What are the treatment options for onychomycosis (fungal toenail infection)?

From the Guidelines

Terbinafine is the recommended first-line treatment for onychomycosis due to its higher efficacy and tolerability compared to other oral antifungal medications. The treatment options for onychomycosis include both topical and oral antifungal medications, as well as procedural interventions. For mild to moderate cases, topical treatments like ciclopirox 8% nail lacquer (applied daily for up to 48 weeks) 1, amorolfine 5% nail lacquer, or efinaconazole 10% solution are recommended. These work by penetrating the nail plate to kill the fungus, though complete cure rates are modest (5-12%) 1.

For more severe or resistant infections, oral medications are more effective, with terbinafine (250mg daily for 6-12 weeks) being the first-line treatment due to its 70-80% cure rate and favorable safety profile 1. Alternative oral options include itraconazole (200mg daily for 12 weeks or pulse therapy of 200mg twice daily for one week per month, repeated for 3-4 months) 1 and fluconazole (150-300mg weekly for 6-12 months) 1.

Some key points to consider when treating onychomycosis include:

• The importance of patient adherence, as complete nail regrowth takes 6-12 months for toenails
• The common recurrence of onychomycosis (10-50%), which can be mitigated with preventive measures like keeping feet dry, wearing breathable footwear, and using antifungal powders 1
• The potential for treatment failure or relapse, which may be attributed to factors such as nail thickness, slow outgrowth, and the presence of dermatophytoma 1
• The need for proper footwear hygiene, including the use of antifungal powders and the potential for discarding old or moldy shoes 1

Overall, the goal of treatment is to achieve fungal-free nails, and terbinafine is the most effective option for achieving this goal 1.

From the FDA Drug Label

Terbinafine tablets 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 Tricho-phyto rubrum

The treatment options for onychomycosis (fungal toenail infection) include:

• Oral antifungal agents: Terbinafine tablets are indicated for the treatment of onychomycosis of the toenail due to dermatophytes 2.
• Topical antifungal agents: Ciclopirox Topical Solution, 8% (Nail Lacquer) is indicated as a component of a comprehensive management program for mild to moderate onychomycosis of toenails without lunula involvement, due to Tricho-phyto rubrum 3. Key considerations:
• Prior to initiating treatment, appropriate nail specimens for laboratory testing should be obtained to confirm the diagnosis of onychomycosis 2.
• A comprehensive management program, including removal of the unattached, infected nails, may be necessary for effective treatment 3.

From the Research

Treatment Options for Onychomycosis

The treatment of onychomycosis, a fungal infection of the toenails, has various options available. These include:

• Systemic therapy with antifungal agents such as terbinafine, itraconazole, and fluconazole 4, 5, 6
• Topical agents like ciclopirox, efinaconazole, and tavaborole 7
• Laser systems 7
• Mechanical modalities, although these are seldom necessary 7

Systemic Therapy

Systemic therapy involves the use of oral antifungal medications. The preferred regimens for these agents are:

• Terbinafine: 250 mg/day for 12 weeks 4, 6
• Itraconazole: pulse therapy with 200mg twice daily for 1 week per month for 3 pulses 6
• Fluconazole: 150 mg/week until the abnormal-appearing nail plate has grown out, typically over a period of 9 to 18 months 6

Efficacy and Safety

The efficacy of these treatments has been demonstrated in various studies. For example, terbinafine has been shown to have a cure rate of 67% to 85% after 6 to 24 weeks of treatment 4. Itraconazole and fluconazole have also been shown to be effective, with good clinical and mycological efficacies obtained with itraconazole 100 to 200 mg daily and fluconazole 150 mg weekly for at least 6 months 5.

Prevention of Relapse

To prevent relapse, it is recommended to use an effective topical antifungal regularly and prophylactically, especially to prevent a recurrence of tinea pedis and onychomycosis 8. Adherence to preventive measures can also reduce the risk of recurrence 7.