From the Guidelines
Terbinafine is the recommended first-line treatment for onychomycosis (toenail fungus) due to its higher efficacy and tolerability compared to other options, with a dosage of 250mg daily for 12-16 weeks. The treatment of onychomycosis depends on the severity of the infection, with topical antifungal medications like ciclopirox (Penlac) nail lacquer or efinaconazole (Jublia) and tavaborole (Kerydin) solutions being effective for mild to moderate cases 1. However, for more severe or resistant infections, oral medications like terbinafine, itraconazole, or fluconazole are more effective 1.
Some key points to consider when treating onychomycosis include:
- Terbinafine has been shown to be superior to itraconazole in terms of efficacy and tolerability, with cure rates of 70-80% for toenail infections and 80-90% for fingernail infections 1.
- Itraconazole is an alternative option, with a dosage of 200mg daily for 12 weeks continuously, or as pulse therapy at a dose of 400mg per day for 1 week per month 1.
- Fluconazole may be a useful alternative in patients unable to tolerate terbinafine or itraconazole, with a dosage of 450mg per week for 3 months in fingernail infections and for at least 6 months in toenail infections 1.
- Proper foot hygiene is essential during treatment, including keeping feet dry, wearing breathable shoes, changing socks daily, and avoiding walking barefoot in public areas.
- Treatment success requires patience, as complete nail regrowth takes 6-18 months, and recurrence rates remain high (10-50%) without preventive measures.
It's also important to note that home remedies like vinegar soaks or over-the-counter options containing undecylenic acid may help with mild cases, but their effectiveness is not well established 1. Overall, the choice of treatment should be based on the severity of the infection, the patient's medical history, and the potential risks and benefits of each option.
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 options for onychomycosis (toenail fungus) include:
- Oral terbinafine: indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
- Topical ciclopirox: indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3 Key considerations:
- Prior to initiating treatment, appropriate nail specimens for laboratory testing should be obtained to confirm the diagnosis of onychomycosis 2
- The comprehensive management program for topical ciclopirox includes removal of the unattached, infected nails as frequently as monthly, by a health care professional 3
From the Research
Treatment Options for Onychomycosis
Onychomycosis, also known as toenail fungus, can be treated using various modalities. The treatment options include:
- Surgical methods
- Chemical methods
- Topical treatments
- Oral treatments
Oral Treatments
Oral treatments for onychomycosis include:
- Terbinafine: a fungicidal antifungal compound shown to be effective in the treatment of onychomycosis 4
- Itraconazole: a systemic treatment approved by the US Food and Drug Administration 5
- Griseofulvin: a systemic treatment approved by the US Food and Drug Administration 5
- Fluconazole: a systemic therapy option for the treatment of onychomycosis 6
Topical Treatments
Topical treatments for onychomycosis include:
- Efinaconazole 10% topical solution: an FDA-approved treatment for onychomycosis patients aged 6 years and above, which functions as an antifungal by disrupting ergosterol synthesis in the fungal cell membrane 7
- Ciclopirox 8% nail lacquer: a topical treatment option for onychomycosis, which may be used alone or in combination with oral antifungal agents 8
- Amorolfine 5% nail lacquer: a topical treatment option for onychomycosis, which may be used alone or in combination with oral antifungal agents 8
- Tavaborole: a topical treatment option that has shown promise in phase III studies 6
Other Treatment Options
Other treatment options for onychomycosis include:
- Laser systems: a treatment option for onychomycosis, although mechanical modalities are sometimes used but are seldom necessary 6
- Combination therapy: using antifungal nail lacquers in combination with oral agents, such as terbinafine and itraconazole, can improve the efficacy of antifungal therapy 8