What are the treatment options for onychomycosis (toe fungus)?

From the Guidelines

Terbinafine 250mg daily for 12-16 weeks is the recommended first-line treatment for onychomycosis (toe fungus) due to its high efficacy and safety profile, as demonstrated in a multicentre, randomized trial involving 508 subjects 1.

Treatment Options

• Topical antifungal medications like ciclopirox (Penlac) nail lacquer, amorolfine, or tavaborole (Kerydin) can be applied directly to the affected nails daily for 6-12 months for mild to moderate cases.
• Oral antifungal medications, such as terbinafine (Lamisil) and itraconazole (Sporanox), are typically more effective for more severe or resistant infections.

Oral Medication Options

• Terbinafine 250mg daily for 12-16 weeks is the first-line treatment due to its high cure rate and safety profile 1.
• Itraconazole (Sporanox) 200mg twice daily for one week per month for 2-3 months is an alternative oral option.
• Fluconazole (Diflucan) 150-300mg once weekly for 3-6 months may be a useful alternative in patients unable to tolerate terbinafine or itraconazole 1.

Important Considerations

• Treatment success requires patience as complete nail regrowth takes 9-12 months for toenails.
• Recurrence is common (10-50%), so preventive measures like keeping feet dry and avoiding walking barefoot in public areas are important even after successful treatment.
• Oral medications work by inhibiting fungal cell membrane formation, while topicals penetrate the nail to kill the fungus directly.
• Griseofulvin is no longer a treatment of choice for onychomycosis unless other drugs are unavailable or contraindicated due to its lower efficacy and longer treatment duration 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 options for onychomycosis (toe fungus) are:

• Terbinafine (PO): indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
• Ciclopirox (TOP): indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3 Key points:
• Terbinafine is taken orally, while ciclopirox is a topical solution
• Both treatments have specific indications and usage guidelines
• Patients should be under medical supervision while using these treatments 2

From the Research

Treatment Options for Onychomycosis (Toe Fungus)

• Oral antifungal medications, such as terbinafine, are effective in treating onychomycosis 4, 5, 6, 7
• Terbinafine has demonstrated excellent fungicidal activity against dermatophytes and variable activity against yeasts and non-dermatophyte molds in vitro 4
• Studies have shown that terbinafine is more effective than itraconazole, fluconazole, and griseofulvin in achieving clinical and mycological cure 4, 7
• Topical antifungal agents, such as efinaconazole and tavaborole, are also available for the treatment of onychomycosis 8
• The choice of treatment depends on the severity of the infection, the type of fungus causing the infection, and the patient's medical history and preferences

Efficacy of Terbinafine

• Terbinafine has been shown to be effective in achieving clinical and mycological cure in patients with onychomycosis 4, 5, 6, 7
• The mycologic cure rates for terbinafine have been reported to be as high as 72.1% to 77.0% 6
• Clinical cure rates for terbinafine have been reported to be as high as 49.5% to 49.2% 6
• Terbinafine has been shown to be more effective than azoles and griseofulvin in achieving clinical and mycological cure 7

Safety and Tolerability of Terbinafine

• Terbinafine has been shown to be well tolerated, with most adverse events being transient and mild to moderate in severity 4, 5, 7
• The most common adverse events associated with terbinafine include gastrointestinal symptoms, infections, and headache 4, 7
• Terbinafine has a low potential for drug-drug interactions, unlike azoles 4