From the Guidelines
The recommended treatment for onychomycosis (toenail fungus) is terbinafine (250 mg daily for 12-16 weeks) due to its higher cure rates and fewer drug interactions compared to alternatives, as supported by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.
Key Considerations
- Terbinafine is generally preferred over itraconazole for dermatophyte onychomycosis due to its higher efficacy and tolerability 1.
- Itraconazole (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) is an alternative option, particularly for Candida onychomycosis 1.
- Topical treatments like ciclopirox 8% nail lacquer or efinaconazole 10% solution can be effective for mild to moderate cases, but are generally less successful than oral medications 1.
- Treatment duration is lengthy due to the slow growth of toenails, and complete cure may take 9-12 months even after completing medication.
Patient Advice
- Keep nails trimmed short to prevent further irritation and infection.
- Wear breathable footwear to reduce moisture and promote a dry environment.
- Use antifungal powders in shoes to prevent reinfection.
- Avoid walking barefoot in public wet areas to reduce the risk of contracting fungal infections.
- Patients with diabetes or compromised immune systems should seek treatment promptly, as fungal infections can lead to more serious complications in these populations.
Evidence Summary
The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 provide a comprehensive overview of the treatment options for onychomycosis, including terbinafine, itraconazole, and topical treatments 1. A multicentre, randomized trial involving 508 subjects demonstrated complete cure rates of 55% for terbinafine and 26% for pulsed itraconazole at 72 weeks 1. Another study demonstrated cure rates of 92% for pulse itraconazole and 40% for pulse terbinafine in the treatment of Candida onychomycosis 1.
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). Toenail onychomycosis: One 250 mg tablet once daily for 12 weeks.
The recommended treatment for onychomycosis (toenail fungus) is terbinafine (PO), with a dosage of one 250 mg tablet once daily for 12 weeks 2.
- Key points:
- The diagnosis of onychomycosis should be confirmed by laboratory testing (KOH preparation, fungal culture, or nail biopsy) before initiating treatment.
- The optimal clinical effect is seen some months after mycological cure and cessation of treatment.
- Important safety information:
- Terbinafine tablets are contraindicated in individuals with a history of allergic reaction to oral terbinafine.
- Treatment with terbinafine tablets should be discontinued if biochemical or clinical evidence of liver injury develops.
- Patients prescribed terbinafine tablets should be warned to report immediately to their physician any symptoms of persistent nausea, anorexia, fatigue, vomiting, right upper abdominal pain or jaundice, dark urine, or pale stools.
From the Research
Treatment Options for Onychomycosis
The treatment for onychomycosis, also known as toenail fungus, can vary depending on the severity and type of infection. Some of the recommended treatment options include:
- Oral antifungal medications such as terbinafine, itraconazole, and fluconazole 3, 4, 5
- Topical agents like ciclopirox, efinaconazole, and tavaborole 6
- Laser systems 6
- Mechanical modalities, although these are seldom necessary 6
Duration of Treatment
The duration of treatment for onychomycosis can also vary. Studies have shown that:
- A treatment period of 12 weeks with terbinafine is sufficient for toenail onychomycosis 3
- 6 weeks of treatment with terbinafine may not be sufficient for toenail onychomycosis, although it may be effective for fingernail infections 4
- Continuous treatment with terbinafine for 12 weeks may be more effective than pulse therapy 7
Efficacy of Treatment
The efficacy of treatment for onychomycosis can depend on various factors, including the type of infection and the treatment regimen. Studies have reported:
- High cure rates with terbinafine treatment, ranging from 67% to 85% 3
- Lower cure rates with pulse therapy compared to continuous treatment 7
- The importance of preventive measures to reduce the risk of recurrence 6
Adverse Effects
The adverse effects of treatment for onychomycosis can include: