From the Guidelines
Terbinafine is the recommended first-line treatment for onychomycosis, due to its higher efficacy and tolerability compared to itraconazole, as demonstrated in several large studies, including a multicentre, randomized trial involving 508 subjects 1. The treatment options for onychomycosis include both oral and topical antifungal medications. Oral medications, such as terbinafine and itraconazole, are generally more effective for moderate to severe infections.
- Terbinafine is licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection, with a higher efficacy rate compared to itraconazole 1.
- Itraconazole is licensed 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. Topical options, such as ciclopirox 8% nail lacquer, efinaconazole 10% solution, tavaborole 5% solution, and amorolfine 5% nail lacquer, may be sufficient for mild cases or patients who cannot tolerate oral medications, and must be applied consistently for 6-12 months. Non-pharmacological approaches, including keeping nails trimmed and dry, wearing breathable footwear, and using antifungal powders in shoes, can also be beneficial in preventing the spread of infection. In severe cases resistant to medication, nail removal may be considered, and treatment success should be monitored by clear nail growth, with complete cure taking 9-12 months as nails grow slowly 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 treatment options for onychomycosis (fungal nail infection) include:
- 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, as a component of a comprehensive management program 3
From the Research
Treatment Options for Onychomycosis
Onychomycosis, a fungal infection of the nail, can be treated using various modalities. The treatment options include:
- Oral antifungal therapy: This is the most common treatment for onychomycosis. The oral antifungal agents used to treat onychomycosis include terbinafine, itraconazole, and fluconazole 4, 5, 6.
- Topical antifungal therapy: Topical antifungal agents such as ciclopirox, efinaconazole, and tavaborole can be used to treat onychomycosis, especially for mild to moderate cases 7, 8.
- Combination therapy: Combination of oral and topical antifungal agents can be used to treat onychomycosis, especially for moderate to severe cases 7.
Efficacy of Treatment Options
The efficacy of treatment options for onychomycosis varies depending on the type of fungus causing the infection and the severity of the infection.
- Terbinafine is effective in treating dermatophyte onychomycosis, with a higher cure ratio compared to other oral antifungal agents 4.
- Itraconazole is effective in treating Candida and non-dermatophyte onychomycosis 4.
- Combination therapy with oral terbinafine and topical ciclopirox can be an effective alternative to continuous oral terbinafine therapy 7.
Safety and Mechanisms of Action
The safety and mechanisms of action of antifungal drugs used to treat onychomycosis have been reviewed 8.