What is the recommended treatment for onychomycosis?

From the Guidelines

The recommended treatment for onychomycosis is terbinafine, given its higher efficacy and tolerability compared to itraconazole, with a dosage of 250 mg daily for 6 weeks for fingernails or 12 weeks for toenails. This recommendation is based on the British Association of Dermatologists' guidelines for the management of onychomycosis 2014, which suggests that terbinafine should be considered as the first choice of treatment unless there are contraindications 1. The guidelines also mention that terbinafine has been shown to be more effective than griseofulvin in dermatophyte onychomycosis, and that intermittent or 'pulse' treatment regimens have been developed for both terbinafine and itraconazole.

Some key points to consider when treating onychomycosis include:

• The importance of consistent medication use for the full prescribed duration, even after visible improvement occurs
• The need for patients to keep nails short, dry, and clean, and to wear breathable footwear
• The potential for nail removal in severe or resistant cases
• The use of topical treatments like ciclopirox 8% nail lacquer or efinaconazole 10% solution for mild cases or as adjunctive therapy
• The fact that oral medications work more effectively because they circulate through the bloodstream to the nail bed, targeting the infection from within, while topical treatments have limited penetration through the nail plate.

It's also worth noting that fluconazole may be a useful alternative in patients unable to tolerate terbinafine or itraconazole, with a once-weekly dosing regimen of 450 mg per week for 3 months in fingernail infections, and for at least 6 months in toenail infections 1. However, fluconazole appears to be less effective than itraconazole or terbinafine, and its use should be considered on a case-by-case basis. In cases of Candida onychomycosis, itraconazole may be considered as the first-line treatment, given its shorter treatment duration and higher efficacy rates compared to terbinafine 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium).

INDICATIONS AND USAGE (To understand fully the indication for this product, please read the entire INDICATIONS AND USAGE section of the labeling.) 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 recommended treatment for onychomycosis includes:

• Terbinafine (PO) for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
• Ciclopirox (TOP) as a topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum, as part of a comprehensive management program that includes removal of the unattached, infected nails 3

From the Research

Treatment Options for Onychomycosis

The recommended treatment for onychomycosis depends on the severity of the infection and the type of fungus causing it.

• Oral antifungal medications, such as terbinafine and itraconazole, are generally recommended for moderate to severe onychomycosis 4, 5, 6.
• Topical antifungal medications, such as ciclopirox and amorolfine, can be effective for mild to moderate onychomycosis 4, 5, 6.
• Combination therapy, using both oral and topical antifungal medications, may be beneficial for some patients 7, 8.

Considerations for Treatment

When determining the best treatment plan for onychomycosis, several factors should be considered, including:

• Disease severity 4, 6
• Infecting pathogen 7, 6
• Medication safety and efficacy 5, 6
• Patient age, comorbidities, and medication history 5, 6
• Likelihood of patient compliance 6

Treatment Duration and Follow-up

Treatment for onychomycosis can be long-term, typically lasting from 3 to 9 months 4.

• Patients should be counseled on the importance of completing the full treatment course and following up with their physician to monitor progress and minimize the risk of recurrence 6.