From the Guidelines
The best topical treatment for onychomycosis is ciclopirox 8% nail lacquer, applied daily to affected nails for up to 48 weeks, as it has been shown to be effective in achieving mycological and clinical cure rates of 34% and 8%, respectively, compared to placebo 1. When using ciclopirox 8% nail lacquer, it is essential to apply the medication to the entire nail plate and under the free edge of the nail, with removal of the lacquer once weekly with alcohol before reapplication. Some key points to consider when treating onychomycosis with topical agents include:
- Filing down thickened nails before application to enhance penetration
- Continuing treatment until a healthy nail grows out completely
- Being aware of the potential for lower cure rates compared to oral antifungals, especially in cases with nail thickness greater than 2 mm or presence of dermatophytoma 1
- Educating patients on preventive measures to avoid reinfection, such as wearing protective footwear, using antifungal powders, and keeping nails short 1 It is crucial to note that onychomycosis has a high recurrence rate, and treatment failure or relapse can occur due to various factors, including incomplete cure, reinfection, or presence of resistant fungal elements 1. Therefore, a comprehensive treatment approach that includes patient education, proper application of topical agents, and follow-up care is necessary to achieve optimal outcomes and minimize the risk of recurrence.
From the FDA Drug Label
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 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.
The best topical strategy for toenail fungus (onychomycosis) is the use of ciclopirox topical solution, 8% as part of a comprehensive management program, which includes:
- Application of ciclopirox topical solution, 8%, for 48 weeks
- Removal of the unattached, infected nails as frequently as monthly by a healthcare professional This treatment is indicated for immunocompetent patients with mild to moderate onychomycosis of toenails without lunula involvement, due to Trichophyton rubrum 2.
From the Research
Topical Treatment Options for Toenail Fungus
- The most effective topical treatment for onychomycosis is still a subject of research, with various studies suggesting different options 3, 4, 5, 6.
- Ciclopirox 8% nail lacquer is one of the available topical treatments, but its efficacy has been reported as disappointing in some studies 4.
- Newer agents such as efinaconazole 10% solution and tavaborole 5% solution have shown promising results in clinical trials, with mycologic cure rates superior to those achieved with ciclopirox 8% nail lacquer 4.
- Amorolfine has also been studied as a potential topical treatment, with some studies suggesting its use in combination with oral terbinafine may be beneficial 5, 6.
Combination Therapy
- Combination therapy with oral and topical antifungal agents may be associated with higher success rates in treating onychomycosis 3, 5, 6.
- The use of oral terbinafine in combination with topical ciclopirox or amorolfine has been studied, with some results suggesting that combination therapy may not show significant differences in efficacy compared to monotherapy with oral terbinafine 6.
Nursing Approaches to Management
- Community nurses play a crucial role in managing skin and nail dermatophyte infections, including onychomycosis 7.
- Topical antifungals are generally the first-line treatment for dermatophyte infections, with oral antifungals reserved for more severe cases or when topical treatment fails 7.
- Addressing poor adherence and other possible causes of treatment failure is essential before assuming antifungal resistance 7.