What are the treatment options for fungal nail infections?

Treatment Options for Fungal Nail Infections

Oral terbinafine is the first-line treatment for fungal nail infections (onychomycosis) with 70-80% efficacy for toenails and 80-90% for fingernails. 1

Diagnosis Confirmation

• Diagnosis should be confirmed through:
  • Microscopic examination with potassium hydroxide (KOH)
  • Mycological culture
  • Nail biopsy in doubtful cases
• Important: Only approximately 50% of nail dystrophies are actually caused by fungi 1

Treatment Algorithm

First-line treatments:

1. For single nail infection:

   • Topical antifungal: Amorolfine 5% nail lacquer applied once or twice weekly for 6-12 months (50% efficacy) 1

2. For multiple nail infections or severe cases:

   • Oral terbinafine: 250mg once daily for 6 weeks (fingernails) or 12 weeks (toenails) 2
     • Highest efficacy: 73-94% mycological cure rate 1
     • Preferred for dermatophyte infections 1

Alternative oral treatments:

1. Itraconazole:

   • 200mg daily for 12 weeks (continuous therapy) 1
   • OR 200mg twice daily for 1 week per month × 2-3 pulses (pulse therapy) 1
   • Particularly effective for Candida onychomycosis (92% cure rate with pulse therapy) 1
   • High-quality evidence shows terbinafine is more effective than azoles like itraconazole 3

2. Fluconazole:

   • 450mg once weekly for 3 months (fingernails) or at least 6 months (toenails) 4
   • Useful alternative when patients cannot tolerate terbinafine or itraconazole 4
   • Once-weekly dosing may improve compliance 4

Alternative topical treatments:

• Ciclopirox 8% lacquer (34% mycological cure rate) 1
• Efinaconazole 10% solution (50% mycological cure rate) 1
• Tioconazole 28% solution (contraindicated in pregnancy) 1

Special Considerations

By Pathogen Type:

• Dermatophytes: Terbinafine preferred (highest efficacy) 1
• Candida species: Itraconazole is particularly effective 1, though terbinafine has also shown efficacy 5
• Non-dermatophyte molds: Itraconazole has shown effectiveness (88% cure rate) 6
• Mixed infections: Itraconazole effective (84% clinical cure, 68% mycological cure) 6

Special Populations:

• HIV patients: Terbinafine and fluconazole preferred (fewer interactions with antiretrovirals) 1
• Diabetic patients: Terbinafine preferred (fewer drug interactions) 1
• Pediatric patients: Terbinafine dosing varies by weight:
  • <20kg: 62.5mg daily
  • 20-40kg: 125mg daily

  • 40kg: 250mg daily 1

Common Adverse Effects

Terbinafine:

• Gastrointestinal symptoms
• Headache
• Taste disturbance (may become permanent)
• Liver problems (rare but serious) 2

Itraconazole:

• Headache
• Gastrointestinal complaints
• More drug interactions than terbinafine 4

Fluconazole:

• Headache
• Skin rash
• Gastrointestinal complaints
• Insomnia 4

Prevention of Recurrence

• Keep nails short and clean
• Dry feet thoroughly after bathing
• Wear cotton, absorbent socks and change daily
• Apply antifungal powders to shoes and feet
• Avoid sharing nail clippers
• Wear protective footwear in public areas
• Treat concomitant fungal infections promptly 1

Treatment Failure Management

• Partial nail removal plus antifungal therapy
• Alternative antifungal drug
• Complete nail avulsion combined with antifungal therapy 1

Common Pitfalls to Avoid

• Not confirming diagnosis before starting treatment
• Inadequate treatment duration
• Simultaneous use of corticosteroids with antifungals
• Unrealistic expectations about improvement speed
• Not addressing predisposing factors
• Not implementing preventive measures 1