What is the recommended treatment for onychomycosis (fungal infection of the nails)?

From the Guidelines

Itraconazole is preferred over fluconazole for the treatment of onychomycosis due to its higher efficacy rates and shorter treatment duration. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, itraconazole has significantly greater efficacy than terbinafine for the treatment of onychomycosis, and fluconazole appears to be less effective than itraconazole or terbinafine 1.

Treatment Options

• Itraconazole can be given 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.
• Fluconazole can be given at a dose of 150-450 mg per week for 3 months in fingernail infections and for at least 6 months in toenail infections, but it is generally considered a less effective option 1.
• Terbinafine is also a viable option, with a dose of 250 mg per day for 6 weeks in fingernail and 12-16 weeks in toenail infection, and is generally preferred over itraconazole due to its higher efficacy and tolerability 1.

Important Considerations

• Before starting oral antifungals, liver function tests are recommended as these medications can cause hepatotoxicity 1.
• Recurrence is common, occurring in 10-50% of cases, so preventive measures like keeping feet dry, wearing breathable footwear, and using antifungal powders can help prevent reinfection after successful treatment.
• The choice of treatment should be based on the individual patient's needs and medical history, taking into account the potential benefits and risks of each option.

From the FDA Drug Label

Cases of CHF, peripheral edema, and pulmonary edema have been reported in the postmarketing period among patients being treated for onychomycosis and/or systemic fungal infections.

The FDA drug label does not answer the question.

From the Research

Itraconazole vs Fluconazole Dosing Regimen for Onychomycosis

• The treatment of onychomycosis involves the use of oral antifungal agents, with itraconazole and fluconazole being two of the options 2, 3, 4.
• Itraconazole has been shown to be effective in the treatment of onychomycosis, with a broad spectrum of activity against dermatophytes, Candida, and non-dermatophyte molds 3.
• The dosing regimen for itraconazole can be either continuous or pulse therapy, with both regimens being safe and effective 3.
• Fluconazole is also an alternative for the treatment of onychomycosis, with a recommended dosing regimen of 150 mg weekly for more than 6 months 4.
• The choice of antifungal agent and dosing regimen should be based on the causative agent, severity of the infection, and patient factors such as liver function and potential drug interactions 2, 5.

Efficacy and Safety of Itraconazole and Fluconazole

• Itraconazole has been shown to be effective in the treatment of onychomycosis, with clinical cure rates ranging from 52-82% and mycologic cure rates ranging from 74-86% 3.
• Fluconazole has also been shown to be effective, with clinical cure rates and mycologic cure rates being higher with longer treatment durations 4.
• Both itraconazole and fluconazole have been shown to be safe, with few adverse effects reported 3, 4, 5.
• However, both agents can interact with other drugs and have potential hepatic, renal, cutaneous, cardiovascular, neurological, hemopoietic, and obstetric adverse events 5.

Comparison of Itraconazole and Fluconazole

• Itraconazole and fluconazole have different mechanisms of action and spectra of activity, with itraconazole being a broad-spectrum agent and fluconazole being more specific for dermatophytes 2, 4.
• The dosing regimens for itraconazole and fluconazole also differ, with itraconazole being given continuously or in pulses and fluconazole being given weekly for more than 6 months 3, 4.
• The choice of antifungal agent and dosing regimen should be based on the individual patient's needs and factors such as liver function and potential drug interactions 2, 5.