From the Guidelines
Itraconazole should be prescribed as 200 mg per day for 12 weeks continuously, or alternatively as ‘pulse therapy’ at a dose of 400 mg per day for 1 week per month, with two pulses recommended for fingernail onychomycosis and three pulses for toenail onychomycosis, as per the British Association of Dermatologists' guidelines 1.
Treatment Regimen
The treatment regimen for onychomycosis using Itraconazole involves:
- Continuous therapy: 200 mg per day for 12 weeks
- Pulse therapy: 400 mg per day for 1 week per month, with two pulses for fingernail onychomycosis and three pulses for toenail onychomycosis It is essential to take Itraconazole with food to enhance absorption and avoid antacids within 2 hours of dosing.
Important Considerations
Before starting treatment with Itraconazole, liver function tests should be performed, and the medication should be avoided in patients with liver disease or heart failure, as indicated in the guidelines 1. Additionally, drug interactions are common with Itraconazole, particularly with statins, benzodiazepines, and certain cardiac medications, so a thorough medication review is essential before initiating therapy.
Comparison with Other Treatments
While Terbinafine is generally preferred over Itraconazole due to its higher efficacy and tolerability, as shown in several large studies 1, Itraconazole remains a viable treatment option for onychomycosis. Patients should be aware that complete nail clearing may take 6-12 months even after completing treatment, as the healthy nail needs time to grow out. Itraconazole works by inhibiting fungal cell membrane synthesis through disruption of ergosterol production.
From the Research
Treatment Regimen for Onychomycosis using Itraconazole
The treatment regimen for onychomycosis using itraconazole involves:
- Pulse therapy with itraconazole 400 mg daily for 1 week per month for 3 months 2, 3
- Alternatively, itraconazole 200 mg twice daily for 1 week per month for 3 months 4, 5
- For patients with proximal nail involvement, a fourth treatment cycle may be administered 3
- The efficacy of itraconazole is influenced by the extent of nail involvement, with higher cure rates achieved in patients without proximal nail involvement 3
Comparison of Treatment Regimens
Studies have compared the efficacy and safety of different treatment regimens, including:
- Continuous therapy with itraconazole 200 mg once daily for 3 months 2, 5
- Intermittent therapy with itraconazole 200 mg twice daily for 1 week per month for 3 months 4, 5
- Pulse therapy with itraconazole 400 mg daily for 1 week per month for 3 months 2, 3
- The intermittent schedule was not associated with a lower cure rate, despite lower itraconazole nail concentrations 5
Safety and Efficacy
Itraconazole has been shown to be safe and effective in the treatment of onychomycosis, with:
- Low incidence of adverse events, including headache, fatigue, and minor gastrointestinal problems 2, 3
- High cure rates, with clinical cure achieved in 64-87% of patients and mycological cure achieved in 77% of patients 3
- Itraconazole was significantly more effective than miconazole cream in the treatment of onychomycosis 2