What is the treatment guideline for Onychomycosis?

From the Guidelines

The treatment of onychomycosis typically involves oral antifungal medications as first-line therapy, with terbinafine being the most effective option. For fingernail infections, terbinafine 250 mg daily is recommended for 6 weeks, while toenail infections require 12 weeks of treatment 1. Alternative oral medications include itraconazole (pulse therapy of 200 mg twice daily for 1 week per month, repeated for 2 months for fingernails or 3 months for toenails) and fluconazole (150-300 mg once weekly for 3-6 months for fingernails or 6-12 months for toenails) 1.

Some key points to consider when treating onychomycosis include:

• The choice of antifungal medication should be based on the type of fungus causing the infection, as well as the patient's medical history and potential interactions with other medications 1.
• Topical treatments, such as ciclopirox 8% nail lacquer, may be used for mild cases or as adjunctive therapy, but are generally less effective than oral antifungals 1.
• Mechanical nail debridement by a podiatrist can improve treatment outcomes by reducing fungal load.
• Patients should be monitored for potential side effects of oral antifungals, particularly hepatotoxicity, and liver function tests are recommended before starting therapy and periodically during treatment.
• Complete cure may take 12-18 months as the nail needs to fully regrow, and recurrence rates are high (10-50%), so preventive measures like keeping feet dry, wearing breathable footwear, and using antifungal powders can help prevent reinfection.

It's worth noting that the most recent and highest quality study 1 supports the use of terbinafine as the first-line treatment for onychomycosis, due to its higher efficacy and tolerability compared to other options.

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).

2 DOSAGE AND ADMINISTRATION Fingernail onychomycosis: One 250 mg tablet once daily for 6 weeks. Toenail onychomycosis: One 250 mg tablet once daily for 12 weeks.

The treatment guideline for Onychomycosis is as follows:

• Terbinafine (PO):
  • Fingernail onychomycosis: 250 mg tablet once daily for 6 weeks.
  • Toenail onychomycosis: 250 mg tablet once daily for 12 weeks.
• Ciclopirox (TOP):
  • As a component of a comprehensive management program, for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum.
  • Apply for 48 weeks, in conjunction with monthly removal of the unattached, infected nail by a health care professional. 2, 2, 3

From the Research

Treatment Guidelines for Onychomycosis

The treatment of onychomycosis, a fungal infection of the nail unit, can be challenging due to its chronic nature and the variety of treatment options available.

• The choice of treatment should be based on several factors, including the patient's age and health, the aetiology of the infection, the extent of involvement, and the clinical form of the disease 4.
• Topical monotherapy is recommended when less than 50% of the nail is affected without matrix area involvement, while oral monotherapy or combination therapy is indicated when more than 50% of the nail, including the matrix area, is involved 4.
• Topical treatments, such as efinaconazole, tavaborole, and ciclopirox, can be effective for early onychomycosis without nail matrix involvement 5, 6.
• Oral antifungal agents, including terbinafine, itraconazole, and fluconazole, are also effective and can be used alone or in combination with topical antifungals 5, 6, 7.
• Laser therapy, including 1064nm Nd:YAG lasers and carbon dioxide lasers, is also a treatment option for onychomycosis 5.
• Combination therapy, which increases antifungal spectrum, fungicidal activity, and safety, can provide the best mycological and clinical cure rates 4.
• The treatment approach should also take into account the location and extent of onychomycosis, sensitivity of the drug to the fungal organism, adverse effects profile, dosage schedule, duration of therapy, concomitant medical conditions, and concurrent medications 7.
• To prevent relapse and recurrence, patients should be advised to use prophylactic topical antifungals and to avoid factors that contribute to the development of onychomycosis, such as tinea pedis infections 6, 8.

Treatment Options

• Topical treatments:
  • Efinaconazole
  • Tavaborole
  • Ciclopirox
• Oral antifungal agents:
  • Terbinafine
  • Itraconazole
  • Fluconazole
• Laser therapy:
  • 1064nm Nd:YAG lasers
  • Carbon dioxide lasers
• Combination therapy:
  • Topical and oral antifungals
  • Laser and topical antifungals

Prevention of Relapse and Recurrence

• Prophylactic use of topical antifungals
• Avoidance of factors that contribute to the development of onychomycosis, such as tinea pedis infections
• Regular follow-up with a healthcare provider to monitor the condition and adjust treatment as needed 8