From the Guidelines
Terbinafine should be considered as the first-line treatment for onychomycosis of the fingernail due to its higher efficacy and tolerability compared to itraconazole. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend terbinafine as the first choice of treatment, unless there are contraindications 1. The guidelines suggest a dose of 250 mg per day for 6 weeks for fingernail infection.
Some key points to consider when treating onychomycosis of the fingernail include:
- Terbinafine has been shown to be more effective than itraconazole in several large studies, with complete cure rates of 55% compared to 26% for pulsed itraconazole at 72 weeks follow-up 1.
- Itraconazole is licensed at a dose of 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 1.
- Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists 1.
- The long-term effectiveness of treatment is important to consider, with mycological cure without a second therapeutic intervention found in 46% of terbinafine-treated patients compared to 13% of itraconazole-treated patients at 5-year follow-up 1.
It is worth noting that other studies have reported similar cure rates with terbinafine, with a lower risk of drug interactions 1. However, the most recent and highest quality study suggests that terbinafine is the superior choice for treating onychomycosis of the fingernail 1.
From the FDA Drug Label
Patients should take one 250 mg tablet once daily for 6 weeks for treatment of fingernail onychomycosis The treatment for onychomycosis (fungal infection of the nail) of the fingernail is terbinafine 250 mg tablet once daily for 6 weeks 2.
- The optimal clinical effect is seen some months after mycological cure and cessation of treatment due to the time period required for outgrowth of healthy nail.
- Terbinafine is a prescription antifungal medicine used to treat fungal infections of the fingernails and toenails (onychomycosis) 2 2.
From the Research
Treatment Options for Onychomycosis of the Fingernail
The treatment for onychomycosis (fungal infection of the nail) of the fingernail includes:
- Application of topical antifungal agents such as amorolfine and ciclopirox 3
- Oral treatment using terbinafine (in case of dermatophyte infection), fluconazole (for yeast infections), or alternatively itraconazole if more than 50% of the nail plate is affected or if more than three out of ten nails are affected by the fungal infection 3
- Trimming, filing or grinding the nail, in addition to topical antifungal treatments, is likely to be beneficial 4
- Chemical nail destruction with a combination of urea and bifonazole, followed by treatment with an antifungal ointment, can be used when the nail is markedly thickened 4
Specific Treatment for Different Types of Fungal Infections
- For dermatophyte infections, oral terbinafine is effective in more than 50% of cases 4
- For yeast infections, oral azoles (ketonazole, itraconazole) are more effective than terbinafine 4
- For Candida nail infections, oral azoles (ketonazole, itraconazole) are recommended 4
Considerations for Treatment
- The efficacy and safety of antifungal drugs depend upon their mode of action, the minimal inhibitory concentration (MIC) and its relationship to the minimal fungicidal concentration (MFC), the spectrum of activity and drug kinetics at the involved site 5
- Terbinafine has a low MIC against dermatophytes and is effective over short treatment durations 6, 5
- Oral terbinafine can cause severe adverse effects, including cutaneous, hepatic and haematological effects, in about 1 in 2000 patients 4