What is the treatment for Onychomycosis (fungal infection of the nail)?

From the Guidelines

Onychomycosis is typically treated with oral antifungal medications, with terbinafine being the first-line treatment due to its high cure rate and favorable safety profile, as recommended by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. The treatment of onychomycosis involves the use of oral antifungal medications, which have been shown to be more effective than topical treatments in achieving a complete cure.

• The dosage of terbinafine is 250mg daily for 6 weeks for fingernails or 12 weeks for toenails, as stated in the guidelines 1.
• Alternative options include itraconazole, which can be used as a pulse therapy at a dose of 400mg per day for 1 week per month, with two pulses recommended for fingernails and three pulses for toenails 1.
• Topical treatments like ciclopirox 8% nail lacquer or efinaconazole 10% solution can be used for mild cases or as adjunct therapy, applied daily for up to 48 weeks 1.
• For successful treatment, patients should trim and file infected nails before application, avoid nail polish during treatment, keep nails dry, wear breathable footwear, and complete the full treatment course even if improvement is seen early.
• The British Association of Dermatologists' guidelines also recommend monitoring liver function tests and complete full blood count in adult patients with a history of hepatotoxicity or haematological abnormalities before starting treatment with terbinafine or itraconazole 1.
• The guidelines conclude that terbinafine is superior to itraconazole both in vitro and in vivo for dermatophyte onychomycosis and should be considered the first-line treatment, with itraconazole as the next best alternative 1.

From the FDA Drug Label

Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). 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 (fungal infection of the nail) includes:

• Terbinafine (PO), which is indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 2
• Ciclopirox (TOP), which is indicated as a topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum, as part of a comprehensive management program that includes removal of the unattached, infected nails by a healthcare professional 3

From the Research

Treatment Options for Onychomycosis

The treatment for onychomycosis, a fungal infection of the nail, can be categorized into several modalities, including:

• Surgical methods
• Chemical methods
• Topical treatments
• Oral antifungal agents

Oral Antifungal Agents

Oral antifungal agents are considered the most effective treatment for onychomycosis, with options including:

• Terbinafine 4, 5, 6, 7
• Itraconazole 4, 5, 6, 7
• Griseofulvin 4, 7
• Fluconazole 5, 6

Topical Treatments

Topical treatments are also available, including:

• Ciclopirox 5, 6, 8
• Amorolfine lacquers 6
• Tavaborole 8
• Efinaconazole 8

Other Treatment Methods

Other treatment methods for onychomycosis include:

• Nail avulsion and debridement by chemical or surgical procedures 5
• Device-based therapies 5
• Physical and chemical removal of the diseased nails 6

Considerations for Treatment

When selecting a treatment for onychomycosis, considerations should include:

• The severity and extent of the infection 7
• The patient's medical history and comorbidities 7, 8
• The potential for drug-drug interactions 8
• The need for proper mycological diagnosis before initiating therapy 5