Treatment Regimen for Onychomycosis Using Efinaconazole 10% Solution
Efinaconazole 10% solution (Jublia) should be applied once daily to affected toenails for 48 weeks using the integrated flow-through brush applicator, ensuring complete coverage of the toenail, toenail folds, toenail bed, hyponychium, and the undersurface of the toenail plate. 1
Application Technique
- Apply to clean, dry toenails
- Use the integrated flow-through brush applicator that comes with the medication
- Ensure complete coverage of:
- The toenail surface
- The toenail folds
- Toenail bed
- Hyponychium (tissue beneath the free edge of the nail)
- Undersurface of the toenail plate
Treatment Duration and Efficacy
Efinaconazole 10% solution requires consistent application for the full treatment course:
- Standard treatment duration: 48 weeks (once daily application) 1
- Mycological cure rates: approximately 56% at 52 weeks (4 weeks after completing therapy) 2
- Clinical treatment success: approximately 43-47% at follow-up 2
Patient Selection Considerations
Efinaconazole 10% solution is most appropriate for:
- Mild-to-moderate onychomycosis 3
- Patients with liver or kidney disease who cannot take oral antifungals 3
- Pediatric patients (FDA-approved for age 6 and above) 3
- Maintenance therapy to prevent relapse 3
Patients more likely to respond well include:
- Female patients
- Those with lower BMI
- Mild disease severity
- Short disease duration
- When concomitant tinea pedis is treated 3
Adjunctive Measures
For optimal results, consider these additional measures:
- Gentle nail debridement/filing of affected areas 4
- Treatment of concomitant tinea pedis 4, 3
- Examination of family members for potential sources of infection 4
- Application of absorbent powder and antifungal powders in shoes 4
- Wearing cotton, absorbent socks and keeping nails short 4
Potential Adverse Effects
The most common adverse effects are generally mild and include:
- Ingrown toenail (2.3%)
- Application site dermatitis (2.2%)
- Application site vesicles (1.6%)
- Application site pain (1.1%) 1
Treatment Considerations and Alternatives
While efinaconazole is effective as a topical treatment, it's important to note that:
- Topical therapy generally has limitations including poor nail plate penetration and lengthy treatment duration 4
- For severe cases, oral antifungals like terbinafine remain the first-line treatment with higher cure rates (70-80% for toenail infections) 5, 4
- Extended treatment beyond 48 weeks may increase efficacy without increased safety risk, particularly in patients over 70 years of age or with more severe disease 6
Monitoring and Follow-up
- Assess treatment response at regular intervals
- Complete resolution may take time due to slow nail growth
- Consider longer treatment duration for patients with increased age, increased severity of onychomycosis, or mixed infections 6
Efinaconazole 10% solution represents an important advance in topical treatment of onychomycosis with efficacy comparable to some oral antifungals but with minimal systemic exposure and no drug-drug interactions 7.