From the Guidelines
For onychomycosis caused by Trichophyton rubrum, efinaconazole 10% solution is the most effective topical treatment, with mycological cure rates approaching 50% and complete cure in 15% of patients after 48 weeks of application, as supported by the British Association of Dermatologists' guidelines 1.
Treatment Regimens
The treatment regimens for efinaconazole, tavaborole, and ciclopirox are as follows:
- Efinaconazole 10% solution: applied once daily for 48 weeks, directly to the nail plate, nail bed, and surrounding tissue without nail debridement.
- Tavaborole 5% solution: applied once daily for 48 weeks to the entire nail surface and underside of the nail.
- Ciclopirox 8% nail lacquer: requires daily application for 48 weeks, but needs removal with alcohol once weekly before reapplication, and monthly nail debridement is recommended.
Mechanisms of Action
These medications work through different mechanisms:
- Efinaconazole and ciclopirox disrupt fungal cell membrane integrity.
- Tavaborole inhibits protein synthesis by targeting leucyl-tRNA synthetase.
Treatment Selection
Treatment selection should consider cost, insurance coverage, and patient ability to adhere to the specific application requirements, as well as the potential side effects, such as periungual and nail fold erythema associated with ciclopirox 1.
Cure Rates
Efinaconazole and tavaborole generally show higher cure rates (15-18% complete cure) compared to ciclopirox (5-8%), as reported in the British Association of Dermatologists' guidelines 1.
Patient Considerations
All treatments require patience as visible improvement typically takes 3-6 months, and patients should be informed about the potential benefits and drawbacks of each treatment option, including the need for regular application and potential side effects, as outlined in the guidelines 1.
From the Research
Treatment Regimens for Onychomycosis
The treatment of onychomycosis, a common fungal infection of the nail unit, can be challenging due to its deep-seated nature and the need for antifungal agents to achieve and maintain sufficient drug concentrations throughout the nail unit 2. Topical treatments, such as efinaconazole, tavaborole, and ciclopirox, have been developed to address this issue.
Key Differences in Topical Treatments
- Efinaconazole: A topical triazole antifungal with low minimum inhibitory concentrations against Trichophyton rubrum, Trichophyton mentagrophytes, and Candida albicans, making it an effective treatment for onychomycosis 3, 4.
- Tavaborole: A newer topical antifungal with similar efficacy to efinaconazole, although direct comparisons between the two are limited 5.
- Ciclopirox: An older topical antifungal with lower efficacy compared to efinaconazole and tavaborole, although it remains a treatment option for onychomycosis 2, 5.
Efficacy and Safety
- Efinaconazole: Has demonstrated high mycological cure rates and complete cure rates in clinical trials, with a pooled complete cure rate of 17% and a pooled mycological cure rate of 54% 3.
- Tavaborole: Has shown promising results in clinical trials, although more data are needed to fully establish its efficacy and safety profile 5.
- Ciclopirox: Has been associated with lower cure rates and higher recurrence rates compared to efinaconazole and tavaborole 5.
Treatment Considerations
- Trichophyton rubrum: A common causative pathogen of onychomycosis, which can be effectively treated with efinaconazole, tavaborole, or ciclopirox 2, 3, 4.
- Treatment Duration: Typically 48 weeks for efinaconazole and tavaborole, although the optimal treatment duration may vary depending on the individual patient and the severity of the infection 3, 5.