From the Guidelines
Toenail fungus can be most effectively treated with terbinafine 250mg daily for 12-16 weeks, as it has shown higher efficacy and tolerability compared to other treatments. This recommendation is based on the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. The guidelines suggest that terbinafine should be considered as the first choice of treatment for dermatophyte onychomycosis, unless there are contraindications.
Some key points to consider when treating toenail fungus include:
- The treatment should continue until a new, healthy nail grows completely, which may take 9-12 months for toenails.
- Patients should keep their nails short, dry, and clean, wear breathable footwear, and use antifungal powders to prevent recurrence.
- Those with diabetes or immune disorders should consult a healthcare provider before starting treatment, as they may require specialized care.
- Topical treatments like ciclopirox (Penlac) nail lacquer applied daily for up to 48 weeks, or efinaconazole (Jublia) and tavaborole (Kerydin) solutions applied daily for 48 weeks are effective options for mild to moderate cases 1.
- Oral medications like itraconazole (Sporanox) 200mg twice daily for one week per month for 3-4 months, or fluconazole (Diflucan) 150-300mg once weekly for 6-12 months can be used for more severe or resistant infections.
It's essential to note that the choice of treatment depends on the severity of the infection and the patient's overall health. Terbinafine has been shown to have higher efficacy rates compared to itraconazole, with a complete cure rate of 55% compared to 26% with pulsed itraconazole 1. Therefore, terbinafine is the recommended treatment for toenail fungus.
From the FDA Drug Label
Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). 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 for onychomycosis (toenail fungus) includes:
- 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 that includes removal of the unattached, infected nails as frequently as monthly 3
From the Research
Treatment Options for Onychomycosis
To treat onychomycosis, also known as toenail fungus, several oral antifungal medications are available, including itraconazole, terbinafine, and fluconazole 4. These medications have been shown to be effective in treating onychomycosis, with good clinical and mycological efficacies.
Oral Antifungal Medications
- Itraconazole: 100 to 200 mg daily for 3 months 4
- Terbinafine: 250 mg daily for 3 months 4, 5
- Fluconazole: 150 mg weekly for at least 6 months 4
Treatment Duration
The treatment duration for onychomycosis can vary depending on the medication and the severity of the infection. Studies have shown that:
- Terbinafine: 12 weeks of treatment is sufficient for toenail onychomycosis 5
- Itraconazole: treatment for 3 months is effective 4
- Fluconazole: treatment for at least 6 months is recommended 4
Alternative Therapies
Newer antifungal agents, such as posaconazole, fosravuconazole, voriconazole, and oteseconazole, have been studied as alternative therapies for onychomycosis 6. These agents have shown promise in treating onychomycosis, but more research is needed to determine their efficacy and safety.
Combination Therapy
Combination therapy, such as using ciclopirox topical solution with oral terbinafine, may be an effective treatment option for moderate to severe toenail onychomycosis 7.
Pulse vs Continuous Dose Therapy
Studies have compared the efficacy of pulse vs continuous dose terbinafine therapy in patients with onychomycosis. One study found that continuous dose therapy was more effective than pulse dose therapy 8.