From the Guidelines
Terbinafine should be considered as the first choice of treatment for onychomycosis due to its higher efficacy and tolerability, with a recommended dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection. When treating onychomycosis, it is essential to consider the most effective treatment options to improve patient outcomes and quality of life. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, terbinafine has been shown to be more effective than itraconazole in dermatophyte onychomycosis. Some key points to consider when treating onychomycosis include:
- Terbinafine is licensed at a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 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 1
- Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists 1
- Several large studies demonstrate higher efficacy rates for terbinafine in comparison with itraconazole, with complete cure rates of 55% for terbinafine and 26% for pulsed itraconazole at follow-up at 72 weeks 1
- Long-term effectiveness of treatment during a 5-year blinded prospective follow-up study showed mycological cure without a second therapeutic intervention in 46% of terbinafine-treated patients and 13% of itraconazole-treated patients 1
From the FDA Drug Label
1 INDICATIONS AND USAGE Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium).
INDICATIONS AND USAGE ... 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 Trichophyton rubrum
The treatment for onychomycosis includes:
- Terbinafine (PO), for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
- Ciclopirox (TOP), as a component of a comprehensive management program, for topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum 3
From the Research
Treatment Options for Onychomycosis
The treatment for onychomycosis typically involves oral antifungal therapy, with several options available:
- Fluconazole, itraconazole, and terbinafine are effective in treating onychomycosis and have a good safety profile 4, 5
- Terbinafine is the most effective treatment for dermatophyte onychomycosis, with a cure rate of 70-80% 6
- Itraconazole is effective against Candida onychomycosis, while terbinafine may be more effective against certain species of Candida 5
- The preferred regimens for oral antifungal agents are:
- Itraconazole: pulse therapy with 200mg twice daily for 1 week per month for 3 pulses
- Terbinafine: continuous once daily therapy with 250mg/day for 12 weeks
- Fluconazole: once weekly treatment with 150mg/wk until the abnormal-appearing nail plate has grown out 5
Comparison of Treatment Regimens
Studies have compared the efficacy of different treatment regimens for onychomycosis:
- A study found that continuous dose terbinafine therapy was more effective than pulse dose therapy, with a clinical cure rate of 76.67% compared to 26.67% 7
- Another study found that terbinafine was more effective than griseofulvin, fluconazole, or itraconazole in treating onychomycosis, with a cure rate of 70-80% 6
Emerging Treatment Options
Newer treatment options for onychomycosis are being developed, including: