infection 1
- Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists 1
- Itraconazole is an alternative option, but it has been shown to have lower efficacy rates and higher relapse rates compared to terbinafine 1
- Treatment can take several months as the infected nail grows out, and it is essential to keep feet clean and dry, trim nails regularly, and wear breathable shoes and moisture-wicking socks to prevent the growth of fungus.
It is also important to note that if symptoms persist or worsen after several months of treatment, or if you have diabetes or a weakened immune system, medical attention should be sought for stronger treatments or to rule out other conditions. Additionally, several large studies demonstrate higher efficacy rates for terbinafine in comparison with itraconazole, with a multicentre, randomized trial involving 508 subjects showing complete cure in 55% of patients receiving 16 weeks of continuous terbinafine, compared to 26% of patients receiving pulsed itraconazole 1.
From the FDA Drug Label
Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). 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 treatment for Onychomycosis (fungal infection of the toenail) is:
- Terbinafine (PO), as indicated for the treatment of onychomycosis of the toenail due to dermatophytes 2
- Ciclopirox (TOP), as a component of a comprehensive management program, for mild to moderate onychomycosis of toenails without lunula involvement, due to Trichophyton rubrum 3
From the Research
Treatment Options for Onychomycosis
The treatment for onychomycosis, a fungal infection of the toenail, includes several options:
- Oral antifungal agents: These are the most effective treatment for onychomycosis, with cure rates ranging from 50-90% 4, 5, 6, 7.
- Topical antifungal agents: These are less effective than oral agents, but can be used as an adjunct to systemic therapy 5, 7.
- Surgery: This is not generally recommended as a first-line treatment, but may be considered in severe cases 5.
Oral Antifungal Agents
The most commonly used oral antifungal agents for onychomycosis are:
- Terbinafine: This is considered the treatment of choice for toenail onychomycosis due to its high efficacy, low relapse rates, and cost-effectiveness 4, 5, 6, 7.
- Itraconazole: This is also effective, but may have a higher risk of side effects 4, 5, 6.
- Fluconazole: This may be considered for infections caused by Candida 7.
- Griseofulvin and ketoconazole: These are older agents that are less effective and may have more side effects 4, 5.
Treatment Considerations
When selecting a treatment for onychomycosis, it is important to consider individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species 8. This can help optimize treatment outcomes, patient satisfaction, and safety.