What are the treatment options for onychomycosis (toenail fungus)?

From the Guidelines

Terbinafine 250mg daily for 12-16 weeks is the recommended first-line treatment for toenail fungus due to its higher efficacy and tolerability compared to other options. The treatment of onychomycosis (toenail fungus) depends on the severity of the infection. For mild to moderate cases, topical options such as ciclopirox 8% nail lacquer applied daily for up to 48 weeks can be effective, with a mycological cure rate of 34% compared to 10% with placebo 1. However, for more severe or resistant infections, oral medications are more effective.

Treatment Options

• Terbinafine 250mg daily for 12-16 weeks is the first-line treatment, with a complete cure rate of 55% compared to 26% with pulsed itraconazole 1.
• Itraconazole 200mg daily for 12 weeks continuously, or alternatively as pulse therapy at a dose of 400mg per day for 1 week per month, can be used as an alternative, with a complete cure rate of 26% 1.
• Combination therapy using both oral and topical treatments may improve outcomes.
• Mechanical approaches like nail debridement or removal can help in severe cases.

Prevention of Recurrence

Patients should keep feet dry, wear breathable footwear, avoid walking barefoot in public areas, and treat for the full recommended duration to prevent recurrence, as fungal infections typically require extended treatment due to the slow growth rate of nails. Regular follow-up and re-evaluation of the patient 3-6 months after treatment initiation are crucial to determine the need for further treatment 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). 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

The treatment options for onychomycosis (toenail fungus) include oral antifungal medications, such as terbinafine and azoles.

• Terbinafine has been shown to be effective in treating onychomycosis, with a high cure rate and relatively low risk of adverse events 4, 5, 6, 7, 8.
• Azoles have also been shown to be effective, but may have a higher risk of adverse events compared to terbinafine 8.
• Griseofulvin is another option, but it may have a lower cure rate and a higher risk of adverse events compared to terbinafine and azoles 8.

Duration of Treatment

The duration of treatment for onychomycosis can vary depending on the medication and the severity of the infection.

• Terbinafine is typically taken for 12 weeks, but some studies have shown that a shorter duration of treatment (6 weeks) may be effective in some cases 4, 5.
• Pulse dose therapy, where the medication is taken for a shorter period of time with breaks in between, has also been studied, but the results are mixed 6.

Efficacy of Treatment

The efficacy of treatment for onychomycosis can vary depending on the medication and the individual patient.

• Terbinafine has been shown to have a high cure rate, with some studies reporting a cure rate of up to 85% 4, 7.
• Azoles have also been shown to be effective, but may have a lower cure rate compared to terbinafine 8.
• Griseofulvin may have a lower cure rate compared to terbinafine and azoles 8.

Adverse Events

The risk of adverse events can vary depending on the medication and the individual patient.

• Terbinafine is generally well-tolerated, with common adverse events including gastrointestinal symptoms, infections, and headache 4, 8.
• Azoles may have a higher risk of adverse events, including headache, viral infection, and nausea 8.
• Griseofulvin may have a higher risk of adverse events, including gastrointestinal disturbance, allergic reaction, and nausea 8.