From the Guidelines
The first-line treatment for onychomycosis (toenail fungus) is oral terbinafine, typically prescribed at 250 mg daily for 12 weeks for toenail infection. This recommendation is based on the higher efficacy and tolerability of terbinafine compared to other treatment options, such as itraconazole, as demonstrated in several large studies, including a multicentre, randomized trial involving 508 subjects 1. The study found that terbinafine had a complete cure rate of 55% compared to 26% for pulsed itraconazole at 72 weeks follow-up. Additionally, terbinafine has been shown to have a lower relapse rate and better long-term results compared to itraconazole 1.
Some key points to consider when prescribing terbinafine include:
- Confirmation of the infection through laboratory testing is recommended before starting treatment
- Liver function tests should be performed since terbinafine can occasionally cause hepatotoxicity
- Patients should be advised that complete nail clearing takes time, often 9-12 months for toenails, even after completing the medication course
- Topical treatments like ciclopirox 8% nail lacquer are less effective when used alone but may be considered for mild cases or as adjunctive therapy
- For optimal results, patients should keep nails trimmed, wear breathable footwear, and treat any concurrent tinea pedis (athlete's foot) to prevent reinfection
It is also important to note that terbinafine is generally preferred over itraconazole due to its higher cure rates, fewer drug interactions, and better long-term results, as stated in the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium).
The first-line treatment for onychomycosis (toenail fungus) is terbinafine (PO), as it is directly indicated for this condition in the drug label 2.
- Key points:
- Terbinafine is specifically indicated for onychomycosis of the toenail due to dermatophytes.
- Diagnosis should be confirmed through laboratory testing before initiating treatment.
From the Research
First-Line Treatment for Toenail Fungus
The first-line treatment for onychomycosis (toenail fungus) is typically oral antifungal medications.
- Terbinafine is a commonly used treatment option, with studies showing its efficacy in treating toenail onychomycosis 3, 4, 5, 6, 7.
- The recommended duration of treatment with terbinafine is typically 12 weeks, although some studies suggest that 6 weeks may be sufficient in certain cases 3, 5.
Treatment Efficacy
- Studies have shown that terbinafine has a high mycologic cure rate, with 67-85% of patients achieving a complete cure after 12-24 weeks of treatment 3.
- The efficacy of terbinafine has been compared to other oral antifungals, such as itraconazole, and has been shown to be effective in treating toenail onychomycosis 4.
- A novel treatment protocol using terbinafine has been shown to achieve high mycologic cure rates, with 94% of patients achieving a negative mycologic culture after 48 weeks of treatment 6.
Treatment Duration and Dosing
- The optimal treatment duration for terbinafine is typically 12 weeks, although some studies suggest that 6 weeks may be sufficient in certain cases 3, 5.
- The recommended dosing regimen for terbinafine is 250 mg/day, although some studies have used different dosing regimens 4, 6, 7.
- A study comparing 6 and 12 weeks of terbinafine treatment found that 12 weeks was more effective in achieving a mycologic cure 5.