From the Guidelines
Onychomycosis should be treated with terbinafine as the first-line option, given its higher efficacy and tolerability compared to itraconazole, unless there are contraindications. The treatment approach depends on the severity and extent of the infection, as well as the causative organism. For mild to moderate cases affecting fewer than half the nail, topical treatments like ciclopirox 8% nail lacquer applied daily for up to 48 weeks, efinaconazole 10% solution, or tavaborole 5% solution applied daily for 48 weeks can be effective 1.
Treatment Options
- For more severe or extensive infections, oral medications are preferred, including:
- Combination therapy using both oral and topical agents may improve cure rates.
- Mechanical or chemical nail debridement before starting medication can improve treatment outcomes by reducing fungal load and enhancing drug penetration.
Monitoring and Follow-Up
- Liver function tests should be monitored with oral treatments, especially in patients with pre-existing liver conditions or those taking concomitant hepatotoxic drugs 1.
- Treatment success requires patience as complete nail regrowth takes 6-12 months for fingernails and 12-18 months for toenails.
- Recurrence rates remain high (10-50%) even after successful treatment, emphasizing the need for long-term follow-up and potential repeated treatment courses 1.
Special Considerations
- In cases of Candida onychomycosis, itraconazole may be considered as the first-line treatment due to its higher efficacy in this specific context 1.
- For patients with diabetes or immunosuppression, prompt treatment is crucial to prevent complications and improve quality of life.
From the FDA Drug Label
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.
INDICATIONS AND USAGE ... 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
Treatment of Onychomycosis:
- Oral Treatment: Terbinafine (PO) is administered as one 250 mg tablet once daily for 6 weeks for fingernail onychomycosis and 12 weeks for toenail onychomycosis 2.
- Topical Treatment: Ciclopirox (TOP) is applied for 48 weeks as a component of a comprehensive management program, including removal of the unattached, infected nails as frequently as monthly, for mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3.
From the Research
Diagnosis and Treatment of Onychomycosis
- Onychomycosis should be suspected in patients with discolored nails, nail plate thickening, nail separation, and foul-smelling nails 4.
- Accurate diagnosis is important before initiating treatment because therapy is lengthy and can cause adverse effects 4.
- A potassium hydroxide preparation with confirmatory fungal culture, periodic acid-Schiff stain, or polymerase chain reaction is the preferred diagnostic approach if confirmative testing is cost prohibitive or not available 4.
Treatment Options
- Oral terbinafine is preferred over topical therapy because of better effectiveness and shorter treatment duration 4.
- Terbinafine and itraconazole are the therapeutic agents of choice for treating onychomycosis 5.
- Topical therapy, including ciclopirox 8%, efinaconazole 10%, and tavaborole 5%, is less effective than oral agents but can be used to treat mild to moderate onychomycosis, with fewer adverse effects and drug-drug interactions 4.
- Combination therapy of oral terbinafine and ciclopirox nail lacquer is a safe and more effective treatment for onychomycosis than terbinafine alone, especially in younger patients and in shorter-duration onychomycosis 6.
Prevention of Recurrence
- Preventive measures such as avoiding walking barefoot in public places and disinfecting shoes and socks are thought to reduce the 25% relapse rate 4.
- Methods to prevent onychomycosis recurrences and emerging therapies are also being explored 7.
Special Considerations
- Patients taking terbinafine in combination with tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antipsychotics, beta blockers, or tamoxifen should be monitored for drug-drug interactions 4.
- Itraconazole demonstrated efficacy against onychomycosis of the toenails caused by Scopulariopsis brevicaulis and Aspergillus species 8.
- Terbinafine may also demonstrate efficacy against cases of S. brevicaulis and Aspergillus toe onychomycosis 8.