What are the treatments for onychomycosis that do not cause hepatotoxicity?

From the Guidelines

To treat onychomycosis without causing hepatotoxicity, topical antifungal treatments such as amorolfine or ciclopirox are recommended, as they have minimal systemic absorption and are less likely to cause liver damage. These treatments can be applied directly to the affected nails, and options include over-the-counter products containing terbinafine, clotrimazole, or undecylenic acid, as well as prescription-strength ciclopirox (Penlac) nail lacquer 1. Some key points to consider when using topical treatments include:

• Applying the treatment consistently, even after symptoms improve, to ensure complete eradication of the fungus
• Keeping nails trimmed short, dry, and clean to prevent the fungus from spreading
• Wearing breathable shoes and moisture-wicking socks to reduce moisture and prevent the growth of fungus
• Considering the use of antifungal sprays in shoes and treating any athlete's foot, as these can contribute to nail fungus For severe cases, oral medications may be necessary, but it is essential to discuss liver-friendly options and monitoring with a doctor 1. Some oral medications, such as fluconazole, may be considered as an alternative to terbinafine or itraconazole, but their use should be carefully evaluated due to potential hepatotoxicity 1. Natural remedies like tea tree oil or vinegar soaks can supplement treatment but are generally less effective alone. It is crucial to prioritize treatments that minimize the risk of hepatotoxicity, as liver damage can have severe consequences on morbidity, mortality, and quality of life.

From the FDA Drug Label

The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures. 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 that does not cause hepatotoxicity is Ciclopirox Topical Solution, 8%, (Nail Lacquer), as there is no mention of hepatotoxicity in the provided drug label 2.

• Key points:
  • Ciclopirox is a topical treatment
  • Indicated for mild to moderate onychomycosis
  • No mention of hepatotoxicity in the label Note that the label does not provide a comparison with other treatments, and the information is limited to the specific drug mentioned.

From the Research

Treatments for Onychomycosis without Hepatotoxicity

• Topical antifungal agents such as efinaconazole 10% solution and tavaborole 5% solution have been shown to be effective in treating onychomycosis without the risk of hepatotoxicity 3, 4, 5
• These topical agents have been found to have high mycologic cure rates, with efinaconazole 10% solution being nearly comparable to oral itraconazole in pivotal clinical trials 5
• Ciclopirox 8% nail lacquer is another topical antifungal agent, but its efficacy has been disappointing compared to newer agents like efinaconazole 10% solution and tavaborole 5% solution 5
• Topical therapy can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions compared to oral agents 4
• Nail trimming and debridement used concurrently with pharmacologic therapy can improve treatment response 4

Comparison of Treatments

• Efinaconazole 10% solution and tavaborole 5% solution have been found to be more effective than ciclopirox 8% nail lacquer in treating onychomycosis 5
• Oral terbinafine is preferred over topical therapy due to its better effectiveness and shorter treatment duration, but it may have hepatotoxicity as a side effect 6, 4
• Azoles, another type of oral antifungal agent, have been found to be effective in treating onychomycosis, but may also have hepatotoxicity as a side effect 6

Safety and Efficacy

• Topical antifungal agents like efinaconazole 10% solution and tavaborole 5% solution have been found to be well-tolerated and effective in treating onychomycosis, with minimal risk of hepatotoxicity 3, 4, 5
• The safety and efficacy of these topical agents make them a viable alternative to oral therapy for onychomycosis, especially for patients with comorbidities or those who are at risk of drug-drug interactions 4, 5